1
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Viola A, Fiorino G, Costantino G, Fries W. Epidemiology and clinical course of late onset inflammatory bowel disease. Minerva Gastroenterol (Torino) 2024; 70:52-58. [PMID: 34057332 DOI: 10.23736/s2724-5985.21.02890-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
With the increasing age of the general population in developed countries, the management of several chronic diseases becomes more and more complex due to comorbidities. Some, especially inflammatory bowel diseases, formerly believed to belong to the young adult population, have now been recognized as being present at disease onset also in the ageing population, representing medical challenges different from those in the younger population. In the past few years, knowledge on this special older population has increased, changing initial beliefs concerning epidemiology and course of disease. In the present review, we addressed the most recent evidence concerning their current incidence compared with other age groups, their clinical course, potential risk factors for the development of late-onset IBDs, associated diseases, and cancer risk beyond therapy-related neoplasias.
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Affiliation(s)
- Anna Viola
- Gastroenterology and Clinical Unit for Chronic Bowel Disorders, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy -
| | - Gionata Fiorino
- Department of Gastroenterology, IBD Center, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe Costantino
- Gastroenterology and Clinical Unit for Chronic Bowel Disorders, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Walter Fries
- Gastroenterology and Clinical Unit for Chronic Bowel Disorders, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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2
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D’Auria E, Minutoli M, Colombo A, Sartorio MUA, Zunica F, Zuccotti G, Lougaris V. Allergy and autoimmunity in children: non-mutually exclusive diseases. A narrative review. Front Pediatr 2023; 11:1239365. [PMID: 38027278 PMCID: PMC10652575 DOI: 10.3389/fped.2023.1239365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
In last decades a simultaneous increase in the prevalence of atopic and autoimmune disorders in pediatric population has been observed. Despite the Th1-Th2 paradigm, supporting the polarization of the immune system with Th1 response involved in autoimmune diseases and Th2 response leading to hypersensitivity reactions, recent evidence suggests a possible coexistence of common pathogenic pathways as result of shared immune dysregulation. Similar genes and other mechanisms such as epithelial barrier damage, gut microbiota dysbiosis and reduced number of T regs and IL-10 contribute to the onset of allergy and autoimmunity. IgA deficiency is also hypothesized to be the crosslink between celiac disease and allergy by lowering gut mucous membrane protection from antigens and allergens. The present narrative review aims to give an overview of the co-occurrence of allergic and autoimmune disorders (celiac disease, inflammatory bowel diseases, type 1 diabetes mellitus, thyroid disease, juvenile idiopathic arthritis) in pediatric population, based on the available evidence. We also highlighted the common pathogenic pathways that may underpin both. Our findings confirm that allergic and autoimmune diseases are commonly associated, and clinicians should therefore be aware of the possible coexistence of these conditions in order to ameliorate disease management and patient care. Particular attention should be paid to the association between atopic dermatitis or asthma and celiac disease or type 1 diabetes and vice versa, for therapeutic interventions. Further studies are needed to better clarify mechanisms involved in the pathogenesis and eventually identify new therapeutic strategies.
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Affiliation(s)
- Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Martina Minutoli
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Alessandra Colombo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | | | - Fiammetta Zunica
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental Sciences, ASST – Spedali Civili di Brescia, Paediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia, Brescia, Italy
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3
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Kisiel MA, Sedvall M, Malinovschi A, Franklin KA, Gislason T, Shlunssen V, Johansson A, Modig L, Jogi R, Holm M, Svanes C, Lindholdt L, Carlson M, Janson C. Inflammatory bowel disease and asthma. Results from the RHINE study. Respir Med 2023:107307. [PMID: 37271300 DOI: 10.1016/j.rmed.2023.107307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Asthma and inflammatory bowel disease (IBD) are common inflammatory diseases. The aim of this study was to investigate the associations of IBD with asthma and respiratory symptoms. METHODS This study is based on 13,499 participants from seven northern European countries that filled in a postal questionnaire on asthma, respiratory symptoms, IBD including ulcerative colitis and Crohn's disease and various lifestyle variables. RESULTS There were 195 participants with IBD. The prevalence of asthma (14.5 vs 8.1%, p = 0.001), different respiratory symptoms (range 11.9-36.8% vs range 6.0-18.6%, p < 0.005), non-infectious rhinitis (52.1 vs. 41.6%, p = 0.004) and chronic rhinosinusitis (11.6 vs 6.0%, p = 0.001) were higher in subjects with IBD than in those without IBD. In multivariable regression analysis, the association between IBD and asthma was statistically significant (OR 1.95 (95% CI 1.28-2.96)) after adjusting for confounders such as sex, BMI, smoking history, educational level and physical activity. There was a significant association between asthma and ulcerative colitis (adjusted OR 2.02 (95% CI 1.27-2.19)), and asthma but not Crohn's disease (adjusted OR 1.66 (95% CI 0.69-3.95)). A significant gender interaction was found with a significant association between IBD and asthma in women but not in men ((OR 2.72 (95% CI 1.67-4.46) vs OR 0.87 (95% CI 0.35-2.19), p = 0.038). CONCLUSIONS Patients with IBD, particularly those with ulcerative colitis and female, have a higher prevalence of asthma and respiratory symptoms. Our findings indicate that it is important to consider respiratory symptoms and disorders when examining patients with manifest or suspected IBD.
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Affiliation(s)
- Marta A Kisiel
- Department of Medical Sciences: Environmental and Occupational Medicine, Uppsala University, Uppsala, Sweden.
| | - Martin Sedvall
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Karl A Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Thorarinn Gislason
- The Medical Faculty, University of Iceland, Reykjavik, Iceland; Department of Sleep, Landspitali University Hospital Reykjavik, Reykjavik, Iceland
| | - Vivi Shlunssen
- Dept of Public Health, Danish Ramazzini Centre, Aarhus University and the National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Ane Johansson
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lars Modig
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Rain Jogi
- The Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Mathias Holm
- Section of Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Svanes
- Dept of Global Public Health and Primary Care, Centre for International Health, University of Bergen, Bergen, Norway
| | - Louise Lindholdt
- Dept of Public Health, Danish Ramazzini Centre, Aarhus University and the National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Marie Carlson
- Department of Medical Sciences, Gastroenterology Research Group, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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4
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Nascimento CM, Casaro MC, Perez ER, Ribeiro WR, Mayer MPA, Ishikawa KH, Lino-dos-Santos-Franco A, Pereira JNB, Ferreira CM. Experimental allergic airway inflammation impacts gut homeostasis in mice. Heliyon 2023; 9:e16429. [PMID: 37484240 PMCID: PMC10360590 DOI: 10.1016/j.heliyon.2023.e16429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/30/2023] [Accepted: 05/16/2023] [Indexed: 07/25/2023] Open
Abstract
Background /Aims: Epidemiological data show that there is an important relationship between respiratory and intestinal diseases. To improve our understanding on the interconnectedness between the lung and intestinal mucosa and the overlap between respiratory and intestinal diseases, our aim was to investigate the influence of ovalbumin (OVA)-induced allergic airway inflammation on gut homeostasis. Methods A/J mice were sensitized and challenged with OVA. The animals were euthanized 24 h after the last challenge, lung inflammation was determined by evaluating cells in Bronchoalveolar lavage fluid, serum anti-OVA IgG titers and colon morphology, inflammation and integrity of the intestinal mucosa were investigated. IL-4 and IL-13 levels and myeloperoxidase activity were determined in the colon samples. The expression of genes involved in inflammation and mucin production at the gut mucosa was also evaluated. Results OVA challenge resulted not only in lung inflammation but also in macroscopic alterations in the gut such as colon shortening, increased myeloperoxidase activity and loss of integrity in the colonic mucosal. Neutral mucin intensity was lower in the OVA group, which was followed by down-regulation of transcription of ATOH1 and up-regulation of TJP1 and MUC2. In addition, the OVA group had higher levels of IL-13 and IL-4 in the colon. Ova-specific IgG1 and OVA-specific IgG2a titers were higher in the serum of the OVA group than in controls. Conclusions Our data using the OVA experimental model suggested that challenges in the respiratory system may result not only in allergic airway inflammation but also in the loss of gut homeostasis.
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Affiliation(s)
- Carolina Martins Nascimento
- Institute of Environmental, Chemistry and Pharmaceutical Sciences, Department of Pharmaceutics Sciences, Universidade Federal de São Paulo, Diadema, SP, Brazil
| | - Mateus Campos Casaro
- Institute of Environmental, Chemistry and Pharmaceutical Sciences, Department of Pharmaceutics Sciences, Universidade Federal de São Paulo, Diadema, SP, Brazil
| | - Evelyn Roxana Perez
- Institute of Environmental, Chemistry and Pharmaceutical Sciences, Department of Pharmaceutics Sciences, Universidade Federal de São Paulo, Diadema, SP, Brazil
| | - Willian Rodrigues Ribeiro
- Institute of Environmental, Chemistry and Pharmaceutical Sciences, Department of Pharmaceutics Sciences, Universidade Federal de São Paulo, Diadema, SP, Brazil
| | - Marcia Pinto Alves Mayer
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil
| | - Karin Hitomi Ishikawa
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil
| | | | | | - Caroline Marcantonio Ferreira
- Institute of Environmental, Chemistry and Pharmaceutical Sciences, Department of Pharmaceutics Sciences, Universidade Federal de São Paulo, Diadema, SP, Brazil
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5
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Liljendahl MS, Sevelsted A, Chawes BL, Stokholm J, Bønnelykke K, Andersen ZJ, Bisgaard H. Childhood asthma is associated with development of type 1 diabetes and inflammatory bowel diseases: a Danish nationwide registry study. Sci Rep 2022; 12:21728. [PMID: 36526660 PMCID: PMC9758130 DOI: 10.1038/s41598-022-26067-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Asthma and autoimmune disorders might be affected by opposing immune mechanisms, T helper cells type 2 (Th2) and T helper cells type 1 (Th1) immunity, respectively. Knowledge on comorbidity can increase understanding of the underlying etiologies. We aim to examine the association between childhood asthma and subsequent risk of type 1 diabetes (T1D) and inflammatory bowel diseases (IBD) in Danish children. Children of Danish origin born during 1991-1996 were included and childhood asthma, defined as a minimum of two collected prescriptions of inhalation corticosteroids age 5-7 years, was linked to hospitalisations with either T1D or IBD after age 8. Associations between childhood asthma and incidence of T1D and IBD were analysed using sex- and year stratified Cox regression. A total of 366,200 children were included in the study, 4.9% had asthma, which increased the risk of both T1D and IBD, hazard ratios of 1.32 (1.08-1.61) and 1.27 (1.09-1.48). In this large nationwide Danish study, we found that children with asthma have increased risk of developing immune diseases T1D and IBD. This contradicts the Th1 vs Th2 paradigm and points towards shared disease mechanisms and risk factors.
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Affiliation(s)
- Mie Sylow Liljendahl
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Astrid Sevelsted
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo L. Chawes
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stokholm
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Zorana Jovanovic Andersen
- grid.5254.60000 0001 0674 042XSection of Epidemiology, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hans Bisgaard
- grid.5254.60000 0001 0674 042XCOPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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6
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Zhao M, Shao F, Yu D, Zhang J, Liu Z, Ma J, Xia P, Wang S. Maturation and specialization of group 2 innate lymphoid cells through the lung-gut axis. Nat Commun 2022; 13:7600. [PMID: 36494354 PMCID: PMC9734379 DOI: 10.1038/s41467-022-35347-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
Innate lymphoid cells (ILC) are abundant in mucosal tissues. They serve critical functions in anti-pathogen response and tissue homeostasis. However, the heterogenous composition of ILCs in mucosal sites and their various maturation trajectories are less well known. In this study, we characterize ILC types and functions from both the lung and the small intestine, and identify their tissue-specific markers. We find that ILC2s residing in the lung express CCR2, whereas intestinal ILC2s express CCR4. Through the use of CCR2 and CCR4 reporter mice, we show that ILC2s undergo translocation via the lung-gut axis upon IL-33 treatment. This trajectory of ILC2s is also observed at the postnatal stage. Allergen-induced activation of lung ILC2s affects the homeostasis of gut ILC2s. Together, our findings implicate that ILCs display tissue-specific features in both the lung and gut, and ILC2s mature along the lung-gut axis in particular homeostatic and inflammatory conditions.
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Affiliation(s)
- Min Zhao
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China
| | - Fei Shao
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
| | - Dou Yu
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
| | - Jiaqi Zhang
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
| | - Zhen Liu
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
| | - Jiangwen Ma
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
| | - Pengyan Xia
- grid.11135.370000 0001 2256 9319Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Shuo Wang
- grid.9227.e0000000119573309CAS Key Laboratory of Pathogen Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, 100101 Beijing, China ,grid.410726.60000 0004 1797 8419University of Chinese Academy of Sciences, Beijing, 100049 China
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7
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Brew BK, Osvald EC, Gong T, Hedman AM, Holmberg K, Larsson H, Ludvigsson JF, Mubanga M, Smew AI, Almqvist C. Paediatric asthma and non-allergic comorbidities: A review of current risk and proposed mechanisms. Clin Exp Allergy 2022; 52:1035-1047. [PMID: 35861116 PMCID: PMC9541883 DOI: 10.1111/cea.14207] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
It is increasingly recognized that children with asthma are at a higher risk of other non-allergic concurrent diseases than the non-asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016-2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome-wide association studies, gene expression-functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene-environment interactions, such as epi-genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities.
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Affiliation(s)
- Bronwyn K. Brew
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Clinical MedicineUniversity of New South WalesKensingtonNew South WalesAustralia
| | - Emma Caffrey Osvald
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Tong Gong
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
| | - Anna M. Hedman
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
| | - Kirsten Holmberg
- Child Health and Parenting (CHAP), Department of Public Health and Caring SciencesUppsala UniversityUppsalaSweden
| | - Henrik Larsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- School of Medical SciencesÖrebro UniversityÖrebroSweden
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- Department of PediatricsOrebro University HospitalOrebroSweden
| | - Mwenya Mubanga
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
| | - Awad I. Smew
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
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8
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Alenezy N, Nugent Z, Herman S, Zaborniak K, Ramsey CD, Bernstein CN. Aeroallergen-related Diseases Predate the Diagnosis of Inflammatory Bowel Disease. Inflamm Bowel Dis 2022:6677127. [PMID: 36018043 DOI: 10.1093/ibd/izac184] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Indexed: 12/09/2022]
Abstract
OBJECTIVE This study aimed to determine whether having a diagnosis of asthma or allergic rhinitis (AR) increased the risk of being diagnosed with inflammatory bowel disease (IBD) and whether there was increased incidence of these diseases after a diagnosis of IBD. DESIGN This is a retrospective, historical cohort-based study. We used the administrative data of Manitoba Health and the population-based University of Manitoba IBD Epidemiology Database. We used numbers of prescriptions for drugs used to treat asthma and to treat AR to identify diagnoses of asthma and AR, respectively.We calculated relative risks (RRs) to assess incidence of IBD compared with matched controls after diagnoses of asthma and AR and hazard ratios to determine the incidence of asthma and AR after IBD diagnosis. RESULTS Compared with controls, a diagnosis of asthma or AR preceding a diagnosis of IBD was increased in cases (RR, 1.62; 95% confidence interval [CI], 1.50-1.75; and RR, 2.10; 95% CI, 1.97-2.24) with a similar outcome by subtype of IBD (Crohn's disease vs ulcerative colitis) and by sex. On sensitivity analysis, diagnoses of asthma or AR were comparable when considering at least 5, 10, 15 or 20 drug prescriptions. Persons with IBD were more likely to develop asthma or AR than controls after being diagnosed with IBD (hazard ratio for asthma, 1.31, 95% CI, 1.18-1.45; and hazard ratio for AR, 2.62, 95% CI, 2.45-2.80). CONCLUSIONS The association between asthma, AR, and IBD suggest the possibility that whatever triggers the onset of these atopic diseases may trigger the onset of IBD as well, and aeroallergens are plausible culprits.
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Affiliation(s)
- Namarik Alenezy
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zoann Nugent
- University of Manitoba IBD Clinical and Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Sari Herman
- University of Manitoba IBD Clinical and Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,North York Medical Group, Toronto, Ontario, Canada
| | - Karver Zaborniak
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Clare D Ramsey
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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9
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Freuer D, Linseisen J, Meisinger C. Asthma and the risk of gastrointestinal disorders: a Mendelian randomization study. BMC Med 2022; 20:82. [PMID: 35292014 PMCID: PMC8925069 DOI: 10.1186/s12916-022-02283-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/03/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The question of whether asthma is causally related to gastrointestinal disorders remained unanswered so far. Thus, this study investigated whether there is such a relation and whether the time of onset of asthma plays a role in the occurrence of the following gastrointestinal disorders: peptic ulcer disease (PUD), gastroesophageal reflux disease (GORD), irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD) including the distinction between Crohn's disease (CD) and ulcerative colitis (UC). METHODS Using summary data of genome-wide association studies (GWASs), we ran Mendelian randomization analyses based on up to 456,327 European participants. Outlier assessment, a series of sensitivity analyses and validation of IBD results in a second GWAS were performed to confirm the results. RESULTS Presented ORs represent the average change in the outcome per 2.72-fold increase in the prevalence of the exposure. Genetically predicted childhood-onset asthma was positively associated with PUD, GORD, and IBS with similar odds ratios near 1.003 and adjusted P-values from 0.007 (GORD) to 0.047 (PUD). Furthermore, it was inversely related to IBD (OR = 0.992, 95% CI: 0.986, 0.998, adjusted P = 0.023) and suggestively associated with its UC subtype (OR = 0.990, 95% CI: 0.982, 0.998, adjusted P = 0.059). There were no associations between genetically predicted adult-onset asthma and the mentioned gastrointestinal disorders. CONCLUSIONS This study provides evidence that the presence of asthma onset in childhood increases the risk for GORD, PUD, and IBS but decreases the risk for IBD in adults. The lower risk for IBD may be attributed to a lower risk primarily for UC.
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Affiliation(s)
- Dennis Freuer
- University of Augsburg, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany. .,Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Jakob Linseisen
- University of Augsburg, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany.,Independent Research Group Clinical Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich, Germany
| | - Christa Meisinger
- University of Augsburg, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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10
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Rossi CM, Lenti MV, Merli S, Santacroce G, Di Sabatino A. Allergic manifestations in autoimmune gastrointestinal disorders. Autoimmun Rev 2021; 21:102958. [PMID: 34560305 DOI: 10.1016/j.autrev.2021.102958] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 12/14/2022]
Abstract
Allergic disorders target a young population, are increasing in both incidence and prevalence and are associated with significant disease burden. They result from the complex interplay between (epi)genetic and environmental factors, resulting in a Th2 inflammatory process targeting the epithelium of the respiratory tract (allergic rhinitis and asthma), skin (atopic dermatitis), and gastrointestinal tract (food allergy). Although the exact pathogenic mechanisms remain elusive, an altered immune system response in the gut is increasingly recognized as a relevant step. Allergic and gastrointestinal autoimmune disorders share several epidemiological, pathogenic and risk factors and several treatment modalities. Here we revise the current literature and show that allergic disorders are highly prevalent in gastrointestinal autoimmune diseases, including celiac disease, inflammatory bowel disease, autoimmune pancreatitis, and autoimmune cholangiopathies. No data are available for some autoimmune diseases, such as autoimmune gastritis and autoimmune enteropathy. To ensure the comprehensive care of patients with autoimmune gastrointestinal disorders, along with disease-specific factors, the presence of allergic disorders should be evaluated and treated when present, possibly targeting shared molecular pathways. Future studies are needed to define the exact pathogenic mechanisms underpinning the association between allergic and autoimmune diseases of the gastrointestinal tract.
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Affiliation(s)
- Carlo Maria Rossi
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Stefania Merli
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Giovanni Santacroce
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
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11
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Nowak JK, Dworacka M, Gubaj N, Dossimov A, Dossimov Z, Walkowiak J. Expression profiling of ileal mucosa in asthma reveals upregulation of innate immunity and genes characteristic of Paneth and goblet cells. Allergy Asthma Clin Immunol 2021; 17:82. [PMID: 34332619 PMCID: PMC8325823 DOI: 10.1186/s13223-021-00584-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background The expression profiles of the intestinal mucosa have not been comprehensively investigated in asthma. We aimed to explore this in the Correlated Expression and Disease Association Research (CEDAR) patient cohort. Methods Differential expression analysis of ileal, transverse colon, and rectal biopsies were supplemented by a comparison of transcriptomes from platelets and leukocytes subsets, including CD4+, CD8+, CD14+, CD15+, and CD19+ cells. Asthma patients (n = 15) and controls (n = 15) had similar age (p = 0.967), body mass index (p = 0.870), similar numbers of females (80%) and smoking rates (13.3%). Results Significant differential expression was found in the ileum alone, and not in any other cell/tissue types. More genes were found to be overexpressed (1,150) than under-expressed (380). The most overexpressed genes included Fc Fragment of IgG Binding Protein (FCGBP, logFC = 3.01, pFDR = 0.015), Mucin 2 (MUC2, logFC = 2.78, pFDR = 0.015), and Alpha 1B Defensin (DEFA1B, logFC = 2.73, pFDR = 0.024). Gene ontology implicated the immune system, including interleukins 4 and 13, as well as antimicrobial peptides in this overexpression. There was concordance of gene over- (STAT1, XBP1) and underexpression (NELF, RARA) in asthma and Crohn’s disease ileum when our results were compared to another dataset (p = 3.66 × 10–7). Conclusion Ileal mucosa in asthma exhibits a specific transcriptomic profile, which includes the overexpression of innate immune genes, mostly characteristic of Paneth and goblet cells, in addition to other changes that may resemble Crohn’s disease. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-021-00584-9.
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Affiliation(s)
- Jan K Nowak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, ul. Szpitalna 27/33, 60-572, Poznan, Poland.
| | - Marzena Dworacka
- Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nazgul Gubaj
- Department of Pediatric Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Arystan Dossimov
- Department of Pediatric Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Zhumabek Dossimov
- Department of Pediatric Diseases No. 2, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, ul. Szpitalna 27/33, 60-572, Poznan, Poland
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12
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Rai V, Traboulsi C, Silfen A, Ackerman MT, Erondu AI, Karpin JE, Gulotta G, Rubin DT. Identification of Risk Factors for Coexisting Sinusitis and Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2021; 3. [DOI: 10.1093/crocol/otab054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
Background
This study aimed to analyze the association of coexisting sinusitis and inflammatory bowel disease (IBD), establish significant factors involved in their development, and enable further biological correlation between these 2 diseases.
Methods
The IBD and Sinusitis Study at UChicago Medicine (TISSUe) is a retrospective, single-center study. We reviewed patients to confirm IBD and chronic sinusitis diagnoses. Case-control propensity score matching was performed using matched controls with IBD only or sinusitis only. Statistical methods included chi-squared test and Wilcoxon rank sum test. Logistic regression analysis was performed, and factors were considered significant if P < .05.
Results
Stratifying 214 patients with coexisting IBD and sinusitis, 176 patients had IBD first and 38 patients had sinusitis first. Multivariable analysis of factors associated with subsequent disease with matched controls determined that duration of disease, UC, steroid exposure ever, and younger age of IBD diagnosis were associated with subsequent sinusitis in patients with IBD; steroid exposure ever and duration of sinusitis were significantly associated with subsequent IBD in patients with sinusitis.
Conclusion
This study suggests that IBD maintenance therapies are not associated with increased risk of sinusitis, as proposed by adverse events in clinical trial data; rather, UC diagnosis and duration of disease may be more influential in sinusitis development. While further studies are necessary, this study also demonstrates that sinusitis precedes IBD in some patients, probing its biological association with IBD and possible classification as an extraintestinal manifestation.
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Affiliation(s)
- Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Alexa Silfen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Max T Ackerman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Amarachi I Erondu
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Jordan E Karpin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - George Gulotta
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
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13
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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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14
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Lo CH, Khalili H, Lochhead P, Song M, Lopes EW, Burke KE, Richter JM, Chan AT, Ananthakrishnan AN. Immune-mediated diseases and risk of Crohn's disease or ulcerative colitis: a prospective cohort study. Aliment Pharmacol Ther 2021; 53:598-607. [PMID: 33280139 PMCID: PMC8082435 DOI: 10.1111/apt.16210] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/01/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although immune-mediated diseases (IMDs) including inflammatory bowel diseases (IBDs) are known to cluster, to what extent this is due to common environmental influences is unknown. AIM To examine the incidence of IBD in individuals with another IMD. METHODS We used data from the prospective Nurses' Health Study II cohort (1995-2017) to examine the effect of diagnoses of several common IMDs on subsequent risk of Crohn's disease (CD) or ulcerative colitis (UC) using Cox proportional hazards models, adjusting for detailed diet and lifestyle confounders. RESULTS We documented 132 cases of CD and 186 cases of UC over 2 016 163 person-years of follow-up (median age at IBD diagnosis 50 years). Compared to participants with no history of IMD, the HRs of CD for those with 1 and ≥ 2 IMDs were 2.57 (95% CI 1.77-3.74) and 2.74 (95% CI 1.36 to 5.49), respectively (Ptrend < 0.0001). This association was only modestly attenuated by adjustment for environmental risk factors (HR 2.35 and 2.46, respectively). The risk of UC was not increased, with multivariable-adjusted HRs of 1.22 (95% CI 0.85-1.76) and 1.33 (95% CI 0.67-2.65) for those with 1 and ≥ 2 IMDs, respectively, compared to those with none (Ptrend 0.16) (Pheterogeneity comparing CD and UC 0.037). Asthma, atopic dermatitis, psoriasis and rosacea were individually associated with higher risk of CD (HR ranging from 2.15 to 3.39) but not UC. CONCLUSIONS Individuals with one or more IMDs are at an increased risk for CD but not UC.
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Affiliation(s)
- Chun-Han Lo
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA;,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA;,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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15
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Peng YH, Huang CW, Chou CY, Chiou HJ, Chen HJ, Wu TN, Ho WC. Association between asthma and risk of benign prostatic hyperplasia: a retrospective population-based study. Aging Male 2020; 23:599-606. [PMID: 30632854 DOI: 10.1080/13685538.2018.1552253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The association between asthma and benign prostatic hyperplasia (BPH) has rarely been explored. We investigated whether male asthmatic patients had an increased risk of BPH by conducting this retrospective nationwide population-based study. METHODS We utilized data derived from the National Health Insurance Research Database (NHIRD) in Taiwan. A total of 9778 male patients aged >40 years who were newly diagnosed with asthma between 2000 and 2006 were included in the asthma group. Male enrollees without asthma were selected as the non-asthma group from the same database. Both the groups were followed up until the end of 2013. We performed Cox proportional hazard regression analysis to estimate the risk of BPH and transurethral resection of the prostate (TURP) in the male patients with asthma compared with that in those without asthma. RESULTS The risk of BPH and TURP in the asthma group was 1.40-fold (95% confidence interval [CI] = 1.30-1.42) and 1.30-fold (95% CI= 1.31-1.50) higher than that in the non-asthma group, respectively, after adjusting for comorbidities, relevant medications and number of annual outpatient visits. CONCLUSIONS The male patients with asthma were found to have a higher risk of BPH than did those without asthma.
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Affiliation(s)
- Yi-Hao Peng
- Department of Public Health, China Medical University, Taichung, Taiwan, ROC
- Department of Respiratory Therapy, Asia University Hospital, Asia University, Taichung, Taiwan, ROC
- Department of Respiratory Therapy, China Medical University, Taichung, Taiwan, ROC
| | - Chien-Wen Huang
- Department of Internal Medicine, Division of Chest Medicine, Asia University Hospital, Taichung, Taiwan, ROC
- Department of Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan, ROC
- Institute of Molecular Biology, College of Life Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Che-Yi Chou
- Department of Internal Medicine, Division of Nephrology, Asia University Hospital, Taichung, Taiwan, ROC
- Department of Post-baccalaureate Veterinary Medicine, Asia University, Taichung, Taiwan, ROC
| | - Hung-Jie Chiou
- Department of Surgery, Division of Urology, Asia University Hospital, Taichung, Taiwan, ROC
| | - Hsuan-Ju Chen
- College of Medicine, China Medical University, Taichung, Taiwan, ROC
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Trong-Neng Wu
- Department of Health Care Administration, Asia University, Taichung, Taiwan, ROC
| | - Wen-Chao Ho
- Department of Public Health, China Medical University, Taichung, Taiwan, ROC
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16
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Majowicz SE, Panagiotoglou D, Taylor M, Gohari MR, Kaplan GG, Chaurasia A, Leatherdale ST, Cook RJ, Patrick DM, Ethelberg S, Galanis E. Determining the long-term health burden and risk of sequelae for 14 foodborne infections in British Columbia, Canada: protocol for a retrospective population-based cohort study. BMJ Open 2020; 10:e036560. [PMID: 32868357 PMCID: PMC7462161 DOI: 10.1136/bmjopen-2019-036560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/19/2020] [Accepted: 07/16/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Over one in eight Canadians is affected by a foodborne infection annually; however, the long-term consequences, including the risks and costs of sequelae, are unclear. We aim to estimate the health burden and direct costs of 14 infections commonly transmitted by food, considering the acute illness and subsequent sequelae and mortality, for the population of British Columbia, Canada (~4.7 million). METHODS AND ANALYSIS We will conduct a population-based retrospective cohort study of the British Columbia provincial population, over a 10-year study period (1 January 2005 to 31 December 2014). Exposure is defined as a provincially reported illness caused by Clostridium botulinum, Campylobacter, Cryptosporidium, Cyclospora, Giardia, hepatitis A virus, Listeria, non-typhoidal Salmonella spp, Salmonella Typhi, Salmonella Paratyphi, Shiga toxin-producing Escherichia coli, Shigella, Vibrio parahaemolyticus or Yersinia (excluding pestis). We will link individual-level longitudinal data from eight province-wide administrative health and reportable disease databases that include physician visits, hospitalisations and day surgeries, deaths, stillbirths, prescription medications (except those to treat HIV) and reportable foodborne diseases. Using these linked databases, we will investigate the likelihood of various sequelae and death. Hazard models will be used to estimate the risk of outcomes and their association with the type of foodborne infection. Epidemiological analyses will be conducted to determine the progression of illness and the fraction of sequelae attributable to specific foodborne infections. Economic analyses will assess the consequent direct healthcare costs. ETHICS AND DISSEMINATION This study has been approved by a University of Waterloo Research Ethics Committee (no 30645), the University of British Columbia Behavioral Research Ethics Board (no H16-00021) and McGill University's Institutional Review Board (no A03-M12-19A). Results will be disseminated via presentations to academics, public health practitioners and knowledge users, and publication in peer-reviewed journals. Where such publications are not open access, manuscripts will also be available via the University of Waterloo's Institutional Repository (https://uwspace.uwaterloo.ca).
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Affiliation(s)
- Shannon E Majowicz
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Marsha Taylor
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mahmood R Gohari
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ashok Chaurasia
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Scott T Leatherdale
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - David M Patrick
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Steen Ethelberg
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Eleni Galanis
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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17
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Barbiellini Amidei C, Zingone F, Zanier L, Canova C. Risk of Prevalent Asthma among Children Affected by Inflammatory Bowel Disease: A Population-Based Birth Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124255. [PMID: 32549223 PMCID: PMC7345598 DOI: 10.3390/ijerph17124255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
Literature on the risk of asthma among children with inflammatory bowel disease (IBD) is limited and has reported discording results. To the best of our knowledge, no previous study has evaluated the association between asthma and childhood onset IBD, focusing on pediatric IBD with onset between 10 and 17 years, early-onset IBD (EO-IBD) between 0 and 9 years, and very early-onset IBD (VEO-IBD) between 0 and 5 years, all conditions characterized by different clinical progressions. A nested matched case-control design on a longitudinal cohort of 213,515 newborns was adopted. Conditional binomial regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of asthma among children with IBD compared with controls. We found 162 children with IBD and 1620 controls. Overall, childhood onset IBD was associated with increased risks of being affected by asthma (OR: 1.49 95% CI 1.05–2.12), although a significant risk was only present among males (OR: 1.60 95% CI 1.02–2.51). Children with Crohn’s disease and ulcerative colitis had similarly increased risks, although they failed to attain statistical significance. Risks of asthma based on age at IBD onset were inversely related to age, with the lowest non-significant risks for pediatric IBD and EO-IBD, while children affected by VEO-IBD had the highest risk of asthma (OR: 2.75 95% CI 1.26–6.02). Our study suggests the presence of a higher prevalence of asthma among both male children with IBD and children with VEO-IBD. It could be advisable to pay greater attention to possible respiratory symptoms among these categories at higher risk.
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Affiliation(s)
- Claudio Barbiellini Amidei
- Unit of biostatistics, Epidemiology and Public Health. Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35100 Padua, Italy;
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Section, University Hospital of Padua, 35100 Padua, Italy;
| | - Loris Zanier
- Epidemiological Service, Health Directorate, 33100 Udine, Italy;
| | - Cristina Canova
- Unit of biostatistics, Epidemiology and Public Health. Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35100 Padua, Italy;
- Correspondence:
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18
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Zergham AS, Sekhon AK, Mebasher A, Tserenpil G, Malik BH. Inflammatory Bowel Disease and Obstructive Pulmonary Disease: A Two-way Association? Cureus 2020; 12:e6836. [PMID: 32181078 PMCID: PMC7051109 DOI: 10.7759/cureus.6836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Inflammatory bowel diseases (IBD) is an umbrella term that covers both ulcerative colitis (UC) and Crohn's disease (CD), which are chronic inflammatory conditions of the gastrointestinal system. Airway diseases are one of the most commonly studied manifestations of IBD. It is observed that populations with pre-existing obstructive pulmonary conditions are at higher risk of new-onset IBD. This newly documented evidence of increased incidence of IBD among patients with pulmonary diseases and the higher than the estimated prevalence of pulmonary diseases among IBD sufferers support the hypothesis of a two-way association. This review article focuses on summarizing the current knowledge and available evidence regarding the association between IBD and obstructive pulmonary diseases such as chronic obstructive pulmonary disease (COPD), emphysema, bronchiectasis, and asthma. We utilized PubMed as the primary search source and database and included the free full-text articles available on it, published over the past five years. We reviewed literature from multiple regions of the world, such as the US, UK, China, and Canada and compiled this traditional review article utilizing the information collected from 4,966,459 patients. Specifications such as age and gender were not mentioned in all articles. This review will serve to strengthen the existing research database concerning the relationship between IBD and obstructive pulmonary diseases. It will help to highlight the significance of the two-way association between IBD and obstructive pulmonary disease and the importance of treating these two conditions simultaneously. It will also raise awareness about the importance of timely detection of IBD and associated airway complications, leading to decreased disease burden and the treatment cost.
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Affiliation(s)
- Azka Shahid Zergham
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amanpreet Kaur Sekhon
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amal Mebasher
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Gantuya Tserenpil
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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19
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Sasaki H, Miyata J, Maki Y, Kimizuka Y, Hayashi N, Fujikura Y, Kawana A. Development of Allergic Bronchopulmonary Aspergillosis in a Patient with Crohn's Disease. Intern Med 2019; 58:2835-2838. [PMID: 31243216 PMCID: PMC6815903 DOI: 10.2169/internalmedicine.2785-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an eosinophilic inflammatory condition characterized by exaggerated immune responses to the fungal genus Aspergillus. Pulmonary manifestations in patients with Crohn's disease (CD) are frequent comorbidities. A 66-year-old man with CD treated with an anti-tumor necrosis factor-α antibody presented with dyspnea. Laboratory findings of elevated blood eosinophils and total serum IgE and positive aspergillus-specific antibodies as well as imaging findings of central bronchiectasis and mucoid impaction indicated a diagnosis of ABPA. To our knowledge, this is the first report of ABPA arising in a patient with CD. We discuss the pathophysiological mechanism of this rare complication.
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Affiliation(s)
- Hisashi Sasaki
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Jun Miyata
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Yohei Maki
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Yoshifumi Kimizuka
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Nobuyoshi Hayashi
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Yuji Fujikura
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
| | - Akihiko Kawana
- Division of Infectious Diseases and Respiratory Medicine, Department of Internal Medicine, National Defense Medical College, Japan
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Pérez-Pérez M, Pérez-Rodríguez G, Fdez-Riverola F, Lourenço A. Using Twitter to Understand the Human Bowel Disease Community: Exploratory Analysis of Key Topics. J Med Internet Res 2019; 21:e12610. [PMID: 31411142 PMCID: PMC6711036 DOI: 10.2196/12610] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/23/2019] [Accepted: 04/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Nowadays, the use of social media is part of daily life, with more and more people, including governments and health organizations, using at least one platform regularly. Social media enables users to interact among large groups of people that share the same interests and suffer the same afflictions. Notably, these channels promote the ability to find and share information about health and medical conditions. OBJECTIVE This study aimed to characterize the bowel disease (BD) community on Twitter, in particular how patients understand, discuss, feel, and react to the condition. The main questions were as follows: Which are the main communities and most influential users?; Where are the main content providers from?; What are the key biomedical and scientific topics under discussion? How are topics interrelated in patient communications?; How do external events influence user activity?; What kind of external sources of information are being promoted? METHODS To answer these questions, a dataset of tweets containing terms related to BD conditions was collected from February to August 2018, accounting for a total of 24,634 tweets from 13,295 different users. Tweet preprocessing entailed the extraction of textual contents, hyperlinks, hashtags, time, location, and user information. Missing and incomplete information about the user profiles was completed using different analysis techniques. Semantic tweet topic analysis was supported by a lexicon-based entity recognizer. Furthermore, sentiment analysis enabled a closer look into the opinions expressed in the tweets, namely, gaining a deeper understanding of patients' feelings and experiences. RESULTS Health organizations received most of the communication, whereas BD patients and experts in bowel conditions and nutrition were among those tweeting the most. In general, the BD community was mainly discussing symptoms, BD-related diseases, and diet-based treatments. Diarrhea and constipation were the most commonly mentioned symptoms, and cancer, anxiety disorder, depression, and chronic inflammations were frequently part of BD-related tweets. Most patient tweets discussed the bad side of BD conditions and other related conditions, namely, depression, diarrhea, and fibromyalgia. In turn, gluten-free diets and probiotic supplements were often mentioned in patient tweets expressing positive emotions. However, for the most part, tweets containing mentions to foods and diets showed a similar distribution of negative and positive sentiments because the effects of certain food components (eg, fiber, iron, and magnesium) were perceived differently, depending on the state of the disease and other personal conditions of the patients. The benefits of medical cannabis for the treatment of different chronic diseases were also highlighted. CONCLUSIONS This study evidences that Twitter is becoming an influential space for conversation about bowel conditions, namely, patient opinions about associated symptoms and treatments. So, further qualitative and quantitative content analyses hold the potential to support decision making among health-related stakeholders, including the planning of awareness campaigns.
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Affiliation(s)
- Martín Pérez-Pérez
- Department of Computer Science, University of Vigo, Escuela Superior de Ingeniería Informática, Ourense, Spain.,Biomedical Research Centre, Campus Universitario Lagoas-Marcosende, Vigo, Spain.,Next Generation Computer Systems Group, School of Computer Engineering, Galicia Sur Health Research Institute, Galician Health Service - University of Vigo, Vigo, Spain
| | - Gael Pérez-Rodríguez
- Department of Computer Science, University of Vigo, Escuela Superior de Ingeniería Informática, Ourense, Spain.,Biomedical Research Centre, Campus Universitario Lagoas-Marcosende, Vigo, Spain.,Next Generation Computer Systems Group, School of Computer Engineering, Galicia Sur Health Research Institute, Galician Health Service - University of Vigo, Vigo, Spain
| | - Florentino Fdez-Riverola
- Department of Computer Science, University of Vigo, Escuela Superior de Ingeniería Informática, Ourense, Spain.,Biomedical Research Centre, Campus Universitario Lagoas-Marcosende, Vigo, Spain.,Next Generation Computer Systems Group, School of Computer Engineering, Galicia Sur Health Research Institute, Galician Health Service - University of Vigo, Vigo, Spain
| | - Anália Lourenço
- Department of Computer Science, University of Vigo, Escuela Superior de Ingeniería Informática, Ourense, Spain.,Biomedical Research Centre, Campus Universitario Lagoas-Marcosende, Vigo, Spain.,Next Generation Computer Systems Group, School of Computer Engineering, Galicia Sur Health Research Institute, Galician Health Service - University of Vigo, Vigo, Spain.,Centre of Biological Engineering, Campus de Gualtar, University of Minho, Braga, Portugal
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Abstract
PURPOSE OF REVIEW Immune dysregulation disorders are among the most rapidly growing set of inborn errors of immunity. One particular subset is the category where early-onset inflammatory bowel disease (IBD) is the most common manifestation. These disorders are being increasingly appreciated although there has been minimal effort to articulate a unified approach to their diagnosis and management. This review will cover current thinking and strategies related to diagnosis and management of very early-onset IBD. RECENT FINDINGS There is an expanding set of monogenic causes of early-onset IBD. In many cases, the precise genetic cause dictates management. Lessons learned from the management of these monogenic conditions can sometimes be extrapolated to other refractory cases of IBD. SUMMARY An integrated approach to diagnosis, risk analysis, and management can include diagnostic approaches not often utilized for traditional IBD such as whole exome sequencing. Management can also include nontraditional approaches such as targeted biologics or hematopoietic cell transplantation.
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Willis-Owen SAG, Cookson WOC, Moffatt MF. The Genetics and Genomics of Asthma. Annu Rev Genomics Hum Genet 2019; 19:223-246. [PMID: 30169121 DOI: 10.1146/annurev-genom-083117-021651] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Asthma is a common, clinically heterogeneous disease with strong evidence of heritability. Progress in defining the genetic underpinnings of asthma, however, has been slow and hampered by issues of inconsistency. Recent advances in the tools available for analysis-assaying transcription, sequence variation, and epigenetic marks on a genome-wide scale-have substantially altered this landscape. Applications of such approaches are consistent with heterogeneity at the level of causation and specify patterns of commonality with a wide range of alternative disease traits. Looking beyond the individual as the unit of study, advances in technology have also fostered comprehensive analysis of the human microbiome and its varied roles in health and disease. In this article, we consider the implications of these technological advances for our current understanding of the genetics and genomics of asthma.
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Affiliation(s)
- Saffron A G Willis-Owen
- National Heart and Lung Institute, Imperial College London, London SW7 2AZ, United Kingdom; , ,
| | - William O C Cookson
- National Heart and Lung Institute, Imperial College London, London SW7 2AZ, United Kingdom; , ,
| | - Miriam F Moffatt
- National Heart and Lung Institute, Imperial College London, London SW7 2AZ, United Kingdom; , ,
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Prevalence of allergic diseases in children with inflammatory bowel disease. Postepy Dermatol Alergol 2019; 36:282-290. [PMID: 31333345 PMCID: PMC6640021 DOI: 10.5114/ada.2018.81189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/17/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction There are many similarities between inflammatory bowel disease (IBD) and allergic diseases, including similar epidemiological data, pathomechanism, clinical course and even treatment methods. So far, many studies of IBD comorbidity with other diseases, including allergy, but mainly in adults, have been conducted. Aim To analyse the prevalence of allergic diseases, i.e. food allergy (FA), cow’s milk allergy (CMA), atopic dermatitis (AD), allergic rhinitis (AR) and asthma in children with IBD. Material and methods The study included 105 IBD patients from the Department of Paediatrics, Allergology and Gastroenterology of Collegium Medicum in Bydgoszcz and 100 children without IBD from the Outpatient Clinics. The authors applied the validated questionnaire as a study method. Results At least one allergic disease was found in 26 (43%) IBD children. The allergological diagnosis was made in IBD children more frequently than in the control group (p = 0.04). The difference was more noticeable with regards to skin prick tests (p = 0.02). FA was the most common disease; it was noted in 19 (32%) IBD children; followed by: AD – in 13 (22%), CMA – in 12 (20%), AR – in 10 (17%) and asthma – in 6 (10%) children. The prevalence of allergic diseases in the control and study groups was comparable (p > 0.05). There was no correlation between age of IBD children and allergy (p > 0.05). Asthma was significantly more common in children undergoing biological treatment (p = 0.01). Conclusions Children with IBD should be constantly monitored by medical professionals, not only due to the underlying disease but also due to a possible concomitant allergic disease.
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Walker MM, Talley NJ, Keely S. Follow up on atopy and the gastrointestinal tract - a review of a common association 2018. Expert Rev Gastroenterol Hepatol 2019; 13:437-445. [PMID: 30900475 DOI: 10.1080/17474124.2019.1596025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Primary atopic disorders can be classified as heritable genetic disorders presenting with deregulated pathogenic allergic effector responses irrespective of sensitization. In the last decade, there are parallel rises in the burden of atopic and gastrointestinal (GI) diseases. Areas covered: There is increasing recognition of an association between atopy and GI disease through immune dysregulation, the microbiome and shared genetic pathways. Since the first article on atopy and the GI tract in 2014 in this journal, many more studies have shed light on the shared pathways in these diseases, particularly in the field of eosinophilic GI disease, functional GI disorders, and inflammatory bowel disease. Expert opinion: Understanding the links with common mechanisms in atopy and GI diseases that may lead to better targeting of treatment through manipulation of immune mechanisms, the microbiome, genetics, food allergens and specific GI diseases such as inflammatory bowel disease, functional GI disorders.
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Affiliation(s)
- Marjorie M Walker
- a Faculty of Medicine & Health University of Newcastle , School of Medicine & Public Health , Callaghan , NSW , Australia.,b School of Biomedical Sciences & Pharmacy, Faculty of Health & Medicine , University of Newcastle , Newcastle , NSW , Australia.,c Priority Research Centre for Digestive Health and Neurogastroenterology , University of Newcastle , Newcastle , NSW , Australia
| | - Nicholas J Talley
- c Priority Research Centre for Digestive Health and Neurogastroenterology , University of Newcastle , Newcastle , NSW , Australia.,d Priority Research Centre for Digestive Health & Neurogastroenterology , Hunter Medical Research Institute, New Lambton Heights , Newcastle , NSW , Australia
| | - Simon Keely
- b School of Biomedical Sciences & Pharmacy, Faculty of Health & Medicine , University of Newcastle , Newcastle , NSW , Australia.,c Priority Research Centre for Digestive Health and Neurogastroenterology , University of Newcastle , Newcastle , NSW , Australia.,d Priority Research Centre for Digestive Health & Neurogastroenterology , Hunter Medical Research Institute, New Lambton Heights , Newcastle , NSW , Australia
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McCormick N, Hamilton CB, Koehn CL, English K, Stordy A, Li LC. Canadians' views on the use of routinely collected data in health research: a patient-oriented cross-sectional survey. CMAJ Open 2019; 7:E203-E209. [PMID: 30948649 PMCID: PMC6450795 DOI: 10.9778/cmajo.20180105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Little is known about Canadians' knowledge of and level of support for using administrative and other large, routinely collected data for health research, despite the benefits of this type of research to patients, health care systems and society. We sought to benchmark the views of Canadian adults on this topic. METHODS Researchers and patient leaders of 3 joint and skin disease organizations codeveloped a cross-sectional online survey that was conducted between January and August 2017. The patient partners were engaged as full partners. Recruitment was mainly through the organizations' websites, email and social media. The survey captured respondents' initial perceptions, then (after background information on the topic was provided) elicited their views on the benefits of health research using routinely collected data, data access/privacy concerns, ongoing perceptions and educational needs. RESULTS Of the 230 people who consented, 183 (79.6%) started the survey, and 151 (65.6%) completed the survey. Of the 151, 117 (77.5%) were women, 84 (55.6%) were British Columbians, 87 (57.6%) were university graduates, and 101 (66.9%) had a chronic disease. At the beginning of the survey, 119 respondents (78.8%) felt positively about the use of routinely collected data for health research. Respondents identified the ability to study long-term treatment effects and rare events (114 [75.5%]) and large numbers of people (110 [72.8%]) as key benefits. Deidentification of personal information was the top privacy measure (135 [89.4%]), and 101 respondents (66.9%) wanted to learn more about data stewards' granting access to data. On survey completion, more respondents (141 [93.4%]) felt positively about the use of routinely collected data, but only 87 (57.6%) were confident about data security and privacy. INTERPRETATION Respondents generally supported the use of deidentified routinely collected data for health research. Although further investigation is needed with more representative samples, our findings suggest that additional education, especially about access and privacy controls, may enhance public support for research endeavours using these data.
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Affiliation(s)
- Natalie McCormick
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Clayon B Hamilton
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Cheryl L Koehn
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Kelly English
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Allan Stordy
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Linda C Li
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta.
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26
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Coward S, Clement F, Benchimol EI, Bernstein CN, Avina-Zubieta JA, Bitton A, Carroll MW, Hazlewood G, Jacobson K, Jelinski S, Deardon R, Jones JL, Kuenzig ME, Leddin D, McBrien KA, Murthy SK, Nguyen GC, Otley AR, Panaccione R, Rezaie A, Rosenfeld G, Peña-Sánchez JN, Singh H, Targownik LE, Kaplan GG. Past and Future Burden of Inflammatory Bowel Diseases Based on Modeling of Population-Based Data. Gastroenterology 2019; 156:1345-1353.e4. [PMID: 30639677 DOI: 10.1053/j.gastro.2019.01.002] [Citation(s) in RCA: 258] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 12/03/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Inflammatory bowel diseases (IBDs) exist worldwide, with high prevalence in North America. IBD is complex and costly, and its increasing prevalence places a greater stress on health care systems. We aimed to determine the past current, and future prevalences of IBD in Canada. METHODS We performed a retrospective cohort study using population-based health administrative data from Alberta (2002-2015), British Columbia (1997-2014), Manitoba (1990-2013), Nova Scotia (1996-2009), Ontario (1999-2014), Quebec (2001-2008), and Saskatchewan (1998-2016). Autoregressive integrated moving average regression was applied, and prevalence, with 95% prediction intervals (PIs), was forecasted to 2030. Average annual percentage change, with 95% confidence intervals, was assessed with log binomial regression. RESULTS In 2018, the prevalence of IBD in Canada was estimated at 725 per 100,000 (95% PI 716-735) and annual average percent change was estimated at 2.86% (95% confidence interval 2.80%-2.92%). The prevalence in 2030 was forecasted to be 981 per 100,000 (95% PI 963-999): 159 per 100,000 (95% PI 133-185) in children, 1118 per 100,000 (95% PI 1069-1168) in adults, and 1370 per 100,000 (95% PI 1312-1429) in the elderly. In 2018, 267,983 Canadians (95% PI 264,579-271,387) were estimated to be living with IBD, which was forecasted to increase to 402,853 (95% PI 395,466-410,240) by 2030. CONCLUSION Forecasting prevalence will allow health policy makers to develop policy that is necessary to address the challenges faced by health systems in providing high-quality and cost-effective care.
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Affiliation(s)
- Stephanie Coward
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Calgary, Calgary, Alberta, Canada
| | | | - Eric I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; Children's Hospital of Eastern Ontario IBD Centre and CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; University of Ottawa, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Manitoba, Winnipeg, Manitoba, Canada
| | - J Antonio Avina-Zubieta
- Arthritis Research Canada, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alain Bitton
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; McGill University, Montreal, Quebec, Canada
| | - Mathew W Carroll
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Alberta, Edmonton, Alberta, Canada
| | | | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; British Columbia Children's Hospital, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan Jelinski
- University of Alberta, Edmonton, Alberta, Canada; Alberta Health Services, Edmonton, Alberta, Canada
| | - Rob Deardon
- University of Calgary, Calgary, Alberta, Canada
| | - Jennifer L Jones
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; Dalhousie University, Halifax, Nova Scotia, Canada
| | - M Ellen Kuenzig
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; Children's Hospital of Eastern Ontario IBD Centre and CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; University of Ottawa, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Desmond Leddin
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Limerick, Limerick, Ireland
| | | | - Sanjay K Murthy
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Ottawa, Ottawa, Ontario, Canada; ICES, Toronto, Ontario, Canada; The Ottawa Hospital Research Institute and IBD Centre, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; ICES, Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Anthony R Otley
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Ali Rezaie
- Cedar Sinai Medical Center, Los Angeles, California
| | - Greg Rosenfeld
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; Arthritis Research Canada, University of British Columbia, Vancouver, British Columbia, Canada
| | - Juan Nicolás Peña-Sánchez
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Harminder Singh
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; University of Calgary, Calgary, Alberta, Canada.
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Bernstein CN, Benchimol EI, Bitton A, Murthy SK, Nguyen GC, Lee K, Cooke-Lauder J, Kaplan GG. The Impact of Inflammatory Bowel Disease in Canada 2018: Extra-intestinal Diseases in IBD. J Can Assoc Gastroenterol 2018; 2:S73-S80. [PMID: 31294387 PMCID: PMC6512250 DOI: 10.1093/jcag/gwy053] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/07/2018] [Indexed: 12/21/2022] Open
Abstract
The burden of extra-intestinal disease is high in patients with IBD, some of whom respond to or are prevented by treating the bowel inflammation, whereas others require specific treatment because they are independent of the underlying bowel inflammation. Among the most common extra-intestinal manifestations are other chronic immune-mediated diseases such as erythema nodosum, ankylosing spondylitis and primary sclerosing cholangitis. Patients with IBD are at higher risk of complications in other organ systems such as osteoporosis, venous thromboembolism and cardiovascular disease. In addition, patients with IBD have a higher risk of cancer, including colon cancer. Mental health comorbidity is important and common in IBD though not always recognized and managed. Consequently, patients and care providers need to be vigilant in the surveillance of extra-intestinal manifestations and complications of IBD. Highlights The burden of extra-intestinal disease is high in patients with IBD. Immune-mediated inflammatory diseases (IMIDs) commonly coexist with patients with IBD and the activity of IMIDs can be either dependent or independent of bowel inflammation. Patients with IBD can be diagnosed with coexisting diseases that affect every organ, including bones, blood, heart, liver, and others. Patients with IBD are at increased risk of cancer, including colon cancer, caused by their bowel inflammation, cholangiocarcinoma due to primary sclerosing cholangitis, and rarely lymphoma related to immunosuppressive medications. The best way to prevent or reduce the burden of many of the extra-intestinal disease is to treat the inflammation of IBD, however some extra-intestinal inflammatory diseases run courses that are independent of the intestinal disease activity.
Key Summary Points Patients with IBD are often burdened with extra-intestinal manifestations, some of which respond to or are prevented by treating the bowel inflammation whereas others require specific treatment because they are independent of the underlying bowel inflammation. Other immune-mediated inflammatory diseases (IMIDs) can coexist with IBD. Some IMIDs run an independent course from the bowel inflammation of IBD, such as ankylosing spondylitis, iritis, and primary sclerosing cholangitis. Immune-mediated inflammatory diseases that often have courses that match the bowel inflammation of IBD include erythema nodosum and peripheral arthritis. Immune-mediated inflammatory diseases such as multiple sclerosis and psoriasis have been associated with IBD. However, these conditions may also emerge as complications of therapy for IBD. Patients with IBD are at risk for venous thromboembolic disease, which occurs at a rate of one per 200 person-years. Venous thromboembolic disease can be reduced by treating patients admitted to hospital with an IBD diagnosis with venous thromboembolism prophylaxis. Arterial vascular disease is also increased in IBD patients, including both coronary artery disease and cerebrovascular disease. Osteoporosis is more prevalent in IBD patients and translates to a 40% increased risk of fracture. While corticosteroids increase the risk of osteoporosis, patients with IBD can also develop metabolic bone disease independent of corticosteroid use. Persons with IBD are more likely to be infected with Clostridium difficile than community controls and often without prior antibiotic exposure. Mental health comorbidity is important in IBD. Depression may antedate a diagnosis of IBD by several years and increase post-diagnosis. High stress can exacerbate symptoms in IBD but does not necessarily increase bowel inflammation. Fatigue is a common symptom in IBD and is not always explained by depression, active inflammatory disease or other apparent factors. The risk of colorectal cancer is increased twofold in Crohn’s colitis and in ulcerative colitis and 10-fold in persons with primary sclerosing cholangitis with colitis. Primary sclerosing cholangitis runs a course independent of IBD and can progress to cirrhosis, liver transplantation or death. Patients with IBD and primary sclerosing cholangitis are at higher risk of cholangiocarcinoma, which is often fatal. The risk of lymphoma may be increased in older males with Crohn’s disease and in patients using thiopurines or anti-TNF therapy. The risk for intensive care unit admission is nearly twofold higher for patients with IBD and higher in Crohn’s disease than in ulcerative colitis. Risk factors for intensive care unit admission from the year before admission included cumulative corticosteroid use and IBD-related surgery.
Gaps in Knowledge and Future Directions Patients with IBD are often burdened with extra-intestinal disease. Future research should determine the collective frequency and added costs of living with extra-intestinal disease. Immune-mediated inflammatory diseases are commonly codiagnosed with IBD. Future research should focus on the pathogenesis connecting coexisting IMIDs with IBD. Care pathways that support the investigation and mitigation of extra-intestinal disease are needed. For example, when and how ambulatory patients with IBD should receive prophylaxis against venous thromboembolic disease is unknown. With an aging IBD population, the burden of extra-intestinal disease should be studied in the context of comorbidities of advancing age. Increasing mental health screening and access to mental health care should be a goal of IBD management.
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Affiliation(s)
- Charles N Bernstein
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric I Benchimol
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario IBD Centre, Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Alain Bitton
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,McGill University Health Centre (MUHC) IBD Centre, McGill University, Montreal, Quebec, Canada
| | - Sanjay K Murthy
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Mount Sinai Hospital Centre for IBD, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, ON Ontario Canada
| | | | - Gilaad G Kaplan
- Canadian Gastro-Intestinal Epidemiology Consortium, Ottawa, Ontario, Canada.,Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Co-occurrence of Asthma and the Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis. Clin Transl Gastroenterol 2018; 9:188. [PMID: 30250122 PMCID: PMC6155154 DOI: 10.1038/s41424-018-0054-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 08/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Inflammatory bowel diseases (IBD) and asthma share genetic and environmental risk factors. Consequently, several observational studies have explored an association between IBD and asthma. We systematically reviewed and summarized the literature on the co-occurrence of asthma and IBD. Methods MEDLINE and EMBASE (to April 2017) were searched to identify observational studies on the association between asthma and IBD. Relative risks (RR) were pooled using random effects models. Heterogeneity was assessed using the I2 and Cochran Q statistics. Meta-regression based on study design, source of patients (population-based vs. tertiary-care center) and study location was conducted to explain between-study heterogeneity. Results Eighteen studies were identified (15 Crohn’s disease, 15 ulcerative colitis (UC)). Asthma was associated with both Crohn’s disease (pooled RR 1.30, 95% confidence interval (CI) 1.16–1.47, I2 = 88%) and UC (RR 1.34, 95% CI 1.24–1.44, I2 = 93%). The study design and source of patients and study location explained between-study heterogeneity in Crohn’s disease, but not UC. Conclusion Asthma is associated with both Crohn’s disease and UC. Additional research is needed to determine if one disease influences the risk of developing the other or if the frequent co-occurrence of these diseases result from shared genetic, environmental, and microbial risk factors.
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Kuenzig ME, Sadatsafavi M, Aviña-Zubieta JA, Burne RM, Abrahamowicz M, Beauchamp ME, Kaplan GG, Benchimol EI. Asthma is not associated with the need for surgery in Crohn's disease when controlling for smoking status: a population-based cohort study. Clin Epidemiol 2018; 10:831-840. [PMID: 30038523 PMCID: PMC6049604 DOI: 10.2147/clep.s156772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose Growing evidence suggests asthma and Crohn’s disease commonly cooccur. However, the impact of asthma on the prognosis of Crohn’s disease is unknown. The aim of our study was to assess the effect of asthma on the need for intestinal resection in patients with Crohn’s disease while adjusting for smoking status, imputed from a smaller, secondary data set. Patients and methods Using health administrative data from a universally funded healthcare plan in Alberta, Canada, we conducted a cohort study to assess the effect of asthma on the need for surgery in patients with Crohn’s disease diagnosed between 2002 and 2008 (N=2,113). Validated algorithms were used to identify incident cases of Crohn’s disease, cooccurring asthma, and intestinal resection. The association between asthma and intestinal resection was estimated using multivariable Cox proportional hazards regression. Smoking status was imputed using a novel method using martingale residuals, derived from a data set of 485 patients enrolled in the Alberta Inflammatory Bowel Disease Consortium (2007 to 2014) who completed environmental questionnaires. All analyses were adjusted for age, sex, rural/urban status, and mean neighborhood income quintile. Results Asthma did not increase the risk of surgery in the health administrative data when not adjusting for smoking status (HR 1.03, 95% CI 0.81 to 1.29). The association remained nonsignificant after imputing smoking status in the health administrative data (HR 1.03, 95% CI 0.81 to 1.29). Conclusion Although asthma is associated with an increased risk of Crohn’s disease, co-occurring asthma is not associated with the risk of surgery in these patients. This null association persisted after adjusting for smoking status. This study described a novel method to adjust for confounding (smoking status) in time-to-event analyses, even when the confounding variable is unmeasured in health administrative data.
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Affiliation(s)
- M Ellen Kuenzig
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,Health Information Technology Program, CHEO Research Institute, Ottawa, ON, Canada, .,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada,
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Rebecca M Burne
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Centre for Health Outcomes Research (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marie-Eve Beauchamp
- Centre for Health Outcomes Research (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,Health Information Technology Program, CHEO Research Institute, Ottawa, ON, Canada, .,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada, .,Department of Pediatrics, University of Ottawa; Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Barnes EL, Kappelman MD. Do Shared Exposures Link the Lungs and Gut? Association Between Asthma and Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2017; 15:1353-1354. [PMID: 28458009 DOI: 10.1016/j.cgh.2017.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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