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Calafat M, Lobatón T, Hernández-Gallego A, Mañosa M, Torres P, Cañete F, Cabré E, Ojanguren I, Domènech E. Acute histological inflammatory activity is associated with clinical relapse in patients with ulcerative colitis in clinical and endoscopic remission. Dig Liver Dis 2017; 49:1327-1331. [PMID: 28958412 DOI: 10.1016/j.dld.2017.08.041] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/22/2017] [Accepted: 08/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND It has been suggested that acute histological activity has a prognostic value in the outcome of ulcerative colitis (UC) patients in clinical and endoscopic remission. Our aim was to assess the role of histology as a risk factor for clinical relapse (CR) in patients in both clinical and endoscopic remission. METHODS Patients with left-sided or extensive UC in clinical and endoscopic remission (Mayo endoscopic subscore ≤1) undergoing colonoscopy for dysplasia surveillance with random colonic biopsies between 2005-2015 were included. Basal plasmacytosis, acute (AHA), and the chronic (CHA) histological inflammatory activity of all biopsy sets were evaluated. RESULTS One hundred and thirteen patients were included. Median time in clinical remission at inclusion was 27 months (IQR 15-56). Eight percent of patients relapsed within the first year and 33% during the whole follow-up period. In the univariate analysis, the presence of AHA, alone (P=0.048) or together with a past flare within the previous 12 months (P=0.01), was associated with CR within the first year of follow-up. In the multivariate analysis, AHA, together with a flare within the previous 12 months, remained the only risk factor for relapse (RR=7.5; IC95%; 1.8-29.9; P=0.005). CONCLUSIONS In UC patients in clinical and endoscopic remission, the presence of AHA is a risk factor for clinical relapse.
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Affiliation(s)
- Margalida Calafat
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Triana Lobatón
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.
| | - Alba Hernández-Gallego
- Department of Pathology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Míriam Mañosa
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Paola Torres
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Fiorella Cañete
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Eduard Cabré
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Isabel Ojanguren
- Department of Pathology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Eugeni Domènech
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Abstract
BACKGROUND The expression of elafin in inflammatory bowel disease (IBD) is controversial. Here, we detected the expression of elafin in the peripheral blood and colonic mucosa of patient with IBD and then explored its role and value in assessing the activity and severity of IBD. MATERIALS AND METHODS Sixty-eight patients with IBD were selected as an experimental group. The control group included 38 healthy individuals. The expression of elafin mRNA in peripheral blood leukocytes and in serum was detected by qRT-PCR and enzyme-linked immunosorbent assay, respectively. The inflamed and noninflamed tissues were collected by colonoscopy. The expression of elafin in the intestinal mucosa was determined by immunohistochemistry staining and qRT-PCR. The expression of elafin between groups and among each stage of IBD was compared. The correlations of elafin expression with erythrocyte sedimentation rate and C-reactive protein were determined by Spearman's correlation analysis and with clinical disease activity indices (Best Crohn's Disease Activity Index and modified Mayo scores) by Pearson's correlation analysis. RESULTS Elafin mRNA levels decreased significantly in active ulcerative colitis (UC) but increased in remission UC. However, in Crohn's disease (CD), we did not detect the aforementioned significant differences. Although serum IL-8 levels increased, serum elafin concentrations decreased both in UC and in CD, but the differences among stages were not significant. The expression of elafin in the inflamed colonic mucosa in both CD and UC was lower than that in the normal mucosa in controls and lower than that in the noninflamed mucosa in IBD. Moreover, the relative expression of elafin mRNA in peripheral blood leukocytes in UC was negatively correlated with erythrocyte sedimentation rate, C-reactive protein, and modified Mayo scores, and in CD, it was negatively correlated with Best Crohn's Disease Activity Index scores. CONCLUSIONS Elafin decreased in active patients with IBD and was negatively correlated with disease activity, suggesting that elafin may play a protective role and could be used as an index to evaluate disease activity in IBD.
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353
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Hejl J, Theede K, Møllgren B, Madsen KV, Heidari A, Á Steig A, Fenger M. Point of care testing of fecal calprotectin as a substitute for routine laboratory analysis. Pract Lab Med 2017; 10:10-14. [PMID: 29234707 PMCID: PMC5721267 DOI: 10.1016/j.plabm.2017.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/06/2017] [Accepted: 11/20/2017] [Indexed: 02/06/2023] Open
Abstract
Objectives Fecal calprotectin (FC) is widely used to monitor the activity of inflammatory bowel disease (IBD) and to tailor medical treatment to disease activity. Laboratory testing of fecal samples may have a turnaround time of 1–2 weeks, whereas FC home testing allows results within hours and thus enables a rapid response to clinical deterioration. Design and methods Fifty-five stool samples were analyzed by the IBDoc® Calprotectin Home Testing kit and the BÜHLMANN fCAL® turbo assay on a Roche Cobas 6000 c501. The correlation between the assays was assessed using Spearman's Rho correlation coefficient and the intermediate imprecision of both assays was calculated. Results We found a strong correlation coefficient of 0.887 between FC measured on IBDoc® and the laboratory assay BÜHLMANN fCAL® turbo. The coefficients of variation (CVs) at three different FC levels were in the range 2.3–5.5% (BÜHLMANN fCAL® turbo) and in the range of 4.8–26.6% (IBDoc®). Conclusions This study suggests that IBDoc® is a suitable alternative for the assessment of disease activity in IBD patients.
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Affiliation(s)
- Julie Hejl
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Klaus Theede
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Brian Møllgren
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Kirsten Vikkelsø Madsen
- Faculty of Health and Technology, Metropolitan University College, Sigurdsgade 26, 2200 København N, Denmark
| | - Ashraf Heidari
- Faculty of Health and Technology, Metropolitan University College, Sigurdsgade 26, 2200 København N, Denmark
| | - Anna Á Steig
- Faculty of Health and Technology, Metropolitan University College, Sigurdsgade 26, 2200 København N, Denmark
| | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
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Vázquez Morón JM, Pallarés Manrique H, Machancoses FH, Ramos Lora M, Ruiz Frutos C. Accurate cut-offs for predicting endoscopic activity and mucosal healing in Crohn's disease with fecal calprotectin. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:130-136. [PMID: 28071062 DOI: 10.17235/reed.2017.4542/2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fecal biomarkers, especially fecal calprotectin, are useful for predicting endoscopic activity in Crohn's disease; however, the cut-off point remains unclear. The aim of this paper was to analyze whether faecal calprotectin and M2 pyruvate kinase are good tools for generating highly accurate scores for the prediction of the state of endoscopic activity and mucosal healing. METHODS The simple endoscopic score for Crohn's disease and the Crohn's disease activity index was calculated for 71 patients diagnosed with Crohn's. Fecal calprotectin and M2-PK were measured by the enzyme-linked immunosorbent assay test. RESULTS A fecal calprotectin cut-off concentration of ≥ 170 µg/g (sensitivity 77.6%, specificity 95.5% and likelihood ratio +17.06) predicts a high probability of endoscopic activity, and a fecal calprotectin cut-off of ≤ 71 µg/g (sensitivity 95.9%, specificity 52.3% and likelihood ratio -0.08) predicts a high probability of mucosal healing. Three clinical groups were identified according to the data obtained: endoscopic activity (calprotectin ≥ 170), mucosal healing (calprotectin ≤ 71) and uncertainty (71 > calprotectin < 170), with significant differences in endoscopic values (F = 26.407, p < 0.01). Clinical activity or remission modified the probabilities of presenting endoscopic activity (100% vs 89%) or mucosal healing (75% vs 87%) in the diagnostic scores generated. M2-PK was insufficiently accurate to determine scores. CONCLUSIONS The highly accurate scores for fecal calprotectin provide a useful tool for interpreting the probabilities of presenting endoscopic activity or mucosal healing, and are valuable in the specific clinical context.
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Affiliation(s)
| | | | | | - Manuel Ramos Lora
- UGC Aparato Digestivo, Huelva University Hospital Complex - Hospital Juan Ramón Jiménez , Spain
| | - Carlos Ruiz Frutos
- Environmental Biology and Public Health Department, University of Huelva, Spain
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355
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Heida A, Knol M, Kobold AM, Bootsman J, Dijkstra G, van Rheenen PF. Agreement Between Home-Based Measurement of Stool Calprotectin and ELISA Results for Monitoring Inflammatory Bowel Disease Activity. Clin Gastroenterol Hepatol 2017; 15:1742-1749.e2. [PMID: 28606846 DOI: 10.1016/j.cgh.2017.06.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An increasing number of physicians use repeated measurements of stool calprotectin to monitor intestinal inflammation in patients with inflammatory bowel diseases (IBDs). A lateral flow-based rapid test allows patients to measure their own stool calprotectin values at home. The test comes with a software application (IBDoc; Bühlmann Laboratories AG, Schönenbuch, Switzerland) that turns a smartphone camera into a results reader. We compared results from this method with those from the hospital-based reader (Quantum Blue; Bühlmann Laboratories AG) and enzyme-linked immunosorbent assay (ELISA) analysis. METHODS In a single-center comparison study, we asked 101 participants (10 years of age or older) in the Netherlands to perform the IBDoc measurement on stool samples collected at home, from June 2015 to October 2016. Participants then sent the residual extraction fluid and a fresh specimen from the same bowel movement to our pediatric and adult IBD center at the University Medical Center Groningen, where the level of calprotectin was measured by the Quantum Blue reader and ELISA analysis, respectively. The primary outcome was the agreement of results between IBDoc and the Quantum Blue and ELISA analyses, determined by Bland-Altman plot analysis. RESULTS We received 152 IBDoc results, 138 samples of residual extraction fluid for Quantum Blue analysis, and 170 fresh stool samples for ELISA analysis. Spearman's rank correlation coefficient was 0.94 for results obtained by IBDoc vs Quantum Blue and 0.85 for results obtained by IBDoc vs ELISA. At the low range of calprotectin level (<500 μg/g), 91% of IBDoc-Quantum Blue results were within the predefined limits of agreement (±100 μg/g), and 71% of IBDoc-ELISA results were in agreement. At the high range of calprotectin level (≥500 μg/g), 81% of IBDoc-Quantum Blue results were within the predefined limits of agreement (±200 μg/g) and 64% of IBDoc-ELISA results were in agreement. CONCLUSIONS Measurements of fecal levels of calprotectin made with home-based lateral flow method were in agreement with measurements made by Quantum Blue and ELISA, as long as concentrations were <500 μg/g. For patients with concentrations of fecal calprotectin above this level, findings from IBDoc should be confirmed by another method. (Netherlands Trial Registration Number: NTR5133).
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Affiliation(s)
- Anke Heida
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Mariska Knol
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Anneke Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Josette Bootsman
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
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356
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Uchihara M, Kato J, Tsuda S, Yoshida T, Maekita T, Iguchi M, Kitano M. Blood biomarkers reflect integration of severity and extent of endoscopic inflammation in ulcerative colitis. JGH OPEN 2017; 1:98-104. [PMID: 30483544 PMCID: PMC6207012 DOI: 10.1002/jgh3.12017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/29/2017] [Accepted: 09/13/2017] [Indexed: 12/22/2022]
Abstract
Background and Aim Blood markers are not always regarded as satisfactory surrogate biomarkers for predicting endoscopic activity in ulcerative colitis (UC). However, those biomarkers have been evaluated solely based on endoscopic activity at the most severe colorectal location, taking no account of the extent of inflammation. This study aimed to examine whether integrated evaluation of severity and extent of endoscopic activity improves the performance of blood biomarkers for UC. Methods We performed a retrospective study of UC patients who underwent colonoscopy and blood tests in our hospital. Blood tests were C‐reactive protein (CRP), serum albumin (ALB), and platelet count (PLT). We compared blood markers with two versions of endoscopic activity assessed by Mayo endoscopic subscore (MES): the maximum score of MES in the colorectum (mMES, range: 0–3) and the cumulative score of MES of six colorectal regions (cMES, range: 0–18). Results All three blood markers correlated well with both mMES and cMES, and each marker showed better correlation with cMES than mMES (Spearman rank correlation coefficient: PLT: 0.54 vs 0.47, ALB: −0.65 vs −0.52, and CRP: 0.52 vs 0.38, respectively). The predictability, including sensitivity and specificity, of each marker for endoscopic activity was also better for cMES, resulting in higher degrees of area under the curve (mMES vs cMES: PLT: 0.75 vs 0.83, ALB: 0.77 vs 0.90, and CRP: 0.75 vs 0.90, respectively). Conclusion When incorporating the extent of inflammation, blood markers are better at predicting endoscopic activity of UC than previously considered and could be used as a reliable biomarker in clinical practice.
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Affiliation(s)
- Mayu Uchihara
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Jun Kato
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Saya Tsuda
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Takeichi Yoshida
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Takao Maekita
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine Wakayama Medical University Wakayama Japan
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357
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Abstract
OBJECTIVES Orofacial granulomatosis (OFG) is a chronic inflammatory condition affecting the orofacial area. Its connection to Crohn disease (CD) is debated. Our aim was to describe a cohort of pediatric patients with OFG in detail, study the long-term behavior of OFG, and evaluate factors predicting CD in patients with OFG. METHODS We invited patients diagnosed with OFG at 2 university hospitals, Finland for a follow-up appointment. Patients (n = 29) were examined by a dentist and an otorhinolaryngologist using a structural schema. Orofacial findings were also recorded using digital photographing. Patients filled in questionnaires about general health and special diets. Patients' nutrition was evaluated from food records. The findings were compared between patients with OFG only and OFG with CD. RESULTS Patients with CD had more findings in the orofacial area (total score for orofacial findings median 11) compared to patients with OFG only (total score median 7.5). There was no statistically significant difference in the type of lesions between these groups, except the upper lip was more often affected in patients with CD (n = 11) than in patients with OFG only (n = 0). Most of the patients had normal otorhinolaryngological findings. All patients with elevated anti-Saccharomyces cerevisiae antibody A levels had CD (n = 6) and they presented with more orofacial findings (total score) than patients with normal levels of anti-S cerevisiae antibody A (P = 0.0311). CONCLUSIONS Long-term follow-up of pediatric-onset patients with OFG shows good prognosis. Patients with OFG do not seem to have otorhinolaryngological comorbidity. Anti-S cerevisiae antibody A may serve as a factor to indicate the possible presence of underlying CD in patients with OFG, but further studies are requested.
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358
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Swaminath A, Feathers A, Ananthakrishnan A, Falzon L, Ferry SL. Systematic review with meta-analysis: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease. Aliment Pharmacol Ther 2017; 46:645-656. [PMID: 28815649 PMCID: PMC5798240 DOI: 10.1111/apt.14253] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/30/2017] [Accepted: 07/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite potential adverse-events in a paediatric population, corticosteroids are used to induce remission in paediatric Crohn's disease. Exclusive enteral nutrition also induces remission, but is infrequently used in the USA because corticosteroids are considered the superior therapy. New data have become available since the publication of the most recent meta-analysis in 2007. AIM To see if current literature supports the use of EEN versus CS in paediatric populations. METHODS All studies with comparator arms of exclusive enteral nutrition and an exclusive corticosteroids, with remission clearly defined were identified by searching eight online databases. RESULTS Of 2795 identified sources, nine studies met our inclusion criteria. Eight of these (n = 451), had data that could be abstracted into our meta-analysis. Exclusive enteral nutrition was as effective as corticosteroids in inducing remission (OR = 1.26 [95% CI 0.77, 2.05]) in paediatric Crohn's disease. There was no difference between Exclusive enteral nutrition and corticosteroids efficacy when comparing newly diagnosed Crohn's (OR = 1.61 [95% CI .87, 2.98]) or relapsed (OR = 0.76 [95% CI .29-1.98]). Intestinal healing was significantly more likely among patients receiving Exclusive enteral nutrition compared to corticosteroids (OR = 4.5 [95% CI 1.64, 12.32]). There was no difference in the frequency of biomarker normalisation including CRP (OR = 0.85 [95% CI .44, 1.67]) and faecal calprotectin (OR 2.79 [95% CI .79-10.90]). CONCLUSIONS There is no difference in efficacy between exclusive enteral nutrition and corticosteroids in induction of remission in Crohn's disease in a paediatric population. Exploratory analyses suggest that a greater proportion of patients treated with exclusive enteral nutrition achieved mucosal healing.
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Affiliation(s)
- Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY,
USA
| | | | | | - Louise Falzon
- Columbia University Medical Center, New York, NY, USA
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Correlation of 18F-FDG PET/MRE Metrics with Inflammatory Biomarkers in Patients with Crohn's Disease: A Pilot Study. CONTRAST MEDIA & MOLECULAR IMAGING 2017; 2017:7167292. [PMID: 29097934 PMCID: PMC5625758 DOI: 10.1155/2017/7167292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/03/2017] [Indexed: 12/22/2022]
Abstract
Background To investigate the association between 18F-FDG (Fluorodeoxyglucose) PET (positron emission tomography)/MRE (magnetic resonance enterography) metrics with the inflammatory biomarkers fecal calprotectin and C-reactive protein (CRP) in patients with Crohn's disease (CD). Methods This prospective pilot study was institutional review board (IRB) approved with informed consent obtained. Consecutive CD patients were referred to 18F-FDG PET/MRE. Patients in whom colonoscopy was performed and CRP and fecal calprotectin levels were measured were included. CRP and fecal calprotectin were regarded as positive for inflammation if they were greater than 0.5 mg/dl and 150 mcg/g, respectively. Correlation of quantitative variables was performed using the Pearson's correlation coefficient. Receiver operating characteristic (ROC) curves were drawn and the area under the curve (AUC) was calculated to evaluate the accuracy of PET and MRE metrics in determining the presence of inflammation evaluated by calprotectin and CRP levels. Results Analysis of 21 patients (16 women and 5 men, 43 ± 18 years) was performed. Magnetic resonance index of activity (MaRIA) score had an AUC of 0.63 associated with fecal calprotectin and CRP. Adding apparent diffusion coefficient (ADC) and metabolic inflammatory volume (MIV) to MaRIA score resulted in an AUC of 0.92 with a cutoff value of 447 resulting in 83% and 100% sensitivity and specificity, respectively. Conclusion The addition of ADC and MIV to the MaRIA score increases the accuracy for discrimination of disease activity in patients with CD. Trial registration number is 2015062.
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360
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Starr AE, Deeke SA, Ning Z, Chiang CK, Zhang X, Mottawea W, Singleton R, Benchimol EI, Wen M, Mack DR, Stintzi A, Figeys D. Proteomic analysis of ascending colon biopsies from a paediatric inflammatory bowel disease inception cohort identifies protein biomarkers that differentiate Crohn's disease from UC. Gut 2017; 66:1573-1583. [PMID: 27216938 PMCID: PMC5561380 DOI: 10.1136/gutjnl-2015-310705] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 03/10/2016] [Accepted: 04/25/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Accurate differentiation between Crohn's disease (CD) and UC is important to ensure early and appropriate therapeutic intervention. We sought to identify proteins that enable differentiation between CD and UC in children with new onset IBD. DESIGN Mucosal biopsies were obtained from children undergoing baseline diagnostic endoscopy prior to therapeutic interventions. Using a super-stable isotope labeling with amino acids in cell culture (SILAC)-based approach, the proteomes of 99 paediatric control and biopsies of patients with CD and UC were compared. Multivariate analysis of a subset of these (n=50) was applied to identify novel biomarkers, which were validated in a second subset (n=49). RESULTS In the discovery cohort, a panel of five proteins was sufficient to distinguish control from IBD-affected tissue biopsies with an AUC of 1.0 (95% CI 0.99 to 1.0); a second panel of 12 proteins segregated inflamed CD from UC within an AUC of 0.95 (95% CI 0.86 to 1.0). Application of the two panels to the validation cohort resulted in accurate classification of 95.9% (IBD from control) and 80% (CD from UC) of patients. 116 proteins were identified to have correlation with the severity of disease, four of which were components of the two panels, including visfatin and metallothionein-2. CONCLUSIONS This study has identified two panels of candidate biomarkers for the diagnosis of IBD and the differentiation of IBD subtypes to guide appropriate therapeutic interventions in paediatric patients.
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Affiliation(s)
- Amanda E Starr
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Shelley A Deeke
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Zhibin Ning
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Cheng-Kang Chiang
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Xu Zhang
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Walid Mottawea
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada,Department of Microbiology and Immunology, Mansoura University, Mansoura, Egypt
| | - Ruth Singleton
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre and CHEO Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre and CHEO Research Institute, University of Ottawa, Ottawa, Ontario, Canada,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ming Wen
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - David R Mack
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre and CHEO Research Institute, University of Ottawa, Ottawa, Ontario, Canada,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Figeys
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, Ontario, Canada,Department of Chemistry and Biomolecular Sciences, University of Ottawa, Ottawa, Ontario, Canada
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361
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Khanna R, Jairath V, Feagan BG. The Evolution of Treatment Paradigms in Crohn's Disease: Beyond Better Drugs. Gastroenterol Clin North Am 2017; 46:661-677. [PMID: 28838421 DOI: 10.1016/j.gtc.2017.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite advances in care, most patients with Crohn's disease (CD) develop complications, such as fistulas, or require surgery. Given the recent advances in drug therapy, an opportunity exists to optimize the management of this chronic disease through early use of effective therapies, clear definition of treatment targets, and application of the principles of personalized medicine. In this article, the authors discuss the evolution of treatment algorithms for CD to incorporate these strategies.
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Affiliation(s)
- Reena Khanna
- Department of Medicine, University of Western Ontario, 100 Dundas Street, Suite 200, London, Ontario N6A 5B6, Canada
| | - Vipul Jairath
- Department of Medicine, University of Western Ontario, 100 Dundas Street, Suite 200, London, Ontario N6A 5B6, Canada; Department of Epidemiology & Biostatistics, University of Western Ontario, 100 Dundas Street, Suite 200, London, Ontario N6A 5B6, Canada
| | - Brian G Feagan
- Department of Medicine, University of Western Ontario, 100 Dundas Street, Suite 200, London, Ontario N6A 5B6, Canada; Department of Epidemiology & Biostatistics, University of Western Ontario, 100 Dundas Street, Suite 200, London, Ontario N6A 5B6, Canada.
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362
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The prevalence of irritable bowel syndrome-type symptoms in inflammatory bowel disease patients in remission. Eur J Gastroenterol Hepatol 2017. [PMID: 28639969 DOI: 10.1097/meg.0000000000000921] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Symptoms of irritable bowel syndrome (IBS) are common in inflammatory bowel disease (IBD) and are believed to reflect ongoing inflammation. Consequently, a low prevalence of IBS-type symptoms in IBD patients with normal inflammatory markers is expected. We aimed to investigate the prevalence of IBS-type symptoms in IBD patients in biochemical remission (evidenced by low fecal calprotectin levels) and the relationship of these symptoms with fecal calprotectin levels. PATIENTS AND METHODS In this observational, cross-sectional study, we included all adults with a history of IBD who had calprotectin levels less than 200 µg/g during routine follow-up between August 2014 and May 2015 at our hospital. Patients were excluded if calprotectin was measured because of gastrointestinal complaints. All patients were approached by telephone to evaluate the presence of IBS-type symptoms using Rome III questionnaires. Patients fulfilling IBS criteria were subclassified according to bowel habits. RESULTS In total, 74 patients were included; 33 (45%, 95% confidence interval: 34-56%) fulfilled the IBS criteria. A larger proportion of Crohn's disease patients with IBS-type symptoms had ileal disease compared with Crohn's disease patients without IBS symptoms (55 vs. 24%; P=0.03). Other characteristics were similar between groups. No difference was found in calprotectin levels between patients with and without IBS-type symptoms (P=0.91). The majority of patients with IBS-type symptoms had diarrhea-predominant or mixed-type IBS (64 and 27% of patients with IBS-type symptoms, respectively). CONCLUSION The prevalence of IBS-type symptoms in IBD patients in biochemical remission is high. A significant proportion of IBS-type symptoms is unrelated to ongoing inflammation and probably reflects 'true IBS'.
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Noninvasive Fecal Immunochemical Testing and Fecal Calprotectin Predict Mucosal Healing in Inflammatory Bowel Disease: A Prospective Cohort Study. Inflamm Bowel Dis 2017. [PMID: 28644184 DOI: 10.1097/mib.0000000000001173] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The noninvasive biomarkers fecal immunochemical testing (FIT) and fecal calprotectin (FCP) are sensitive for prediction of mucosal inflammation in inflammatory bowel disease. However, neither test has yet been shown to independently and accurately predict mucosal healing (MH). We aimed to assess the specificity of noninvasive FIT and FCP for MH prediction. METHODS In this prospective cohort study of adult inflammatory bowel disease outpatients presenting for colonoscopy, stool samples for FIT and FCP were collected 48 hours before endoscopy. Using MH defined by Simple Endoscopic Score for Crohn's disease (SES-CD = 0), Rutgeert's score (i0), and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS = 3), receiver operator characteristic curves were plotted, and sensitivity, specificity, positive and negative predictive values, and areas under the curve were calculated. Multivariate logistic regression analysis was used to develop a clinical model for noninvasively predicting MH. RESULTS Eighty patients (40 Crohn's disease and 40 ulcerative colitis) were enrolled. The specificities of FIT <100 ng/mL and FCP <250 μg/g for MH were 0.57 (95% confidence interval, 0.38-0.74) and 0.77 (0.57-0.89), respectively. Positive predictive values for MH for FIT <100 ng/mL and FCP <250 μg/g were 0.78 (0.64-0.87) and 0.77 (0.58-0.90), respectively. In multivariate modeling, combining FIT, FCP, and clinical symptomatic remission improved specificity for MH to 0.90 (0.72-0.97) with positive predictive values of 0.84 (0.60-0.96). Areas under the curve for FIT was higher for patients with ulcerative colitis (0.88) than for patients with Crohn's disease (0.69, P = 0.05). CONCLUSIONS FIT and FCP have similar performance characteristics for identifying MH. Combined, low FIT, low FCP, and clinical remission are specific for MH.
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Shi HY, Chan FKL, Chan AWH, Higashimori A, Kyaw M, Ching JYL, Luk AKC, Wong SH, Wu JCY, Sung JJY, Ng SC. Accuracy of Faecal Immunochemical Test to Predict Endoscopic and Histological Healing in Ulcerative Colitis: A Prospective Study Based on Validated Histological Scores. J Crohns Colitis 2017; 11:1071-1077. [PMID: 28881876 DOI: 10.1093/ecco-jcc/jjx088] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/12/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic and histological healing are associated with improved clinical outcomes in ulcerative colitis [UC]. We aimed to investigate the predictive value of faecal immunochemical test [FIT] for endoscopic and histological healing in UC. METHODS We measured quantitative FIT and faecal calprotectin [FC] in 140 consecutive UC patients who underwent colonoscopy. We assessed the diagnostic accuracy of FIT for predicting endoscopic healing using the Mayo endoscopic subscore [MES 0/1] and for histological healing using the Geboes score [< 2.0] and Nancy index [grade ≤ 1]. The predictive abilities of FIT were compared with those of FC. RESULTS FIT had an area under the curve [AUC] of 0.77 (95% confidence interval [CI] 0.67-0.86, p < 0.001) for endoscopic healing, an AUC of 0.77 [95% CI 0.67-0.86, p < 0.001] using the Geboes score, and 0.77 [95% CI 0.66-0.85, p < 0.001] using the Nancy Index for histological healing. The AUC of FIT was comparable to that of FC for endoscopic healing [p = 0.773] and histological healing [p = 0.767-0.960], and was comparable to colonoscopy for histological healing [p = 0.384-0.673]. FIT < 50 ng/ml predicted endoscopic healing with a sensitivity, specificity, and positive predictive value [PPV] of 72%, 68%, and 82%, respectively, and for histological healing with a sensitivity, specificity, and PPV of 73-75%, 67%, and 78-80%, respectively. Combining FIT with FC led to a higher specificity [90%] for histological healing. Over 85% of patients with FIT < 50 ng/ml and FC < 50 μg/g achieved histological healing. CONCLUSIONS FIT is highly sensitive and accurate to predict endoscopic and histological healing in UC. It represents a promising non-invasive tool for monitoring mucosal healing in UC.
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Affiliation(s)
- Hai Yun Shi
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing, China.,Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Anthony W H Chan
- Department of Anatomical & Cellular Pathology, Chinese University of Hong Kong, Hong Kong, China
| | - Akira Higashimori
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Moe Kyaw
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Jessica Y L Ching
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Arthur K C Luk
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Siew C Ng
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
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Comparative Acceptability and Perceived Clinical Utility of Monitoring Tools: A Nationwide Survey of Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:1425-1433. [PMID: 28570431 DOI: 10.1097/mib.0000000000001140] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Objective control of intestinal inflammation during inflammatory bowel disease (IBD) is becoming the main driver for medical treatment. However, the monitoring tools-related burden remains poorly investigated. We aimed to evaluate their comparative acceptability and utility according to patients with IBD. METHODS After a preliminary phase, the final questionnaire encompassing self-administered and physician questionnaires was prospectively and consecutively submitted to 916 patients with IBD from 20 public and private centers. Acceptability and utility visual analog scales (VAS) were expressed as median with interquartile range. RESULTS Regarding the group of patients with Crohn's disease (n = 618), venipuncture (VAS = 9.3 [8.8-9.7]) and ultrasonography (VAS = 9.3 [8.7-9.7]) were the most acceptable tools (P < 0.0001, for each comparison), whereas rectosigmoidoscopy was the least acceptable tool (VAS = 4.4 [1.2-7.3]) (P < 0.0001, for each comparison). Wireless capsule endoscopy (VAS = 8.5 [5.2-9.3]), magnetic resonance enterocolonography (VAS = 8.0 [5.0-9.2]), and stools collection (VAS = 7.7 [4.6-9.3]) were more acceptable than colonoscopy (VAS = 6.7 [4.3-8.9]) (P < 0.0001, for each comparison). The acceptability was assessed in 298 patients with ulcerative colitis for venipuncture (VAS = 9.4 [8.8-9.7]), stools collection (VAS = 8.1 [5.7-9.4]), colonoscopy (VAS = 7.5 [4.7-9.2]), and rectosigmoidoscopy (VAS = 6.7 [2.8-9.1]); (P < 0.001 for each comparison). All monitoring tools were considered as highly useful by patients with IBD. Decreased acceptability was related to embarrassment for the collection/transport of stools (60.7%), bowel cleansing (76.3%) for colonoscopy, abdominal discomfort (51.3%) and rectal enema (36.6%) for rectosigmoidoscopy, bowel distension (48.3%) for magnetic resonance enterocolonography, and potential capsule retention (21.4%) for wireless capsule endoscopy. CONCLUSIONS Among the IBD monitoring tools, endoscopy demonstrated the lowest acceptability supporting the development of alternative modalities. Patients' information and examination conditions should be improved to ensure proper monitoring adherence.
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Kwapisz L, Gregor J, Chande N, Yan B, Ponich T, Mosli M. The utility of fecal calprotectin in predicting the need for escalation of therapy in inflammatory bowel disease. Scand J Gastroenterol 2017; 52:846-850. [PMID: 28423962 DOI: 10.1080/00365521.2017.1315740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Fecal calprotectin is an important biomarker used in the evaluation of inflammatory bowel disease. It has proven to be an effective tool in initial screening as well monitoring response to therapy. The aim of this study is to examine the utility of fecal calprotectin both as a predictor for the escalation of therapy in established inflammatory bowel disease and as a predictor of de novo diagnosis. METHODS Patients with signs and symptoms concerning for inflammatory bowel disease presenting to outpatient clinics were recruited to provide fecal calprotectin stool samples prior to endoscopic evaluation. Patients were followed up for at least one year and monitored clinically for any change in symptomatology, escalation of therapy or development of IBD, confirmed endoscopically. RESULTS A total of 126 patients, of whom 72 were known to have underlying inflammatory bowel disease, were included in the final analysis. Among the patients with elevated fecal calprotectin levels and known inflammatory bowel disease, 66% (33/50) went on to have escalation of therapy within 12 months compared to 18% (4/22) if the fecal calprotectin levels were in the normal range (p < .0001). For the remaining patients who at baseline did not have inflammatory bowel disease and a normal endoscopic evaluation, elevated fecal calprotectin resulted in no cases (0/17) of a new diagnosis in the next 12 months. CONCLUSIONS Fecal calprotectin is a useful test for predicting escalation of therapy in established inflammatory bowel disease.
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Affiliation(s)
- Lukasz Kwapisz
- a Department of Medicine, Division of Gastroenterology , London Health Sciences Centre (LHSC), Western University , London , Ontario , Canada
| | - Jamie Gregor
- a Department of Medicine, Division of Gastroenterology , London Health Sciences Centre (LHSC), Western University , London , Ontario , Canada
| | - Nilesh Chande
- a Department of Medicine, Division of Gastroenterology , London Health Sciences Centre (LHSC), Western University , London , Ontario , Canada
| | - Brian Yan
- a Department of Medicine, Division of Gastroenterology , London Health Sciences Centre (LHSC), Western University , London , Ontario , Canada
| | - Terry Ponich
- a Department of Medicine, Division of Gastroenterology , London Health Sciences Centre (LHSC), Western University , London , Ontario , Canada
| | - Mahmoud Mosli
- b Department of Medicine, Division of Gastroenterology , King Abdulaziz University , Jeddah , Saudi Arabia
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Samaan MA, Pavlidis P, Johnston E, Warner B, Digby-Bell J, Koumoutsos I, Fong S, Goldberg R, Patel K, Gulati S, Medcalf L, Sastrillo M, Brown-Clarke C, Bidewell-Sullivan J, Forsyth K, Lee E, Stanton A, Duncan J, Chung-Faye G, Dubois P, Powell N, Anderson S, Sanderson J, Hayee B, Irving PM. Vedolizumab: early experience and medium-term outcomes from two UK tertiary IBD centres. Frontline Gastroenterol 2017; 8:196-202. [PMID: 28839909 PMCID: PMC5558276 DOI: 10.1136/flgastro-2016-100720] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/01/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To gain an understanding of the efficacy of vedolizumab in a 'real-world' setting. DESIGN Retrospective cohort study using prospectively maintained clinical records. SETTING Two UK tertiary inflammatory bowel disease (IBD) centres. PATIENTS Patients with IBD commenced on vedolizumab at Guy's & St Thomas' and King's College Hospitals during November 2014-November 2015. INTERVENTION Vedolizumab, a monoclonal antibody to α-4 β-7 integrins that selectively inhibit leucocyte migration into the gut. MAIN OUTCOME MEASURES Clinical disease activity was assessed at baseline, weeks 14 and 30 using Harvey-Bradshaw Index (HBI) for Crohn's disease (CD) and Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis (UC). Response was defined as HBI or SCCAI reduction ≥3. Remission was defined as HBI <5 or SCCAI <3. Continuous data are summarised as medians, followed by range. RESULTS Fifty patients were included: 27 CD, 20 UC and 3 IBD-U (included in the UC group for analysis). At baseline visit, the median HBI was 8 (1-16) and SCCAI was 6 (0-15). At week 14, these values had fallen to 5 (0-15) (p=0.117) and 4 (0-10) (p=0.005), respectively. Additionally, week 30 data were available for 19 patients (9 CD, 10 UC). The clinical disease activity scores at that point were HBI 2 (0-7) (p=0.039) and SCCAI 2 (0-10) (p=0.023). At baseline, 37 (74%) of the 50 patients had clinically active disease. Of the patients with active disease, 22 (59%) responded and 14 (38%) achieved remission at week 14. CONCLUSIONS Our early experience with vedolizumab demonstrates a clear benefit in terms of disease control as well as a steroid-sparing effect in a cohort, which included patients with complex and previously refractory disease.
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Affiliation(s)
- Mark A Samaan
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | | | - Emma Johnston
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Ben Warner
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | | | - Ioannis Koumoutsos
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Steven Fong
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Rimma Goldberg
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Kamal Patel
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Shraddha Gulati
- IBD Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Lucy Medcalf
- IBD Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Marlene Sastrillo
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | | | | | - Katrina Forsyth
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Emma Lee
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Anna Stanton
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Julie Duncan
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Guy Chung-Faye
- IBD Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Patrick Dubois
- IBD Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Nick Powell
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Simon Anderson
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Jeremy Sanderson
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
| | - Bu'Hussain Hayee
- IBD Service, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter M Irving
- IBD Centre, Guy's & St Thomas’ NHS Foundation Trust, IBD Centre, London, UK
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Turvill J, Rook L, Rawle M, Robins G, Smale S, Kant P, Phillips A. Validation of a care pathway for the use of faecal calprotectin in monitoring patients with Crohn's disease. Frontline Gastroenterol 2017; 8:183-188. [PMID: 28839907 PMCID: PMC5558279 DOI: 10.1136/flgastro-2016-100780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION We have previously published an evidence-based care pathway for the use of faecal calprotectin (FC) to monitor patients with Crohn's disease established on therapy. Patients are treated as low, intermediate or high risk of continuing Crohn's disease activity based on their FC, whatever their phenotype and surgical status are. Low-risk patients (FC <100 µg/g) are offered 12 monthly follow-ups or step down of therapy if asymptomatic or initial expectant symptomatic treatment. Intermediate-risk patients (FC 100-250 µg/g) are reviewed at 6 months with a repeat FC. High-risk patients (two consecutive FCs >250 µg/g) are flagged up to the responsible clinician as likely having an active Crohn's disease. METHODS To validate this care pathway over a 2-year period, by determining its negative predictive value (NPV) and positive predictive value (PPV). RESULTS 123 patients were managed by means of the care pathway for a mean of 24.4 months. The NPV and PPV were 0.97 (CI 0.93 to 0.98) and 0.85 (CI 0.80 to 0.94), respectively (sensitivity: 0.92 (0.83 to 0.96) and specificity: 0.95 (0.92 to 0.98)). Importantly 69% of patients with FC >250 µg/g were in clinical remission, the care pathway identifying patients who would benefit from presymptomatic disease modification. CONCLUSIONS This validation of a pragmatic clinical care pathway demonstrates a safe and effective mechanism by which to use FC to monitor risk of disease activity in patients with Crohn's disease established on therapy. It provides a framework for prioritising follow-up and for identifying patients at risk of continuing disease activity or those in whom therapy could be stepped down.
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Affiliation(s)
- James Turvill
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Lisa Rook
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Maxine Rawle
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Gerry Robins
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Simon Smale
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Prashant Kant
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Anne Phillips
- Department of Gastroenterology, York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
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Rubin DT, Cohen RD, Sandborn WJ, Lichtenstein GR, Axler J, Riddell RH, Zhu C, Barrett AC, Bortey E, Forbes WP. Budesonide Multimatrix Is Efficacious for Mesalamine-refractory, Mild to Moderate Ulcerative Colitis: A Randomised, Placebo-controlled Trial. J Crohns Colitis 2017; 11:785-791. [PMID: 28333362 PMCID: PMC5881669 DOI: 10.1093/ecco-jcc/jjx032] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/03/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Safety and efficacy of budesonide multimatrix, an oral extended-release second-generation corticosteroid designed for targeted delivery throughout the colon, were examined for induction of remission in patients with mild to moderate ulcerative colitis refractory to baseline mesalamine therapy. METHODS A randomised, double-blind, placebo-controlled, multicentre trial evaluated efficacy and safety of budesonide multimatrix for induction of remission [ulcerative colitis disease activity index score ≥ 4 and ≤ 10] in 510 adults randomised to once-daily oral budesonide multimatrix 9 mg or placebo for 8 weeks. Patients continued baseline treatment with oral mesalamine ≥ 2.4 g/day. RESULTS Combined clinical and endoscopic remission at Week 8 was achieved by 13.0% and 7.5% of patients receiving budesonide multimatrix [n = 230] or placebo [n = 228], respectively, in the modified intention-to-treat population [p = 0.049]. Clinical remission [ulcerative colitis disease activity index rectal bleeding and stool frequency subscale scores of 0] was similar in both groups [p = 0.70]. More patients receiving budesonide multimatrix vs placebo achieved endoscopic remission [ulcerative colitis disease activity index mucosal appearance subscale score of 0; 20.0% vs 12.3%; p = 0.02] and histological healing [27.0% vs 17.5%; p = 0.02]. Adverse event rates were similar [budesonide multimatrix, 31.8%; placebo, 27.1%]. Mean morning cortisol concentrations decreased at Weeks 2, 4, and 8 with budesonide multimatrix but remained within the normal range. CONCLUSION Budesonide multimatrix was safe and efficacious for inducing clinical and endoscopic remission for mild to moderate ulcerative colitis refractory to oral mesalamine therapy.
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Affiliation(s)
- David T. Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Russell D. Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - William J. Sandborn
- Division of Gastroenterology, University of California [UC] San Diego and UC San Diego Health System, San Diego, CA, USA
| | - Gary R. Lichtenstein
- Division of Gastroenterology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Axler
- Toronto Digestive Disease Associates, Toronto, ON, Canada
| | - Robert H. Riddell
- Department of Pathology and Laboratory Medicine, Mt Sinai Hospital, Toronto, ON, Canada
| | - Cindy Zhu
- Salix Pharmaceuticals, Raleigh, NC, USA
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Clinical Utility of Fecal Calprotectin Monitoring in Asymptomatic Patients with Inflammatory Bowel Disease: A Systematic Review and Practical Guide. Inflamm Bowel Dis 2017; 23:894-902. [PMID: 28511198 PMCID: PMC5434712 DOI: 10.1097/mib.0000000000001082] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In asymptomatic patients with inflammatory bowel disease (IBD), "monitoring" involves repeated testing aimed at early recognition of disease exacerbation. We aimed to determine the usefulness of repeated fecal calprotectin (FC) measurements to predict IBD relapses by a systematic literature review. METHODS An electronic search was performed in Medline, Embase, and Cochrane from inception to April 2016. Inclusion criteria were prospective studies that followed patients with IBD in remission at baseline and had at least 2 consecutive FC measurements with a test interval of 2 weeks to 6 months. Methodological assessment was based on the second Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist. RESULTS A total of 1719 articles were identified; 193 were retrieved for full text review. Six studies met eligibility for inclusion. The time interval between FC tests varied between 1 and 3 months. Asymptomatic patients with IBD who had repeated FC measurements above the study's cutoff level had a 53% to 83% probability of developing disease relapse within the next 2 to 3 months. Patients with repeated normal FC values had a 67% to 94% probability to remain in remission in the next 2 to 3 months. The ideal FC cutoff for monitoring could not be identified because of the limited number studies meeting inclusion criteria and heterogeneity between selected studies. CONCLUSIONS Two consecutively elevated FC values are highly associated with disease relapse, indicating a consideration to proactively optimize IBD therapy plans. More prospective data are necessary to assess whether FC monitoring improves health outcomes.
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371
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Klang E, Kopylov U, Eliakim R, Rozendorn N, Yablecovitch D, Lahat A, Ben-Horin S, Amitai MM. Diffusion-weighted imaging in quiescent Crohn's disease: correlation with inflammatory biomarkers and video capsule endoscopy. Clin Radiol 2017; 72:798.e7-798.e13. [PMID: 28506799 DOI: 10.1016/j.crad.2017.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/05/2017] [Accepted: 04/04/2017] [Indexed: 02/08/2023]
Abstract
AIM To investigate the role of restricted diffusion in quiescent Crohn's disease (CD) patients and its association with inflammatory biomarkers and endoscopic disease. MATERIAL AND METHODS Fifty-two quiescent CD patients prospectively underwent magnetic resonance enterography (MRE) and video capsule endoscopy (VCE) and were tested for the inflammatory biomarkers, faecal calprotectin (FCP) and C-reactive protein (CRP). Restricted diffusion in the distal ileum was qualitatively (absence/presence) and quantitatively (apparent diffusion coefficient [ADC]) assessed by two readers. The VCE-based Lewis score was calculated for the distal ileum. Restricted diffusion sensitivity and specificity for VCE ulcerations were assessed for patients with elevated (>100 μg/g) or normal (<100 μg/g) FCP. Receiver operating characteristic (ROC) curve was used to assess the ability of ADC to identify patients with concurrent VCE ulceration and elevated FCP. RESULTS The sensitivity and specificity of restricted diffusion for patients with VCE ulceration were higher in patients with elevated FCP (reader 1: 71.4%, 80%, reader 2: 76.2%, 100%, respectively) compared to patients with normal FCP (reader 1: 46.2%, 61.5%; reader 2: 15.4%, 76.9%, respectively). The ADC had a high diagnostic accuracy for identifying patients that had concurrent VCE ulceration and elevated FCP (reader 1: AUC=0.819, reader 2: AUC=0.832). CONCLUSION In quiescent CD patients, the presence of restricted diffusion is suggestive of an active inflammation, associated with elevated FCP. Thus, DWI may serve as a clinical tool in the follow-up of these patients, implying subclinical inflammatory flares.
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Affiliation(s)
- E Klang
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel; Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - U Kopylov
- Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - R Eliakim
- Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - N Rozendorn
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel; Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel.
| | - D Yablecovitch
- Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - A Lahat
- Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - S Ben-Horin
- Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - M M Amitai
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel; Department of Gastroenterology, The Chaim Sheba Medical Center, Ramat Gan, Israel
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Circulating cathelicidin levels correlate with mucosal disease activity in ulcerative colitis, risk of intestinal stricture in Crohn's disease, and clinical prognosis in inflammatory bowel disease. BMC Gastroenterol 2017; 17:63. [PMID: 28494754 PMCID: PMC5427565 DOI: 10.1186/s12876-017-0619-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/20/2017] [Indexed: 02/08/2023] Open
Abstract
Background Cathelicidin (LL-37) is an antimicrobial peptide known to be associated with various autoimmune diseases. We attempt to determine if cathelicidin can accurately reflect IBD disease activity. We hypothesize that serum cathelicidin correlates with mucosal disease activity, stricture, and clinical prognosis of IBD patients. Methods Serum samples were collected from two separate cohorts of patients at the University of California, Los Angeles. Cohort 1 consisted of 50 control, 23 UC, and 28 CD patients. Cohort 2 consisted of 20 control, 57 UC, and 67 CD patients. LL-37 levels were determined by ELISA. Data from both cohorts were combined for calculation of accuracies in indicating mucosal disease activity, relative risks of stricture, and odds ratios of predicting disease development. Results Serum cathelicidin levels were inversely correlated with Partial Mayo Scores of UC patients and Harvey-Bradshaw Indices of CD patients. Among IBD patients with moderate or severe initial disease activity, the patients with high initial LL-37 levels had significantly better recovery than the patients with low initial LL-37 levels after 6–18 months, suggesting that high LL-37 levels correlate with good prognosis. Co-evaluation of LL-37 and CRP levels was more accurate than CRP alone or LL-37 alone in the correlation with Mayo Endoscopic Score of UC patients. Low LL-37 levels indicated a significantly elevated risk of intestinal stricture in CD patients. Conclusion Co-evaluation of LL-37 and CRP can indicate mucosal disease activity in UC patients. LL-37 can predict future clinical activity in IBD patients and indicate risk of intestinal stricture in CD patients. Electronic supplementary material The online version of this article (doi:10.1186/s12876-017-0619-4) contains supplementary material, which is available to authorized users.
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373
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Smolinska A, Bodelier AGL, Dallinga JW, Masclee AAM, Jonkers DM, van Schooten FJ, Pierik MJ. The potential of volatile organic compounds for the detection of active disease in patients with ulcerative colitis. Aliment Pharmacol Ther 2017; 45:1244-1254. [PMID: 28239876 DOI: 10.1111/apt.14004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 07/26/2016] [Accepted: 02/01/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND To optimise treatment of ulcerative colitis (UC), patients need repeated assessment of mucosal inflammation. Current non-invasive biomarkers and clinical activity indices do not accurately reflect disease activity in all patients and cannot discriminate UC from non-UC colitis. Volatile organic compounds (VOCs) in exhaled air could be predictive of active disease or remission in Crohn's disease. AIM To investigate whether VOCs are able to differentiate between active UC, UC in remission and non-UC colitis. METHODS UC patients participated in a 1-year study. Clinical activity index, blood, faecal and breath samples were collected at each out-patient visit. Patients with clear defined active faecal calprotectin >250 μg/g and inactive disease (Simple Clinical Colitis Activity Index <3, C-reactive protein <5 mg/L and faecal calprotectin <100 μg/g) were included for cross-sectional analysis. Non-UC colitis was confirmed by stool culture or radiological evaluation. Breath samples were analysed by gas chromatography time-of-flight mass spectrometry and kernel-based method to identify discriminating VOCs. RESULTS In total, 72 UC (132 breath samples; 62 active; 70 remission) and 22 non-UC-colitis patients (22 samples) were included. Eleven VOCs predicted active vs. inactive UC in an independent internal validation set with 92% sensitivity and 77% specificity (AUC 0.94). Non-UC colitis patients could be clearly separated from active and inactive UC patients with principal component analysis. CONCLUSIONS Volatile organic compounds can accurately distinguish active disease from remission in UC and profiles in UC are clearly different from profiles in non-UC colitis patients. VOCs have demonstrated potential as new non-invasive biomarker to monitor inflammation in UC.
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Affiliation(s)
- A Smolinska
- Department of Pharmacology and Toxicology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - A G L Bodelier
- Department of Gastroenterology and Hepatology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | - J W Dallinga
- Department of Pharmacology and Toxicology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - A A M Masclee
- Department of Gastroenterology and Hepatology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - D M Jonkers
- Department of Gastroenterology and Hepatology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - F-J van Schooten
- Department of Pharmacology and Toxicology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - M J Pierik
- Department of Gastroenterology and Hepatology, NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
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374
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Torres J, Mehandru S, Colombel JF, Peyrin-Biroulet L. Crohn's disease. Lancet 2017; 389:1741-1755. [PMID: 27914655 DOI: 10.1016/s0140-6736(16)31711-1] [Citation(s) in RCA: 1467] [Impact Index Per Article: 209.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/09/2016] [Accepted: 07/12/2016] [Indexed: 02/06/2023]
Abstract
Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract, with increasing incidence worldwide. Crohn's disease might result from a complex interplay between genetic susceptibility, environmental factors, and altered gut microbiota, leading to dysregulated innate and adaptive immune responses. The typical clinical scenario is a young patient presenting with abdominal pain, chronic diarrhoea, weight loss, and fatigue. Assessment of disease extent and of prognostic factors for complications is paramount to guide therapeutic decisions. Current strategies aim for deep and long-lasting remission, with the goal of preventing complications, such as surgery, and blocking disease progression. Central to these strategies is the introduction of early immunosuppression or combination therapy with biologicals in high-risk patients, combined with a tight and frequent control of inflammation, and adjustment of therapy on the basis of that assessment (treat to target strategy). The therapeutic armamentarium for Crohn's disease is expanding, and therefore the need to develop biomarkers that can predict response to therapies will become increasingly important for personalised medicine decisions in the near future. In this Seminar, we provide a physician-oriented overview of Crohn's disease in adults, ranging from epidemiology and cause to clinical diagnosis, natural history, patient stratification and clinical management, and ending with an overview of emerging therapies and future directions for research.
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Affiliation(s)
- Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Saurabh Mehandru
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University Hospital of Nancy-Brabois, Vandœuvre-lès-Nancy, France
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375
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Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet 2017; 389:1756-1770. [PMID: 27914657 PMCID: PMC6487890 DOI: 10.1016/s0140-6736(16)32126-2] [Citation(s) in RCA: 2041] [Impact Index Per Article: 291.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/15/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis is a chronic inflammatory disease affecting the colon, and its incidence is rising worldwide. The pathogenesis is multifactorial, involving genetic predisposition, epithelial barrier defects, dysregulated immune responses, and environmental factors. Patients with ulcerative colitis have mucosal inflammation starting in the rectum that can extend continuously to proximal segments of the colon. Ulcerative colitis usually presents with bloody diarrhoea and is diagnosed by colonoscopy and histological findings. The aim of management is to induce and then maintain remission, defined as resolution of symptoms and endoscopic healing. Treatments for ulcerative colitis include 5-aminosalicylic acid drugs, steroids, and immunosuppressants. Some patients can require colectomy for medically refractory disease or to treat colonic neoplasia. The therapeutic armamentarium for ulcerative colitis is expanding, and the number of drugs with new targets will rapidly increase in coming years.
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Affiliation(s)
- Ryan Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saurabh Mehandru
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick B Allen
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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376
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Diederen K, Hoekman DR, Leek A, Wolters VM, Hummel TZ, de Meij TG, Koot BGP, Tabbers MM, Benninga MA, Kindermann A. Raised faecal calprotectin is associated with subsequent symptomatic relapse, in children and adolescents with inflammatory bowel disease in clinical remission. Aliment Pharmacol Ther 2017; 45:951-960. [PMID: 28138990 DOI: 10.1111/apt.13950] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/27/2016] [Accepted: 12/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Reliable data on inflammatory biomarkers for predicting relapse of paediatric inflammatory bowel disease (IBD) are lacking. AIM To investigate the predictive value of faecal calprotectin (FC) and CRP for symptomatic relapse in pediatric IBD in clinical remission. METHODS In this cross-sectional cohort study, patients <18 years with Crohn's disease or ulcerative colitis in clinical remission ≥3 months were included. At baseline, clinical and biochemical disease activity were assessed using the abbreviated-Pediatric Crohn's Disease Activity Index or Pediatric Ulcerative Colitis Activity Index, and FC and CRP respectively. Disease course over the subsequent 12 months was retrospectively assessed. RESULTS In total, 114 patients (56% males; median age 14.9 years) were included. Baseline FC was higher in patients that developed symptomatic relapse [median (IQR), relapse 370 μg/g (86-1100) vs. remission 122 μg/g (40-344), P = 0.003]. Baseline FC was predictive of symptomatic relapse within 6 months [HR per 250 μg/g (95% CI): 1.46 (1.21-1.77), P < 0.001], with good predictive accuracy (AUC: 0.82). Optimal FC cut-off was 350 μg/g, with positive and negative predictive value of 41% and 96%. Baseline CRP was higher in patients that developed symptomatic relapse [median (IQR), relapse 1.0 μg/g (0.6-5.0) vs. remission 1.0 μg/g (0.4-2.0), P = 0.033]. Baseline CRP was predictive of symptomatic relapse within 6 months from baseline [HR per 1 mg/L (95% CI): 1.10 (1.02-1.19), P = 0.011], with fair predictive accuracy (AUC: 0.72). Optimal CRP cut-off was 1.0 mg/L, with positive and negative predictive value of 21% and 94%. CONCLUSIONS Faecal calprotectin and CRP are predictive of symptomatic relapse and may be valuable in management of paediatric IBD in clinical remission.
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Affiliation(s)
- K Diederen
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - D R Hoekman
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - A Leek
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - V M Wolters
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Z Hummel
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - T G de Meij
- Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - B G P Koot
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M M Tabbers
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - A Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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377
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Abstract
Over the last thirty years knowledge on fecal biomarkers (FM) has substantially increased. Nowadays these non-invasive inflammation markers are used in the daily management of inflammatory bowel disease (IBD). The interest in investigating FM was motivated by the need of a simple, quick, disposable and less invasive marker of disease activity, which might remove the need for endoscopy when following up with patients. Areas covered: Current literature was reviewed for articles regarding the role of FM in IBD diagnosis, activity, flare prediction, medication and surgical treatment response as well as how FM may differ in adult and paediatric IBD patient populations. Expert commentary: Although FM is relevant in IBD patient follow-up, there isn't enough data regarding FM reference values for different ages, different disease subtypes, disease localization/extension or response to therapy. Serial measurements of FM for each patient may be useful in accessing relapse in most patients. FM presented more consistent results when used as a predictive tool of relapse after ileocecal surgery in Crohn's disease. Ongoing research will clarify FM role in decision-making IBD daily practice.
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Affiliation(s)
- Paula Ministro
- a Gastroenterology Department , Tondela - Viseu Hospital Center , Viseu , Portugal
| | - Diana Martins
- a Gastroenterology Department , Tondela - Viseu Hospital Center , Viseu , Portugal
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378
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Guirgis M, Wendt E, Wang LM, Walsh A, Burger D, Bryant RV, Kent A, Adamson R, Brain O, Travis SPL, Keshav S. Beyond Histological Remission: Intramucosal Calprotectin as a Potential Predictor of Outcomes in Ulcerative Colitis. J Crohns Colitis 2017; 11:460-467. [PMID: 27856523 DOI: 10.1093/ecco-jcc/jjw174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 11/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Histological remission and low faecal calprotectin are positive prognostic factors in ulcerative colitis [UC]. Intramucosal calprotectin [iMC], which can be readily determined by immunohistochemistry, has not so far been evaluated as a predictor of outcome in UC. We aimed to investigate the relationship between iMC and clinical, endoscopic, and histological measures of remission in UC, and the independent prognostic value of iMC. METHODS Ambulant patients with UC were recruited for a study comparing clinical activity indices. Sigmoidoscopy and biopsy were performed at the index visit. Clinical, endoscopic, and histological activity were scored and iMC semi-quantitatively measured using immunohistochemistry for the S100A8/9 heterodimer on colonic biopsies, scored as the mean number of positive cells in five high-power fields [HPF]. At the end of follow-up [6 years], data on steroid use, hospitalisation, and colectomy ['adverse outcomes'] were collected. RESULTS iMC was determined in 83 patients and 20 controls, and correlated with clinical, endoscopic, and histological activity [r = 0.51, 0.65, 0.53, p > 0.001, respectively]. iMC was lowest (median 2.4, interquartile range [IQR]: 5.2-5, p < 0.001) in patients with concordance between clinical, endoscopic, and histological remission. Median iMC > 5/HPF was associated with adverse outcome (hazard ratio [HR] 3.36, confidence interval [CI] 1.58, 7.15, p < 0.001). Only 53%, 33%, and 25% of patients in histological remission with iMC > 5 cells/HPF avoided an adverse outcome after 1, 3, and 6 years, respectively. CONCLUSIONS iMC was lowest in patients with concordant clinical, endoscopic, and histological remission. Median iMC > 5/HPF was associated with adverse outcomes despite histological remission. Therefore iMC is a potentially useful independent marker of activity.
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Affiliation(s)
- Marianne Guirgis
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Emily Wendt
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospital, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Daniel Burger
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Robert V Bryant
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Alex Kent
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Rebecca Adamson
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
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379
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Greuter T, Lang S, Holler E, Hawkey CJ, Rogler G, Biedermann L. Serum REG3alpha and C-Reactive Protein Levels in Crohn's Disease Patients Undergoing Immunoablation and Autologous Hemopoetic Stem Cell Transplantation in the ASTIC Trial. Digestion 2017; 92:83-9. [PMID: 26278889 DOI: 10.1159/000437300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/29/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND REG3α has been recently shown to be a highly accurate biomarker for graft-versus-host-disease (GvHD). Given the unmet need of such biomarkers in Crohn's disease (CD) and the similarities between CD and GvHD, we aimed at investigating the role of serum REG3α as a diagnostic and prognostic biomarker in CD patients undergoing autologous hemopoetic stem cell transplantation (HSCT) in the multicenter Autologous Stem Cell Transplantation International Crohn's Disease (ASTIC) trial and to compare it to C-reactive protein (CRP). METHODS Stored serum samples from the ASTIC trial were analyzed using a commercially available human PAP1 ELISA-kit to measure REG3α levels. CRP was available from prior analysis in the ASTIC trial. These levels were correlated with clinical and endoscopic disease activity as well as overall clinical and endoscopic outcome 1 year after autologous HSCT. RESULTS One hundred thirty two serum samples were available for analysis. The mean concentration of REG3α was 101.8 ng/ml (95% CI 22.6-258.3). No significant elevation of REG3α was found among patients with active disease compared to those in remission (106.3 vs. 91.4). Patients with moderate to severe endoscopic disease activity showed substantially, although not significantly elevated REG3α levels compared to those in remission (95.4 vs. 52.4, p = 0.052). Baseline serum REG3α levels of patients without clinical or endoscopic remission 1 year after HSCT were not elevated compared to those in remission (63.1 vs. 66.9, and 68.4 vs. 59.2, respectively). In contrast, CRP was significantly elevated in patients with active disease compared to patients in remission (14.1 vs. 6.0 mg/dl, p = 0.032). In addition, CRP was elevated, although not significantly, in patients with severe endoscopic disease compared to those in endoscopic remission (18.7 vs. 4.1, p = 0.062). Furthermore, baseline CRP was reduced in patients with clinical and endoscopic remission after HSCT compared to those without remission, although not significantly (8.8 vs. 21.4, n.s. and 8.1 vs. 12.4, n.s.). CONCLUSION Given the divergent findings compared to GvHD, we conclude that serum REG3α is not an accurate diagnostic and predictive biomarker in CD patients undergoing HSCT. In contrast, CRP is a valuable biomarker in order to differentiate active disease from remission. However, CRP does not seem to be of prognostic value for HSCT outcome.
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Affiliation(s)
- Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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380
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Evidence of Bidirectional Associations Between Perceived Stress and Symptom Activity: A Prospective Longitudinal Investigation in Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 23:473-483. [PMID: 28221251 DOI: 10.1097/mib.0000000000001040] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our aim was to explore the relationships among perceived stress, intestinal inflammation, and inflammatory bowel disease (IBD) symptoms over time. METHODS Participants were recruited from a population-based registry of persons with IBD and assessed at months 0, 3, and 6. Key dependent measures were the Manitoba IBD Index (symptom activity), Cohen's Perceived Stress Scale, and fecal calprotectin in stool (intestinal inflammation). RESULTS Complete data were available for 417 participants at months 0; 369 provided follow-up data. Active symptoms were reported by 54% of those with Crohn's disease (CD) and 40% of those with ulcerative colitis (UC) and approximately one-third consistently had fecal calprotectin measures ≥250 μg/g, suggestive of active inflammation. A significant proportion of participants had indications of inflammation but no active symptoms over the 6 months. Correlations of month 0 perceived stress and disease activity measures with values at months 3 and 6 for both CD and UC indicated strong temporal stability. In hierarchical multiple regression analyses, month 0 symptom activity was thus a strong predictor of later symptom activity for CD and UC. Perceived stress predicted change in symptom activity from 0 to 3 months for CD, as did use of prednisone for UC. Comparably, month 0 perceived stress was a strong predictor of later perceived stress for CD and UC, while month 0 symptom activity predicted change in perceived stress from 0 to 3 months for both CD and UC. CONCLUSIONS The analysis revealed prospective bidirectional relationships between perceived stress and IBD symptoms but no relationship between perceived stress and change in intestinal inflammation as assessed by fecal calprotectin.
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381
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Maréchal C, Aimone-Gastin I, Baumann C, Dirrenberger B, Guéant JL, Peyrin-Biroulet L. Compliance with the faecal calprotectin test in patients with inflammatory bowel disease. United European Gastroenterol J 2017; 5:702-707. [PMID: 28815034 DOI: 10.1177/2050640616686517] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We investigated, for the first time, levels of compliance with faecal calprotectin test in inflammatory bowel disease patients. METHODS All consecutive adult inflammatory bowel disease patients having been prescribed an faecal calprotectin test between December 2014-July 2015 were included. At their next visit to the hospital, patients had to return a stool sample for the faecal calprotectin test and answer a simple questionnaire: 'Have you brought a stool sample? If not, why not? If so, did you encounter any difficulties when collecting the sample? Were you aware of faecal calprotectin before being asked to take the test?'. RESULTS One hundred and one patients were included (50 men; 77 patients with Crohn's disease). The range age was 40 years (19-68). Eighty-nine patients were being treated with infliximab, 10 were on vedolizumab, and two were not being treated with a biologic. Thirty-seven patients (35%) had performed the faecal calprotectin test. Eighty-one patients (80%) had not been aware of faecal calprotectin before being asked to take the test. Of the 64 patients who did not take the test, the prime reasons for non-compliance were forgetfulness (n = 49, 76.6%), a lack of perceived benefit for the test (n = 7, 11%), constipation (n = 5, 7.8%), refusal to handle faeces (n = 2, 3.1%), and difficulty collecting the stool sample (n = 1, 1.5%). CONCLUSION Only one-third of the patients performed the faecal calprotectin test. The main reason for non-compliance was forgetfulness. Our present results emphasise the need for better patient education on the importance of complying with faecal calprotectin testing and the future of faecal calprotectin testing at home.
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Affiliation(s)
- Chloé Maréchal
- INSERM U954, Nancy University Hospital, Nancy, France.,Department of Hepatogastroenterology, Nancy University Hospital, Nancy, France
| | | | - Cédric Baumann
- PARC Clinical Research Support Facility, Nancy University Hospital, Nancy, France
| | - Bastien Dirrenberger
- INSERM U954, Nancy University Hospital, Nancy, France.,Department of Hepatogastroenterology, Nancy University Hospital, Nancy, France
| | - Jean-Louis Guéant
- INSERM U954, Nancy University Hospital, Nancy, France.,Department of Biochemistry, Nancy University Hospital, Nancy, France
| | - Laurent Peyrin-Biroulet
- INSERM U954, Nancy University Hospital, Nancy, France.,Department of Hepatogastroenterology, Nancy University Hospital, Nancy, France
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382
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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383
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Muthas D, Reznichenko A, Balendran CA, Böttcher G, Clausen IG, Kärrman Mårdh C, Ottosson T, Uddin M, MacDonald TT, Danese S, Berner Hansen M. Neutrophils in ulcerative colitis: a review of selected biomarkers and their potential therapeutic implications. Scand J Gastroenterol 2017; 52:125-135. [PMID: 27610713 DOI: 10.1080/00365521.2016.1235224] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This review article describes the role of neutrophils in mucosal injury and the resulting crypt abscesses characteristic of ulcerative colitis. We also review selected biomarkers for monitoring neutrophil presence and activity in the mucosa as well as their potential as therapeutic targets. MATERIAL We have collated and selectively reviewed data on the most prominent well-established and emerging neutrophil-related biomarkers and potential therapeutic targets (calprotectin, lactoferrin, CXCR1, CXCR2, MMP-9, NGAL, elafin, HNE, pANCAs, MPO, CD16, CD177, CD64, HNPs, SLPI and PTX3) in ulcerative colitis. RESULTS Systemic and intestinal neutrophil activity increases substantially in active ulcerative colitis, driving tissue damage and extra-intestinal manifestations. Calprotectin is a robust neutrophil and disease biomarker, and a few neutrophil-related targets are being clinically explored as therapeutic targets. CONCLUSION We propose that targeting neutrophils and their inflammatory mediators per se is an opportunity that should be explored to identify new effective medical therapies. The overall clinical goal for neutrophil-targeted therapy will be to modulate, but not completely silence, neutrophil activity, thereby abolishing the destructive inflammation with associated acute and chronic tissue damage without compromising host-defense.
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Affiliation(s)
- Daniel Muthas
- a Department of Respiratory , Inflammation and Autoimmunity, AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Anna Reznichenko
- b Department of Cardiovascular and Metabolic Diseases , AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Clare A Balendran
- c Department of Personalised HealthCare & Biomarkers , AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Gerhard Böttcher
- d Department of Drug Safety and Metabolism , AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Ib Groth Clausen
- a Department of Respiratory , Inflammation and Autoimmunity, AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Carina Kärrman Mårdh
- a Department of Respiratory , Inflammation and Autoimmunity, AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Tomas Ottosson
- a Department of Respiratory , Inflammation and Autoimmunity, AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Mohib Uddin
- c Department of Personalised HealthCare & Biomarkers , AstraZeneca R&D Gothenburg , Mölndal , Sweden
| | - Thomas T MacDonald
- e Blizard Institute, Barts and the London School of Medicine and Dentistry, QMUL , London , UK
| | - Silvio Danese
- f Department of Gastroenterology , IBD Center, Humanitas Research Hospital , Milan , Italy
| | - Mark Berner Hansen
- a Department of Respiratory , Inflammation and Autoimmunity, AstraZeneca R&D Gothenburg , Mölndal , Sweden.,g Digestive Disease Center K, Bispebjerg Hospital, University of Copenhagen , Copenhagen , Denmark
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384
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Jairath V, Levesque BG, Vande Casteele N, Khanna R, Mosli M, Hindryckx P, Travis S, Duijvestein M, Rimola J, Panes J, D'Haens G, Sandborn WJ, Feagan BG. Evolving Concepts in Phases I and II Drug Development for Crohn's Disease. J Crohns Colitis 2017; 11:246-255. [PMID: 27487793 DOI: 10.1093/ecco-jcc/jjw137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/16/2016] [Accepted: 06/29/2016] [Indexed: 02/08/2023]
Abstract
The highest attrition rates during drug development programmes occur at the proof of concept stage. Given the large number of molecules under development for Crohn's disease, a need exists to improve the efficiency of early drug development by fast-tracking promising agents and terminating ineffective ones. Multiple opportunities are available to achieve these goals, including the use of more responsive outcome measures, and the incorporation of sophisticated pharmacokinetic modelling and/or highly specific pharmacodynamic markers into exposure-based dosing regimens and novel trial designs. In this article we review these strategies and propose an integrated paradigm of early drug development in Crohn's disease.
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Affiliation(s)
- Vipul Jairath
- Department of Medicine, University of Western Ontario, London, ON, Canada.,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Barrett G Levesque
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Niels Vande Casteele
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.,KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, ON, Canada.,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Pieter Hindryckx
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,University Hospital of Ghent, Ghent, Belgium
| | - Simon Travis
- Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jordi Rimola
- Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Julian Panes
- Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Geert D'Haens
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - William J Sandborn
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Department of Medicine, University of Western Ontario, London, ON, Canada .,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
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385
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Vetter M, Neurath MF, Atreya R. [Crohn's disease - use of biomarkers in general practice]. MMW Fortschr Med 2017; 159:63-68. [PMID: 28224516 DOI: 10.1007/s15006-017-9279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Marcel Vetter
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | | | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Ulmenweg 18, D-91054, Erlangen, Deutschland.
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386
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Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. Gastroenterology 2017; 152:515-532.e2. [PMID: 27773805 PMCID: PMC5285476 DOI: 10.1053/j.gastro.2016.10.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 02/08/2023]
Abstract
Chronic watery diarrhea poses a diagnostic and therapeutic challenge and is often a disabling condition for patients. Although acute diarrhea is likely to be caused by infection, the causes of chronic diarrhea (>4 weeks in duration) are more elusive. We review the pathophysiology, diagnosis, and treatment of chronic diarrhea. Drawing on recent insights into the molecular mechanisms of intestinal epithelial transport and barrier function, we discuss how diarrhea can result from a decrease in luminal solute absorption, an increase in secretion, or both, as well as derangements in barrier properties. We also describe the various extraepithelial factors that activate diarrheal mechanisms. Finally, clinical evaluation and tests used in the assessment of patients presenting with chronic diarrhea are reviewed, and an algorithm guiding therapeutic decisions and pharmacotherapy is presented.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joseph H. Sellin
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Kim E. Barrett
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA
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387
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Wehkamp J, Götz M, Herrlinger K, Steurer W, Stange EF. Inflammatory Bowel Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:72-82. [PMID: 26900160 DOI: 10.3238/arztebl.2016.0072] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inflammatory bowel diseases are common in Europe, with prevalences as high as 1 in 198 persons (ulcerative colitis) and 1 in 310 persons (Crohn's disease). METHODS This review is based on pertinent articles retrieved by a search in PubMed and in German and European guidelines and Cochrane reviews of controlled trials. RESULTS Typically, the main clinical features of inflammatory bowel diseases are diarrhea, abdominal pain, and, in the case of ulcerative colitis, peranal bleeding. These diseases are due to a complex immunological disturbance with both genetic and environmental causes. A defective mucosal barrier against commensal bowel flora plays a major role in their pathogenesis. The diagnosis is based on laboratory testing, ultrasonography, imaging studies, and, above all, gastrointestinal endoscopy. Most patients with Crohn's disease respond to budesonide or systemic steroids; aminosalicylates are less effective. Refractory exacerbations may be treated with antibodies against tumor necrosis factor (TNF) or, more recently, antibodies against integrin, a protein of the cell membrane. In ulcerative colitis, aminosalicylates are given first; if necessary, steroids or antibodies against TNF-α or integrin are added. Maintenance therapy to prevent further relapses often involves immunosuppression with thiopurines and/or antibodies. Once all conservative treatment options have been exhausted, surgery may be necessary. CONCLUSION The treatment of chronic inflammatory bowel diseases requires individually designed therapeutic strategies and the close interdisciplinary collaboration of internists and surgeons.
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Affiliation(s)
- Jan Wehkamp
- Department of Internal Medicine I - Gastroenterology, Hepatology, Infectiology, University Hospital of Tübingen, Asklepios Klinik Nord - Heidberg, Hamburg, Department of Internal Medicine I (Gastroenterology, Hepatology and Endocrinology), Robert-Bosch-Krankenhaus, Stuttgart
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388
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High Percentage of IBD Patients with Indefinite Fecal Calprotectin Levels: Additional Value of a Combination Score. Dig Dis Sci 2017; 62:465-472. [PMID: 27933473 PMCID: PMC5258807 DOI: 10.1007/s10620-016-4397-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Monitoring mucosal inflammation in inflammatory bowel disease (IBD) is of major importance to prevent complications and improve long-term disease outcome. The correlation of clinical activity indices with endoscopic disease activity is, however, moderate. Fecal calprotectin (FC) is a better predictor of mucosal inflammation, but values between 100 and 250 µg/g are difficult to interpret in clinical practice. We aimed to evaluate the occurrence of indefinite FC levels in a real-life IBD cohort and study the additional value of a combination of biochemical markers and clinical activity indices. METHODS In total, 148 Crohn's disease (CD) and 80 ulcerative colitis (UC) patients visiting the outpatient clinic were enrolled. FC, clinical disease activity scored by the Harvey-Bradshaw index or Simple Clinical Colitis Activity Index, and C-reactive protein (CRP) were assessed. In a subset of patients, endoscopic activity was scored by the simple endoscopic score-Crohn's disease and Mayo endoscopic subscore. Clinical activity index, CRP, and FC were integrated in a combination score and compared with endoscopy. RESULTS Indefinite FC values were present in 24% of CD and 15% of UC. In the cohort of patients with endoscopy scores available, the combination score predicted endoscopic disease activity in CD with a sensitivity of 83% and specificity of 69% [positive predictive value (PPV) 58%, negative predictive value (NPV) 89%]. In UC, this was 88 and 75% (PPV 93%, NPV 60%). CONCLUSIONS A combination of FC with clinical activity indices or CRP may aid in classifying patients with indefinite disease activity according to FC alone.
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389
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Hibi T, Imai Y, Senoo A, Ohta K, Ukyo Y. Efficacy and safety of golimumab 52-week maintenance therapy in Japanese patients with moderate to severely active ulcerative colitis: a phase 3, double-blind, randomized, placebo-controlled study-(PURSUIT-J study). J Gastroenterol 2017; 52:1101-1111. [PMID: 28324167 PMCID: PMC5606947 DOI: 10.1007/s00535-017-1326-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/25/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The global phase 3 studies of golimumab [PURSUIT-SC and PURSUIT-maintenance (M)], an anti-tumor necrosis factor-α (anti-TNFα) antibody, have demonstrated clinical efficacy and safety as induction and maintenance therapies in patients with moderate to severely active ulcerative colitis (UC). This study aimed to evaluate the efficacy and safety of golimumab as maintenance therapy in the Japanese population. METHODS In this phase 3, double-blind (DB), placebo-controlled, parallel group, randomized withdrawal study, 144 Japanese patients with moderately to severely active UC received golimumab doses of 200 mg (at week 0) and 100 mg (at week 2) subcutaneously during the 6-week open-label induction phase. Patients who responded to golimumab induction therapy entered the DB maintenance (M) phase and were randomized (1:1) to receive 100 mg of golimumab subcutaneous injection (SC) or placebo every 4 weeks for 52 weeks. The primary endpoint was clinical response through M-week 54; secondary endpoints included clinical remission and mucosal healing at M-week 30 and 54. RESULTS Among induction responders, more patients on golimumab treatment (56.3%) maintained clinical response through M-week 54 versus the placebo group (19.4%). At both M-week 30 and 54, 50% golimumab-treated patients achieved clinical remission versus the placebo group (6.5%) and a higher proportion of patients on golimumab (59.4%) experienced mucosal healing than the placebo group (16.1%). Incidence of treatment-emergent adverse events was 96.9% in the golimumab group and 71% in the placebo group. Overall, the efficacy and safety results in this study were comparable with those observed in global studies. CONCLUSIONS Golimumab SC treatment maintained clinical efficacy through week 54 among induction responders, and no new safety signals were observed in the patients with moderate to severely active UC. CLINICAL TRIAL REGISTRATION The study is registered at ClinicalTrials.gov NCT01863771.
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Affiliation(s)
- Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato Institute Hospital, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8462 Japan
| | - Yuya Imai
- Janssen Pharmaceutical K.K., Tokyo, Japan
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390
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Level of Fecal Calprotectin Correlates With Severity of Small Bowel Crohn's Disease, Measured by Balloon-assisted Enteroscopy and Computed Tomography Enterography. Clin Gastroenterol Hepatol 2017; 15:56-62. [PMID: 27565523 DOI: 10.1016/j.cgh.2016.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Previous studies have not found a correlation between fecal level of calprotectin and small bowel Crohn's disease (CD). However, these studies evaluated patients mainly by ileocolonoscopy, which views up to only the terminal ileum rather than entire small intestine. We investigated whether level of fecal calprotectin (FC) is a marker of active CD of the small bowel, identified by balloon-assisted enteroscopy and computed tomography enterography (CTE). METHODS We performed a prospective study of 123 patients with CD (35 with ileitis, 72 with ileocolitis, and 16 with colitis) evaluated by balloon-assisted enteroscopy from May 2012 through July 2015 at Toho University Sakura Medical Centre in Japan. Patients with strictures detected by balloon-assisted enteroscopy were evaluated by CTE (n = 17). Fecal samples were collected from each patient, and levels of calprotectin were measured; patient demographic variables and medical history were also collected. We developed a CTE scoring system for disease severity that was based on bowel wall thickness, mural hyperenhancement, and engorged vasa recta. The association between level of FC and simple endoscopic index for CD score or CTE was evaluated by using Spearman rank correlation coefficient. RESULTS Level of FC correlated with the simple endoscopic index for CD score (r = 0.6362, P < .0001), even in patients with only active disease of the small intestine (r = 0.6594, P = .0005). In the 17 patients with strictures that could not be passed with the enteroscope, CTE detected all lesions beyond the strictures as well as areas in the distal side of the strictures. Level of FC correlated with CTE score in these patients (r = 0.4018, P = .0011, n = 63). In receiver operating characteristic analyses, the FC cutoff value for mucosal healing was 215 μg/g; this cutoff value identified patients with healing with 82.8% sensitivity, 71.4% specificity, positive predictive value of 74.3%, negative predictive value of 80.6%, odds ratio of 12.0, and area under the receiver operating characteristic curve value of 0.81. CONCLUSIONS A combination of measurement of level of FC and CTE appears to be effective for monitoring CD activity in patients with small intestinal CD, including patients with strictures that cannot be passed by conventional endoscopy.
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391
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Thorsvik S, Damås JK, Granlund AVB, Flo TH, Bergh K, Østvik AE, Sandvik AK. Fecal neutrophil gelatinase-associated lipocalin as a biomarker for inflammatory bowel disease. J Gastroenterol Hepatol 2017; 32:128-135. [PMID: 27640344 DOI: 10.1111/jgh.13598] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Accurate, noninvasive biomarkers are needed to diagnose and monitor inflammatory bowel disease (IBD). Neutrophil gelatinase-associated lipocalin (NGAL), also known as lipocalin 2, is expressed in inflamed colonic epithelium and neutrophilic granulocytes. This study explores its properties as a biomarker in feces and plasma and, for the first time, compares fecal NGAL systematically with the existing fecal biomarker calprotectin. METHODS Neutrophil gelatinase-associated lipocalin was measured in feces from 73 patients with IBD, 21 patients with infectious enterocolitis, 21 patients with irritable bowel syndrome, and 23 healthy subjects using ELISA. The results were correlated to calprotectin, clinical score, endoscopic score, and high-sensitive C-reactive protein. Plasma from 119 patients with IBD and 28 healthy controls was analyzed for NGAL. RESULTS Fecal NGAL levels (median and interquartile range) were significantly elevated in active ulcerative colitis (UC) 6.05 (3.6-15.1) mg/kg and Crohn's disease (CD) 4.9 (1.5-7.7) mg/kg, compared with patients with inactive UC 1.3 (0.4-2.6) mg/kg, inactive CD 1.5 (0.5-1.7) mg/kg, irritable bowel syndrome 0.4 (0.2-0.6) mg/kg, and healthy controls (HC) 0.3 (0.1-0.4) mg/kg. Patients with infectious enterocolitis had significantly higher fecal-NGAL levels, 2.7 (1.4-5.6) mg/kg than HC. Sensitivity and specificity was 94.7% and 95.7%, respectively, for distinguishing between active IBD and HC. Stability of NGAL in stool was excellent for 7 days in room temperature. Plasma NGAL was significantly elevated in UC and CD compared with HC. CONCLUSIONS Fecal NGAL is a promising biomarker for IBD. As existing biomarkers are expressed mainly in granulocytes, NGAL's epithelial localization may give supplementary diagnostic information.
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Affiliation(s)
- Silje Thorsvik
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology, St. Olav's University Hospital, Trondheim, Norway
| | - Jan Kristian Damås
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Infectious Diseases, St. Olav's University Hospital, Trondheim, Norway
| | - Atle vB Granlund
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Medical Microbiology, St. Olav's University Hospital, Trondheim, Norway
| | - Trude Helen Flo
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kåre Bergh
- The Central Norway Regional Health Authority (RHA), Stjørdal, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ann Elisabet Østvik
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology, St. Olav's University Hospital, Trondheim, Norway.,Department of Medical Microbiology, St. Olav's University Hospital, Trondheim, Norway
| | - Arne Kristian Sandvik
- Centre of Molecular Inflammation Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Gastroenterology, St. Olav's University Hospital, Trondheim, Norway.,Department of Medical Microbiology, St. Olav's University Hospital, Trondheim, Norway
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392
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Jensen MD, Brodersen JB, Kjeldsen J. Capsule endoscopy for the diagnosis and follow up of Crohn's disease: a comprehensive review of current status. Ann Gastroenterol 2016; 30:168-178. [PMID: 28243037 PMCID: PMC5320029 DOI: 10.20524/aog.2016.0119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy (CE) has revolutionized the diagnosis and monitoring of small bowel Crohn’s disease (CD). The procedure is patient friendly and noninvasive, and compared to cross-sectional imaging, CE allows a direct and detailed evaluation of the entire small bowel mucosa with a high sensitivity for the earliest lesions of CD. Today, CE is the leading modality for visualizing the small bowel in suspected CD, and validated activity indices are available for the follow up of patients with established CD. CE of the entire gastrointestinal tract (panenteric CE) was recently introduced as a new diagnostic approach in patients examined for CD, and preliminary results are promising. There are important limitations, involving mainly capsule retention. Furthermore, a diagnostic criterion for CD has never been validated, and lesions detected by CE are not specific for CD. Hence, concern has been raised about a low specificity compared to other diagnostic modalities. Important questions about the optimal bowel preparation, selection of patients for CE and the optimal reading protocol remain to be clarified. The aim of this review is to evaluate the performance of CE for diagnosing CD and assess disease activity in known CD; to compare the diagnostic accuracy of CE to that of cross-sectional imaging; to discuss limitations; and to define the place of CE in the diagnostic algorithm in suspected or known CD.
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Affiliation(s)
- Michael Dam Jensen
- Department of Internal Medicine, Section of Gastroenterology, Lillebaelt Hospital Vejle (Michael Dam Jensen)
| | - Jacob Broder Brodersen
- Department of Internal Medicine, Section of Gastroenterology, Hospital of Southwest Jutland, Esbjerg (Jacob Broder Brodersen)
| | - Jens Kjeldsen
- Department of Medical Gastroenterology, Odense University Hospital, Odense (Jens Kjeldsen), Denmark
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393
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Fecal HMGB1 Reveals Microscopic Inflammation in Adult and Pediatric Patients with Inflammatory Bowel Disease in Clinical and Endoscopic Remission. Inflamm Bowel Dis 2016; 22:2886-2893. [PMID: 27755215 DOI: 10.1097/mib.0000000000000938] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fecal high mobility group box 1 (HMGB1) has been suggested to be a novel noninvasive biomarker of gut inflammation. We aimed to assess the reliability of fecal HMGB1, compared with fecal calprotectin (FC), in detecting intestinal inflammation in pediatric and adult patients with inflammatory bowel disease (IBD) and to evaluate the accuracy of HMGB1 in identifying patients with IBD in clinical and endoscopic remission who still have histologic features of inflammation. METHODS Stool samples from 85 children with IBD (49 Crohn's disease [CD] and 36 ulcerative colitis [UC] and 119 adults [57 Crohn's disease and 62 ulcerative colitis]) were analyzed for the study. Age-matched healthy subjects were used as controls. Fecal HMGB1 and fecal calprotectin were detected through western blot and ELISA, respectively. RESULTS Fecal HMGB1 expression was significantly increased in pediatric and adult patients with Crohn's disease and ulcerative colitis and strongly correlated with the disease severity. Fecal calprotectin and HMGB1 significantly correlated in pediatric (r: 0.60, P < 0.001) and adult (r: 0.72, P < 0.001) IBD patients. Moreover, in patients with clinical and endoscopic remission only fecal HMGB1 showed a strong match with the degree of histological scores of inflammation (CGHAS/IGHAS for Crohn's disease and Geboes Score for ulcerative colitis). CONCLUSIONS Fecal HMGB1 is confirmed to be a reliable biomarker of intestinal inflammation; indeed, it significantly correlates with fecal calprotectin in pediatric and adult IBD patients. Moreover, only fecal HMGB1 identifies histologic inflammation in subjects with IBD in clinical and endoscopic remission.
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394
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Kalla R, Kennedy NA, Ventham NT, Boyapati RK, Adams AT, Nimmo ER, Visconti MR, Drummond H, Ho GT, Pattenden RJ, Wilson DC, Satsangi J. Serum Calprotectin: A Novel Diagnostic and Prognostic Marker in Inflammatory Bowel Diseases. Am J Gastroenterol 2016; 111:1796-1805. [PMID: 27596694 DOI: 10.1038/ajg.2016.342] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 07/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is an unmet need for novel blood-based biomarkers that offer timely and accurate diagnostic and prognostic testing in inflammatory bowel diseases (IBD). We aimed to investigate the diagnostic and prognostic utility of serum calprotectin (SC) in IBD. METHODS A total of 171 patients (n=96 IBD, n=75 non-IBD) were prospectively recruited. A multi-biomarker model was derived using multivariable logistic regression analysis. Cox proportional hazards model was derived to assess the contribution of each variable to disease outcomes. RESULTS SC correlated strongly with current biomarkers, including fecal calprotectin (FC) (n=50, ρ=0.50, P=1.6 × 10-4). SC was the strongest individual predictor of IBD diagnosis (odds ratio (OR): 9.37 (95% confidence interval (CI): 2.82-34.68), P=4.00 × 10-4) compared with other markers (C-reactive protein (CRP): OR 8.52 (95% CI: 2.75-28.63), P=2.80 × 10-4); albumin: OR 6.12 (95% CI: 1.82-22.16), P=0.004). In a subset of 50 patients with paired SC and FC, the area under receiver operating characteristic discriminating IBD from controls was better for FC than for SC (0.99, (95% CI 0.87-1.00) and 0.87 (95% CI:0.78-0.97), respectively; P=0.01). At follow-up (median 342 days; interquartile range: 88-563), SC predicted treatment escalation and/or surgery in IBD (hazard ratio (HR) 2.7, 95% CI: 1.1-4.9), in particular Crohn's disease (CD) (HR 4.2, 95% CI 1.2-15.3). A model incorporating SC and either CRP or albumin has a positive likelihood ratio of 24.14 for IBD. At 1 year, our prognostic model can predict treatment escalation in IBD in 65% of cases (95% CI: 43-79%) and 80% (95% CI: 31-94%) in CD if ≥2 blood marker criteria are met. CONCLUSIONS A diagnostic and prognostic model that combines SC and other blood-based biomarkers accurately predicts the inflammatory burden in IBD and has the potential to predict disease and its outcomes. Our data warrant further detailed exploration and validation in large multicenter cohorts.
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Affiliation(s)
- Rahul Kalla
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Nicholas A Kennedy
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Nicholas T Ventham
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Ray K Boyapati
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
- Centre for Inflammation Research, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Alex T Adams
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Elaine R Nimmo
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Micaela R Visconti
- Metabolic Bone Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Hazel Drummond
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Gwo-Tzer Ho
- Centre for Inflammation Research, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Rebecca J Pattenden
- Department of Clinical Chemistry, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - David C Wilson
- Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Jack Satsangi
- Gastrointestinal Unit, Centre for Molecular Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
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Zhang Y, Wang PX, Zhang HJ. Role of biomarkers in diagnosis and evaluation of disease activity of Crohn's disease. Shijie Huaren Xiaohua Zazhi 2016; 24:4389-4395. [DOI: 10.11569/wcjd.v24.i32.4389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a group of chronic, relapsing inflammatory gastrointestinal diseases with unknown etiology. The goals of treatment are to induce the transition from active stage into inactive stage and to maintain remission. Therefore, it is important to diagnose and assess disease activity in patients with CD. Recently, noninvasive markers for intestinal inflammation have been wildly adopted in clinical practice in order to differentiate CD from other diseases, to grade inflammation, to assess the response to therapy, and to demonstrate recurrent inflammation after medical or surgically-induced remission. Fecal and serum calprotectins are among the best-studied noninvasive biomarkers of inflammation in CD which have attracted clinicians' attention. This paper gives an overview of the clinical implications of biomarkers for diagnosing and monitoring disease activity of CD.
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Li LQ, Zeng J, Wang S, Chen X, Jiang Z. Fecal calprotectin for diagnosis of inflammatory bowel disease: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2016; 24:4272-4278. [DOI: 10.11569/wcjd.v24.i31.4272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the value of the fecal calprotectin in the diagnosis of inflammatory bowel disease (IBD) patients systematically.
METHODS PubMed, EMBASE, CNKI, and Wanfang digital journals database were searched for the studies which evaluated the value of the fecal calprotectin in the diagnosis of IBD patients. Meta-Disc 1.40 was used to calculate the pooled sensitivity, specificity and 95% confidence intervals (95%CI). The summary receiver operating characteristic curve (SROC), the area under the curve (AUC), and Q* were also calculated.
RESULTS A total of 13 studies involving 721 IBD patients and 664 controls were finally included in this meta-analysis. The pooled sensitivity and specificity were 0.86 (95%CI: 0.84-0.88) and 0.76 (95%CI: 0.74-0.79), respectively. The AUC was 0.9169, and the Q* was 0.8498.
CONCLUSION Fecal calprotectin is a good noninvasive marker with high sensitivity and specificity in the diagnosis of IBD patients.
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397
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Fecal calprotectin for the prediction of small-bowel Crohn's disease by capsule endoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2016; 28:1137-44. [PMID: 27415156 DOI: 10.1097/meg.0000000000000692] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Fecal calprotectin is a well-established marker of mucosal inflammation. Although the correlation of elevated calprotectin levels with colonic inflammation has been confirmed repeatedly, it is less established for the small bowel. The aim of the current study was to assess the diagnostic accuracy of calprotectin for the prediction of active small-bowel disease on capsule endoscopy by performing a diagnostic test meta-analysis. MATERIALS AND METHODS A comprehensive search was performed using PubMed/Embase. Studies addressing patients with suspected/established Crohn's disease (CD) evaluated with calprotectin and videocapsule were included. A diagnostic meta-analysis was carried out; pooled diagnostic sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for each cut-off. RESULTS Seven studies (463 patients) were entered into the final analysis. The DOR was significant for all the evaluated FC cut-offs (50 μg/g: sensitivity 0.83, specificity 0.53, DOR-5.64; 100 μg/g: sensitivity 0.68, specificity 0.71, DOR-5.01; 200 μg/g: sensitivity 0.42, specificity 0.94, DOR-13.64). On sensitivity analyses, when only studies addressing suspected Crohn's or retrospective studies were included, the results did not change significantly. For studies including patients with suspected CD only, the overall accuracy for FC cut-off 50 μg/g was further increased (sensitivity 0.89, specificity 0.55, DOR-10.3), with a negative predictive value of 91.8%. SUMMARY AND CONCLUSION Fecal calprotectin has a significant diagnostic accuracy for the detection of small-bowel CD. Our results suggest that in patients with suspected CD with calprotectin <50 μg/g, the likelihood of positive diagnosis is very low.
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398
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Abstract
Therapeutic advances in the management of IBD have led to a paradigm shift in the assessment of IBD disease activity. Beyond clinical remission, objective assessment of inflammation is now critical to guiding subsequent therapy as part of a 'treat to target' strategy. Multiple domains of disease activity assessment in IBD exist, each of which has its merits, although none are perfect. The aim of this Review is to comprehensively evaluate measures of disease activity in both ulcerative colitis and Crohn's disease, including clinical, endoscopic, histological and radiological assessment tools, as well as the use of biomarkers and quality of life evaluation. A subjective appraisal of the best indices for use in clinical practice is provided, based on index validation, responsiveness and experience in clinical trials, international specialist opinion, and practicality and suitability for use in clinical practice. This Review aims to enable the reader to gain confidence in IBD disease activity assessment and to give ready access to the necessary tools.
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399
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Iborra M, Beltrán B, Nos P. Noninvasive Testing for Mucosal Inflammation in Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2016; 26:641-56. [PMID: 27633593 DOI: 10.1016/j.giec.2016.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Biomarkers have gained increasing attention for the diagnosis and follow-up of inflammatory bowel disease (IBD). Endoscopy remains the gold standard for assessing disease activity. Biomarkers are rapid, inexpensive, and noninvasive, and can be used in different stages of the disease with high sensitivity and specificity. Calprotectin and tests for C-reactive protein are used to assess the disease activity, predict relapse, and monitor treatment response. New noninvasive tests are being studied. This review discusses current evidence for these surrogate markers, their potential clinical applications, and limitations in disease management. We highlight recent advances in IBD biomarkers and future uses.
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Affiliation(s)
- Marisa Iborra
- Gastroenterology Department, Department of Digestive Disease, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), La Fe University and Polytechnic Hospital, Av. Fernando Abril Martorell, 106, Valencia 46026, Spain
| | - Belén Beltrán
- Gastroenterology Department, Department of Digestive Disease, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), La Fe University and Polytechnic Hospital, Av. Fernando Abril Martorell, 106, Valencia 46026, Spain
| | - Pilar Nos
- Gastroenterology Department, Department of Digestive Disease, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), La Fe University and Polytechnic Hospital, Av. Fernando Abril Martorell, 106, Valencia 46026, Spain.
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400
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Abstract
Mild Crohn's disease (CD) is classified as those patients who are ambulatory, with <10 % weight loss, are eating and drinking without abdominal mass, tenderness, obstructive symptoms, or fever, and endoscopically they have non-progressive mild findings. Initial evaluation of mild CD should focus on assessment for high-risk features requiring more aggressive therapy. In contrast to moderate-to-severe disease, where therapy is focused on mucosal healing, the management of mild CD is focused on symptom management, while exposing the individual to minimal therapeutic risks. Budesonide is the most commonly used medication for mild CD given its safety profile. Assessment of inflammatory markers, in concert with computed-tomography (CT) or magnetic resonance (MR) enterographies and endoscopic studies, should be considered in clinical remission to ensure that mucosal inflammation is not present. Endoscopic inflammation can precede clinical recurrence. Individuals with mild CD require routine vaccination, monitoring for iron-deficiency anemia and vitamin D deficiency, and colorectal cancer screening when appropriate.
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Affiliation(s)
- Frank I Scott
- Crohn's and Colitis Center, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12605 E 16th Ave., Aurora, CO, 80045, USA.
| | - Gary R Lichtenstein
- Perelman Center for Advanced Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 7-South, Room 753, Philadelphia, PA, 19104, USA
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