Survival and causes of death in Italian patients with ulcerative colitis. A GISC nationwide study

MicroRNA expression in inflammatory bowel disease-associated colorectal cancer

MicroRNAs (miRNAs) are non-coding RNA molecules composed of 19–25 nucleotides that regulate gene expression and play a central role in the regulation of several immune-mediated disorders, including inflammatory bowel diseases (IBD). IBD, represented by ulcerative colitis and Crohn’s disease, is characterized by chronic intestinal inflammation associated with an increased risk of colorectal cancer (CRC). CRC is one of the most prevalent tumors in the world, and its main risk factors are obesity, physical inactivity, smoking, alcoholism, advanced age, and some eating habits, in addition to chronic intestinal inflammatory processes and the use of immunosuppressants administered to IBD patients. Recent studies have identified miRNAs associated with an increased risk of developing CRC in this population. The identification of miRNAs involved in this tumorigenic process could be useful to stratify cancer risk development for patients with IBD and to monitor and assess prognosis. Thus, the present review aimed to summarize the role of miRNAs as biomarkers for the diagnosis and prognosis of IBD-associated CRC. In the future, therapies based on miRNA modulation could be used both in clinical practice to achieve remission of the disease and restore the quality of life for patients with IBD, and to identify the patients with IBD at high risk for tumor development.

Mitochondrial transcription factor A plays opposite roles in the initiation and progression of colitis-associated cancer

Background

Mitochondria are key regulators in cell proliferation and apoptosis. Alterations in mitochondrial function are closely associated with inflammation and tumorigenesis. This study aimed to investigate whether mitochondrial transcription factor A (TFAM), a key regulator of mitochondrial DNA transcription and replication, is involved in the initiation and progression of colitis‐associated cancer (CAC).

Methods

TFAM expression was examined in tissue samples of inflammatory bowel diseases (IBD) and CAC by immunohistochemistry. Intestinal epithelial cell (IEC)‐specific TFAM‐knockout mice (TFAM^△IEC) and colorectal cancer (CRC) cells with TFAM knockdown or overexpression were used to evaluate the role of TFAM in colitis and the initiation and progression of CAC. The underlying mechanisms of TFAM were also explored by analyzing mitochondrial respiration function and biogenesis.

Results

The expression of TFAM was downregulated in active IBD and negatively associated with the disease activity. The downregulation of TFAM in IECs was induced by interleukin‐6 in a signal transducer and activator of transcription 3 (STAT3)/miR‐23b‐dependent manner. In addition, TFAM knockout impaired IEC turnover to promote dextran sulfate sodium (DSS)‐induced colitis in mice. Of note, TFAM knockout increased the susceptibility of mice to azoxymethane/DSS‐induced CAC and TFAM overexpression protected mice from intestinal inflammation and colitis‐associated tumorigenesis. By contrast, TFAM expression was upregulated in CAC tissues and contributed to cell growth. Furthermore, it was demonstrated that β‐catenin induced the upregulation of TFAM through c‐Myc in CRC cells. Mechanistically, TFAM promoted the proliferation of both IECs and CRC cells by increasing mitochondrial biogenesis and activity.

Conclusions

TFAM plays a dual role in the initiation and progression of CAC, providing a novel understanding of CAC pathogenesis.

Risk of Colorectal Cancer in Ulcerative Colitis Patients: A Systematic Review and Meta-Analysis

Background

Ulcerative colitis (UC) patients have an increased risk for the development of colorectal cancer (CRC). Our aim was to assess the risk of CRC in UC patients compared with disease extent, disease duration, and geographic variation.

Methods

In this systematic review and meta-analysis, we searched PubMed, scientific meetings, and the bibliographies of identified articles, with English language restrictions for studies published from 1988 to 2018, and assessed the risk of CRC in UC patients. Patients with Crohn's disease, family history of CRC, and colorectal adenomatous polyp (CAP) were excluded from this research. The study was registered with PROSPERO, number CRD42018102213.

Findings

We included 58 studies that included 267566 UC patients. Extensive UC and left-sided UC had a higher risk of CRC than proctitis UC. Geography also played a role in UC-associated CRC development. The time of malignant transformation in Asian UC patients started after 10-20 years of this disease duration. North American UC-associated CRC patients significantly increased in more than 30 years of this disease duration.

Conclusion

In a systematic review of the literature, we found that disease extent, disease duration, and geography were strong, independent risk factors in UC-associated CRC development.

Mortality Risk of Inflammatory Bowel Disease: A Case-Control Study of New York State Death Records

BACKGROUND

Studies examining the mortality risk of inflammatory bowel disease (IBD) have yielded conflicting results, and most do not account for recent advancements made in the treatment of Crohn's disease (CD) and ulcerative colitis (UC). We aim to assess the overall, premature, and cause-specific mortality in IBD patients over a 17-year time period and to evaluate any differences since the introduction of biologic therapy.

METHODS

A death record case-control study was performed to explore the odds of premature death (before age 65) and all-cause mortality among those with IBD. Cases consisted of IBD patients (1,129 with CD and 841 with UC) who died in New York State (NYS) from 1993 to 2010. Controls (n = 7880) were matched 4:1 on the basis of sex and zip code from those who died in NYS in the same time frame, without an IBD diagnosis.

RESULTS

Compared with matched controls, those with CD (OR 1.56, CI 95% 1.34-1.82), but not UC (OR 0.72, CI 95% 0.59-0.89), were more likely to die prematurely. Both those with UC and CD were more likely to die from a gastrointestinal cause (CD OR 15.28, 95% CI 12.11-19.27; UC OR 14.02, 95% CI 10.76-18.26). There was no difference in the cause or age of death before and after the introduction of anti-TNF agents in those with IBD.

CONCLUSIONS

Both CD and UC cases were more likely to die of a gastrointestinal etiology, and CD patients were more likely to die prematurely. There was no significant difference in the premature death, average age of death, and cause of death in this IBD population after the availability of anti-TNF therapy.

Myeloid disorders after autoimmune disease

Autoimmune diseases (ADs) are associated with an increased risk not only of lymphoproliferative disorders but also of myeloid malignancies. The excess risk of myelodysplastic syndromes and/or acute myeloid leukemia is observed across several AD types, including systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disorders, multiple sclerosis, among others. The risk of developing myeloid neoplasms (MNs) is dependent on several variables, including the specific AD type, chronicity and severity of the AD, type and duration of exposure of disease modifying anti-rheumatic drugs or cytotoxics/immunosuppressives, and genetic predisposition risk. Putative triggering factors linking AD to elevated MN risk include AD-directed medications, shared genetic susceptibilities between the two disease entities, and chronic immune stimulation or bone marrow infiltration by the AD. Molecular mechanisms underpinning leukemogenesis remain largely speculative and warrant further investigation. Leukemias arising in patients with AD are not always 'therapy-related' in that MNs may develop in certain AD subtypes even among patients with no prior therapy exposure. Only a few studies have attempted to determine factors associated with MN development in AD but failed to demonstrate consistent characteristic clinical or paraclinical features. These reports have failed to demonstrate a clear correlation between individual agent exposure and subsequent leukemia development due to the low rates of therapy exposure compounded by the rarity of MN occurrence. Notwithstanding, the leukemogenic potential is best documented with agents such as azathioprine, cyclophosphamide, and mitoxantrone; this risk of MN development does not appear to be shared by biologic approaches such as anti-tumor necrosis factors-alpha inhibitors. In this article, we discuss plausible biologic mechanisms underlying MN pathogenesis in AD and review the data available on the development of MNs in patients with AD.

Inflammatory bowel disease and cardiovascular disease incidence and mortality: A meta-analysis

Background

The risk of cardiovascular disease occurrence and death in inflammatory bowel disease patients is still unclear.

Design

Meta-analysis.

Methods

Pertinent studies were identified by searching articles in PubMed and Web of Knowledge to December 2017 and reviewing the reference lists of the retrieved articles. We used the fixed-effect model to pool the study-specific estimates when there was no indication of heterogeneity; otherwise, the random-effect model was used.

Results

A total of 27 articles was included, of which 11 studies reported the risk of cardiovascular disease incidence and 16 studies reported the risk of cardiovascular disease death. The pooled relative risks were 1.25 (95% confidence interval (CI): 1.08, 1.44), 1.17 (95% CI: 1.07, 1.27) and 1.12 (95% CI: 1.05, 1.21) for cerebrovascular disease, coronary heart disease and myocardial infarction, respectively. In particular, the pooled relative risk was much higher in females. The pooled standardized mortality ratios were 1.01 (95% CI: 0.90, 1.14) for Crohn's disease patients and 0.93 (95% CI: 0.86, 1.01) for ulcerative colitis patients with low heterogeneity across studies. No publication bias was detected.

Conclusions

There was a positive association between inflammatory bowel disease and higher risk of cardiovascular disease incidence, particularly in females. Such an association was not observed for cardiovascular disease mortality.

MK2 contributes to tumor progression by promoting M2 macrophage polarization and tumor angiogenesis

Chronic inflammation is a major risk factor for colorectal cancer. The p38/MAPKAP Kinase 2 (MK2) kinase axis controls the synthesis of proinflammatory cytokines that mediate both chronic inflammation and tumor progression. Blockade of this pathway has been previously reported to suppress inflammation and to prevent colorectal tumorigenesis in a mouse model of inflammation-driven colorectal cancer, by mechanisms that are still unclear. Here, using whole-animal and tissue-specific MK2 KO mice, we show that MK2 activity in the myeloid compartment promotes tumor progression by supporting tumor neoangiogenesis in vivo. Mechanistically, we demonstrate that MK2 promotes polarization of tumor-associated macrophages into protumorigenic, proangiogenic M2-like macrophages. We further confirmed our results in human cell lines, where MK2 chemical inhibition in macrophages impairs M2 polarization and M2 macrophage-induced angiogenesis. Together, this study provides a molecular and cellular mechanism for the protumorigenic function of MK2.

SMAD2 and the Relationship of Colorectal Cancer to Inflammatory Bowel Disease

Inflammatory bowel diseases (IBDs) affecting the colon [Crohn's disease (CD) and ulcerative colitis (UC)] are associated with an increased risk of colorectal cancer (CRC). Our previous work using oligonucleotide array data indicated that SMAD2 was significantly underexpressed in UC dysplastic tissue compared to benign UC. The aim of this current study was to determine whether single nucleotide polymorphisms (SNPs) within the SMAD2 gene are associated with IBD dysplasia/cancer. We performed an SNP haplotype-based case-control association study. Leukocyte DNA was obtained from 489 unrelated Caucasians (158 UC, 175 CD, 71 CRC, 85 controls). Eleven SNPs were genotyped. All 11 SNPs were in Hardy-Weinberg equilibrium in the control population. Strong linkage disequilibrium was observed among nearly all SMAD2 SNPs. There were no significant associations between SMAD2 allele or haplotype frequencies. Power calculations indicated good power for single-marker analysis (>0.8) and reasonably good power against effects of 0.1–0.15 for haplotype analysis. SMAD2 SNPs were not associated with the development of IBD dysplasia/cancer. This incongruity between our previous microarray data and the findings from this genotype study may be attributed to mechanisms such as alternative splicing of pre-mRNA SMAD2 and/or cross talk with other cellular pathways.

Inflammatory bowel disease: Efficient remission maintenance is crucial for cost containment

The inflammatory bowel diseases (IBD) are chronic incurable inflammatory disorders of the gut. Some 10% run a downhill course, requiring emergency medical support and often surgery; another small subset are monogenic, and, threatening pediatric patients, are the challenge of these days. The majority of the IBDs, however, are polygenic low-penetrance diseases, running a lifetime waxing-and-waning course. The prevalent trend is towards a slow worsening and steady cost increase. Each and all drugs of the available arsenal exhibit strengths and weaknesses: Mesalamines are chiefly effectively for mild-moderate colitis, and do not work in Crohn’s; steroids do not control some 40% of the ulcerative colitis cases, and are not indicated for Crohn’s; thiopurines are effective in the maintenance of the IBDs but do not prevent relapses on withdrawal; biologics are still being used empirically (not monitored) causing further increase of their cost over that of hospitalization. Against all these caveats, two simple rules still hold true: Strict adherence maintenance and avoidance of colitogenic drugs. This matter is expanded in this minireview.

The Pattern of Underlying Cause of Death in Patients with Inflammatory Bowel Disease in England: A Record Linkage Study

BACKGROUND AND AIMS

Numerous studies have established that mortality risk in inflammatory bowel disease [IBD] patients is higher than in the general population, but the causes of death have seldom been examined. We aimed to describe causes of death in IBD.

METHODS

A matched cohort study using UK general practice data from Clinical Practice Research Datalink linked to death registration records. We described the distribution of causes of death among IBD patients by age at death and time since IBD diagnosis. We estimated age-specific mortality rates and hazard ratios of death in multivariable Cox proportional hazards models.

RESULTS

20293 IBD patients were matched to 83261 non IBD patients. The mortality rate was 40% higher in IBD patients [2005 deaths] than in non IBD patients [6024 deaths] (adjusted overall hazard ratio: = 1.4, 95% confidence interval [CI]: = 1.4-1.5], with greater risk of death in Crohn's disease [hazard ratio: = 1.6, 1.5-1.7] than in ulcerative colitis [1.3, 1.3-1.4]. Causes attributable to IBD constituted 3.7% of all deaths in ulcerative colitis and 8.3% in Crohn's disease. Among IBD patients, death was less likely to be due to circulatory, respiratory or neoplastic diseases than among non IBD patients. In both IBD and non IBD patients all these causes became more clinically important with advancing age, with the commonest neoplastic cause of death being lung cancer rather than gastrointestinal cancers.

CONCLUSIONS

IBD patients have an additional risk of death. Most IBD patients die of circulatory or respiratory causes, and the contribution to mortality from long-term complications of IBD is clinically less important.

Mortality Trends in Crohn's Disease and Ulcerative Colitis: A Population-based Study in Québec, Canada

BACKGROUND

Mortality rates greater than in the general population have been reported in the population with Crohn's disease (CD), but reports for ulcerative colitis (UC) are conflicting. Trends with time were rarely described. We aimed to assess whether CD and UC mortality in Québec differs from that in the general population and to describe the trends over a 10-year observation period.

METHODS

This is a population-based cohort study using the Québec administrative health databases and death certificates registry. All-cause and cause-specific standardized mortality ratios (SMRs) were computed for 1999 to 2008. A time trend analysis was used to assess changes in the SMR with the calendar year.

RESULTS

All-cause mortality was significantly increased in CD and UC compared to the general population: SMR: CD 1.45 (95% confidence interval: 1.34-1.58), UC 1.21 (95% confidence interval: 1.12-1.32). In CD, mortality from digestive conditions, all neoplasms, digestive neoplasms, and colorectal, lymphatic, and lung cancer was significantly higher than in the general population. In UC, mortality from digestive, respiratory, and infectious conditions was also significantly increased. In both CD and UC, there was a decrease with time in all-cause SMRs and in digestive conditions, digestive neoplasms, colorectal cancer, and infectious diseases. SMRs for lung cancer and respiratory conditions increased over time in CD.

CONCLUSIONS

All-cause mortality was significantly higher in CD and UC populations than in the general population. However, a decreasing trend with time was observed in all-cause and some cause-specific SMRs. In CD, SMRs for lung cancer and respiratory conditions increased during the observation period.

Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies

OBJECTIVE

Patients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial.

DESIGN

We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD.

RESULTS

33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67-2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91-1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78-3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95-3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19-1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78-6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93-1.14).

CONCLUSION

The risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia.

Systematic review with meta-analysis: the declining risk of colorectal cancer in ulcerative colitis

BACKGROUND

Patients with ulcerative colitis (UC) have an increased risk of developing colorectal cancer (CRC); however, the magnitude of this effect is open to debate.

AIM

To assess the risk of CRC in UC patients by systematic review and meta-analysis.

METHODS

A systematic literature search was performed up to November 2013. We selected studies describing the incidence and prevalence of CRC in patients with UC. Articles were assessed for quality using the Newcastle-Ottawa Scale. Cumulative incidence and incidence rates of CRC were combined and analysed using the generic inverse variance method. Sub-analyses were performed to identify factors associated with an increased risk of developing CRC.

RESULTS

A total of 81 studies (181 923 patients) met the inclusion criteria. The incidence rate of CRC in patients with UC was 1.58 per 1000 patient-years (py) [95% confidence interval (CI), 1.39–1.76]. Results were heterogeneous (I2 = 81–89%). The incidence rate was 4.02/1000 py (95%CI = 2.74–5.31) in studies that only included patients with extensive colitis, and 1.24/1000 py (95%CI = 1.01–1.47) in population-based studies. The incidence rate was 0.91/1000 py (95%CI = 0.61–1.2) in the first decade of disease, 4.07/1000 py (95%CI = 2.58–5.56) in the second, and 4.55/1000 py (95%CI = 2.64–6.46) in the third. The incidence rate decreased from 4.29/1000 py in the studies published in the 1950s to 1.21/1000 py in studies published in the last decade.

CONCLUSIONS

The risk of patients with ulcerative colitis developing colorectal cancer has decreased steadily over the last six decades, but the extent and duration of the disease increase this risk.

Aggressive plasmablastic multiple myeloma in a 42-year-old: is inflammatory bowel disease or infliximab treatment to be blamed?

A man in his early 40s with a history of ulcerative colitis, treated with infliximab, was diagnosed with plasmablastic multiple myeloma. He was treated with chemotherapy and stem cell transplant but developed recurrence and ultimately died from metastatic disease. Could inflammatory bowel disease or infliximab therapy have any role in development of myeloma in this young patient? The role of inflammatory bowel disease and infliximab therapy in the development of multiple myeloma is controversial but interesting and worth considering.

The long-term outcomes of a cohort of Sri Lankan patients with ulcerative colitis: a retrospective study at two national referral centers and review of literature

BACKGROUND

Inflammatory bowel disease, especially ulcerative colitis, is increasing in many "non-Western" countries, including Sri Lanka. The aim was to evaluate long-term outcomes of ulcerative colitis in a Sri Lankan population.

METHODS

A retrospective cohort study was conducted at the gastroenterology clinics of the Colombo North Teaching Hospital, Ragama and the National Hospital of Sri Lanka, Colombo; the two major referral centers for ulcerative colitis. All cases had histological confirmation of ulcerative colitis. Three outcomes: colectomy, development of colorectal carcinoma, and death were assessed. Patients not attending the clinic during the previous 4 weeks, or their families, were contacted to obtain clinical details and survival status. In those who had died, the cause of death was confirmed from clinical records and death certificates.

RESULTS

Details of 348/425 (81.9%) patients with ulcerative colitis (mean age 45.6 [standard deviation {SD} 14.3] years, male/female ratio = 1.00:1.03) were available. The mean follow-up was 6.8 (SD 6.5) years. The cumulative colectomy rates at 1, 5, 10, and 15 years were 1.5%, 4.0%, 5.5%, and 9.3% respectively. The cumulative probability of colorectal cancer in this cohort after 10 and 15 years was 0.47% and 2.36% respectively. The cumulative survival rate after 1, 5, 10, and 15 years was 99.7%, 98.9%, 98.1%, and 94.5% respectively. Patients with pancolitis were more likely to have disease-related death (P = 0.05). Multivariate analysis (Cox proportional hazards model) showed that an older age at diagnosis was associated with long-term mortality (hazard ratio, 1.11; P = 0.001).

CONCLUSION

In this cohort, colectomy, colorectal carcinoma, and death rates were low, suggesting a relatively benign disease course for ulcerative colitis.

Crohn's disease and ulcerative colitis are associated with elevated standardized mortality ratios: a meta-analysis

BACKGROUND

Evidence regarding all-cause and cause-specific mortality in inflammatory bowel disease (IBD) is conflicting, and debate exists over appropriate study design to examine these important outcomes. We conducted a comprehensive meta-analysis of all-cause and cause-specific mortality in both Crohn's disease (CD) and ulcerative colitis (UC), and additionally examined various effects of study design on this outcome.

METHODS

A systematic search of PubMed and EMBASE was conducted to identify studies examining mortality rates relative to the general population. Pooled summary standardized mortality ratios (SMR) were calculated using random effect models.

RESULTS

Overall, 35 original articles fulfilled the inclusion and exclusion criteria, reporting all-cause mortality SMRs varying from 0.44 to 7.14 for UC and 0.71 to 3.20 for CD. The all-cause mortality summary SMR for inception cohort and population cohort UC studies was 1.19 (95% confidence interval, 1.06-1.35). The all-cause mortality summary SMR for inception cohort and population cohort CD studies was 1.38 (95% confidence interval, 1.23-1.55). Mortality from colorectal cancer, pulmonary disease, and nonalcoholic liver disease was increased, whereas mortality from cardiovascular disease was decreased.

CONCLUSIONS

Patients with UC and CD have higher rates of death from all causes, colorectal-cancer, pulmonary disease, and nonalcoholic liver disease.

Mortality from inflammatory bowel diseases

Ulcerative colitis (UC) and Crohn's disease (CD) may directly result in morbidity and rarely mortality from complications such as colorectal cancer or sepsis. Mortality rates compared with the matched general population, measured by standardized mortality ratio, may therefore be increased. This review examines the evidence derived from cohort- and population-based mortality studies. In CD the majority of studies and two meta-analyses demonstrated increased standardized mortality ratios of ≈ 1.5-fold, especially for those diagnosed at younger ages and requiring extensive or multiple resection surgery. In UC mortality rates are similar to those of the general population in most studies and a meta-analysis. Proctocolectomy removes the inflammatory burden of UC and can manage colorectal dysplasia but may result in perioperative complications. There is no clear temporal trend of improvement in survival for either CD or UC. Few data are available from countries outside Europe and North America, so geographical influences remain largely unknown.

Differential microRNA expression tracks neoplastic progression in inflammatory bowel disease-associated colorectal cancer

One of the most serious complications faced by patients with inflammatory bowel disease (IBD) is the potential development of colorectal cancer (CRC). There is a compelling need to enhance the accuracy of cancer screening of IBD patients. MicroRNAs (miRNAs) are small nonprotein-coding RNAs that play important roles in CRC oncogenesis. In this study, we report differential miRNA expression in IBD patients with associated CRC from non-neoplastic tissue to dysplasia and eventually cancer. In addition, we identify and examine the role of dysregulated miRNAs in the TP53 pathway. In our CD patients, six miRNAs were upregulated from non-neoplastic tissue to dysplasia, but downregulated from dysplasia to cancer (miR-122, miR-181a, miR-146b-5p, let-7e, miR-17, miR-143) (P < 0.001). Six differentially expressed miRNAs affected the TP53 pathway (miR-122, miR-214, miR-372, miR-15b, let-7e, miR-17) (P < 0.001). Using two human colon cancer cell lines (HT-29 and HCT-116), E2F1, an upstream regulator of TP53, was downregulated in both cell lines transfected with let-7e (P < 0.05) as well as in HCT-116 cells transfected with miR-17 (P < 0.05). Additionally, cyclin G, a cell-cycle regulator miR-122 target was downregulated in both cell lines (P < 0.05). Unique differentially expressed miRNAs were observed in CD-associated CRC progression. Six of these miRNAs had a tumorigenic effect on the TP53 pathway; the effect of three of which was studied using cell lines.

Mortality in ulcerative colitis and Crohn's disease. A population-based study in Finland

BACKGROUND

An increased mortality has been reported in patients with Crohn's disease (CD), while figures have remained similar or decreased in patients with ulcerative colitis (UC) compared to the population in general. We evaluated the long-term mortality risk of patients with inflammatory bowel diseases (IBD) in a well-defined population.

METHODS

The data were based on a prospective IBD register in our catchment area; follow-up covered 1986-2007. The population based cohort comprised 1915 adult patients, 1254 with UC, 550 with CD, and 111 with inflammatory bowel disease unclassified (IBDU). The mortality rate and causes of death were obtained from Statistics Finland.

RESULTS

We recorded 223 deaths among the 1915 patients with IBD within a follow-up of 29,644 person-years. The standardised mortality rate (SMR) was 1.14 in CD and 0.90 in UC. In cause-specific mortality; the risk of death in diseases of the digestive system was significantly increased in CD (SMR 5.38). The mortality in colorectal cancer was non-significantly increased in both UC and CD (SMR 1.80 and 1.88, respectively). Compared to the background population, there were significantly fewer deaths due to mental and behavioural disorders due to use of alcohol (0 observed, 10.2 expected in IBD).

CONCLUSIONS

The overall mortality in CD and CU was not different from that in the population. In cause-specific mortality, diseases of the digestive system were significantly increased. Deaths due to mental and behavioural disorders resulting from alcohol consumption were less common in patients with IBD than in the population at large in Finland.

Acute myeloid leukemia developing in patients with autoimmune diseases

Therapy-related acute myeloid leukemia is an unfortunate complication of cancer treatment, particularly for patients with highly curable primary malignancies and favorable life expectancy. The risk of developing therapy-related acute myeloid leukemia also applies to patients with non-malignant conditions, such as autoimmune diseases treated with cytotoxic and/or immunosuppressive agents. There is considerable evidence to suggest that there is an increased occurrence of hematologic malignancies in patients with autoimmune diseases compared to the general population, with a further increase in risk after exposure to cytotoxic therapies. Unfortunately, studies have failed to reveal a clear correlation between leukemia development and exposure to individual agents used for the treatment of autoimmune diseases. Given the dismal outcome of secondary acute myeloid leukemia and the wide range of available agents for treatment of autoimmune diseases, an increased awareness of this risk and further investigation into the pathogenetic mechanisms of acute leukemia in autoimmune disease patients are warranted. This article will review the data available on the development of acute myeloid leukemia in patients with autoimmune diseases. Possible leukemogeneic mechanisms in these patients, as well as evidence supporting the association of their primary immunosuppressive status and their exposure to specific therapies, will also be reviewed. This review also supports the idea that it may be misleading to label leukemias that develop in patients with autoimmune diseases who are exposed to cytotoxic agents as 'therapy-related leukemias'. A better understanding of the molecular defects in autoimmune disease patients who develop acute leukemia will lead to a better understanding of the association between these two diseases entities.

Pretreatment with the probiotic VSL#3 delays transition from inflammation to dysplasia in a rat model of colitis-associated cancer

Evidence supports involvement of microflora in the transition of chronic inflammation to neoplasia. We investigated the protective efficacy of the probiotic VSL#3 in a model of colitis-associated colorectal cancer. Chronic colitis was induced in Sprague-Dawley rats by administration of trinitrobenzene sulfonic acid (TNBS), followed 6 wk later by systemic reactivation. To induce colitis-associated dysplasia and cancer, the animals received TNBS (intravenously) twice a week for 10 wk. One group received VSL#3 in drinking water from 1 wk before colitis induction until death. The colons were examined for damage and presence of dysplasia or cancer. Samples were analyzed for cell proliferation and apoptosis, vitamin D receptor (VDR) expression, angiogenic factors, and presence of alkaline sphingomyelinase or phosphatase. Microbial community composition was evaluated by terminal restriction fragment-length polymorphism analysis of the bacterial 16S rRNA gene. None of the probiotic-treated animals developed carcinoma, and no high-grade dysplasia was found in either the proximal or mid colon. In contrast, 29% of the animals in the control group developed carcinoma in one or more regions of the colon. VSL#3-treated animals had significantly less damage than the vehicle treated-controls in all areas of the colon, and this correlated with decreased richness and diversity of the mucosally adherent microbiota. Treatment with the probiotic increased the antiangiogenic factor angiostatin, VDR expression, and alkaline sphingomyelinase. We concluded that pretreatment with the probiotic VSL#3 can attenuate various inflammatory-associated parameters, delaying transition to dysplasia and cancer, thus offering its potential therapeutic use in patients with long-standing colitis.

Cancer in inflammatory bowel disease 15 years after diagnosis in a population-based European Collaborative follow-up study

AIM OF THE STUDY

To determine the occurrence of intestinal and extraintestinal cancers in the 1993-2009 prospective European Collaborative Inflammatory Bowel Disease (EC-IBD) Study Group cohort.

PATIENTS-METHODS

A physician per patient form was completed for 681 inflammatory bowel disease patients (445UC/236CD) from 9 centers (7 countries) derived from the original EC-IBD cohort. For the 15-year follow up period, rates of detection of intestinal and extraintestinal cancers were computed.

RESULTS

Patient follow-up time was fifteen years. In total 62/681 patients (9.1%) [41 with ulcerative colitis/21 with Crohn's disease, 36 males/26 females] were diagnosed with sixty-six cancers (four patients with double cancers). Colorectal cancer was diagnosed in 9/681 patients [1.3%] (1 Crohn's disease and 8 ulcerative colitis). The remaining 53 cancers were extraintestinal. There was a higher prevalence of intestinal cancer in the Northern centers compared to Southern centers [p=NS]. Southern centers had more cases of extraintestinal cancer compared to Northern centers [p=NS]. The frequency of all observed types of cancers in Northern and in Southern centers did not differ compared to the expected one in the background population.

CONCLUSIONS

In the fifteen-year follow up of the EC-IBD Study Group cohort the prevalence of cancer was 9.1% with most patients having a single neoplasm and an extraintestinal neoplasm. In Northern centers there were more intestinal cancers while in Southern centers there were more extraintestinal cancers compared to Northern centers. In this IBD cohort the frequency of observed cancers was not different from that expected in the background population.

Prevalence of inflammatory bowel disease related dysplasia and cancer in 1500 colonoscopies from a referral center in northwestern Greece

BACKGROUND AND AIM

To report on the prevalence of inflammatory bowel disease (IBD) related intestinal dysplasia and cancer in northwestern Greece.

PATIENTS AND METHODS

Single referral center retrospective study. The policy among all gastroenterologists of the area regarding medical treatment, patient follow up and bowel surveillance strategies including risk factors is the same.

RESULTS

We analyzed 1494 colonoscopies from 696 consecutive IBD patients (494 UC). The follow up time [median, IQR] was 16 [8-23] years and the age at diagnosis was 28 [21-49] years. The number of patient years at risk was 16.219. Disease location for UC was: pancolitis 761 (59%), left sided colitis 455 (35%), and proctitis 69 (6%). Disease location for CD was: colitis 142 (66%), ileitis 45 (22%) and ileocolitis 21 (10%). Disease activity was in remission in 1240 (83%) of them. In total, 498 (72%) patients were on mesalazine, 169(24%) on immunosuppression and 29 (4%) on biologicals. Biopsies were taken randomly in 1429 (96%) endoscopies and were targeted in 65 (4%) of them. We recorded 69 (9.4%) cases with dysplasia and 10 (1.4%) cases with intestinal cancer (9 in UC). No difference was found for dysplasia and cancer in patients who followed up for 10-20 years or for more than 20 years.

CONCLUSIONS

The prevalence of dysplasia and cancer is increased in UC compared to CD but the prevalence of high-grade dysplasia is comparatively low. Intestinal cancer prevalence is increasing after the first decade and then practically remains stable.

Mortality in inflammatory bowel disease in the Netherlands 1991-2002: results of a population-based study: the IBD South-Limburg cohort

BACKGROUND

The aim was to evaluate overall and disease-specific mortality in a population-based inflammatory bowel disease (IBD) cohort in the Netherlands, as well as risk factors for mortality.

METHODS

IBD patients diagnosed between 1 January 1991 and 1 January 2003 were included. Standardized mortality ratios (SMRs) were calculated overall and with regard to causes of death, gender, as well as age, phenotype, smoking status at diagnosis, and medication use.

RESULTS

At the censoring date, 72 out of 1187 patients had died (21 Crohn's disease [CD], 47 ulcerative colitis [UC], and 4 indeterminate colitis [IC] patients). The SMR (95% confidence interval [CI]) was 1.1 (0.7-1.6) for CD, 0.9 (0.7-1.2) for UC and 0.7 (0.2-1.7) for IC. Disease-specific mortality risk was significantly increased for gastrointestinal (GI) causes of death both in CD (SMR 7.5, 95% CI: 2.8-16.4) and UC (SMR 3.4, 95% CI: 1.4-7.0); in CD patients, especially in patients <40 years of age at diagnosis. For UC, an increased SMR was noted in female patients and in patients <19 years and >80 years at diagnosis. In contrast, UC patients had a decreased mortality risk from cancer (SMR 0.5, 95% CI; 0.2-0.9).

CONCLUSIONS

In this population-based IBD study, mortality in CD, UC, and IC was comparable to the background population. The increased mortality risk for GI causes might reflect complicated disease course, with young and elderly patients at diagnosis needing intensive follow-up. Caution in interpreting the finding on mortality risk from cancer is needed as follow-up was probably to short to observe IBD-related cancers.

Characterization of N-acetyltransferase 1 and 2 polymorphisms and haplotype analysis for inflammatory bowel disease and sporadic colorectal carcinoma

Background

N-acetyltransferase 1 (NAT1) and 2 (NAT2) are polymorphic isoenzymes responsible for the metabolism of numerous drugs and carcinogens. Acetylation catalyzed by NAT1 and NAT2 are important in metabolic activation of arylamines to electrophilic intermediates that initiate carcinogenesis. Inflammatory bowel diseases (IBD) consist of Crohn's disease (CD) and ulcerative colitis (UC), both are associated with increased colorectal cancer (CRC) risk. We hypothesized that NAT1 and/or NAT2 polymorphisms contribute to the increased cancer evident in IBD.

Methods

A case control study was performed with 729 Caucasian participants, 123 CRC, 201 CD, 167 UC, 15 IBD dysplasia/cancer and 223 controls. NAT1 and NAT2 genotyping were performed using Taqman based techniques. Eight single nucleotide polymorphisms (SNPs) were characterized for NAT1 and 7 SNPs for NAT2. Haplotype frequencies were estimated using an Expectation-Maximization (EM) method. Disease groups were compared to a control group for the frequencies at each individual SNP separately. The same groups were compared for the frequencies of NAT1 and NAT2 haplotypes and deduced NAT2 phenotypes.

Results

No statistically significant differences were found for any comparison. Strong linkage disequilibrium was present among both the NAT1 SNPs and the NAT2 SNPs.

Conclusion

This study did not demonstrate an association between NAT1 and NAT2 polymorphisms and IBD or sporadic CRC, although power calculations indicate this study had sufficient sample size to detect differences in frequency as small as 0.05 to 0.15 depending on SNP or haplotype.

Hematological malignancies in chronic inflammatory bowel diseases: report of five cases and review of the literature

Several forms of primary and secondary hematological malignancies were rarely observed during the clinical course of inflammatory bowel diseases (IBD). Patients needing a prolonged treatment with immunosuppressants, such as azathioprine or methotrexate, with familiarity and genetic predisposition seem to be at a higher risk of leukemia. On the other hand, asthenia, thickness, and fever may be the symptoms of the onset of each kind of hematological malignancy. The finding of anemia, alteration of leukocyte count and large undetermined cells may suggest increased probability of abnormal proliferation of a single white blood cell line. In this report, the occurrence of hematological malignancies is described in five patients affected by IBD (three with ulcerative colitis and two with Crohn's disease) attending our Gastroenterology Unit.

Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: results from a systematic review and meta-analysis

OBJECTIVES

Inflammation in general, and C-reactive protein (CRP) in particular, are closely associated with atherosclerosis. Similarly, the risk of cardiovascular (CV) disease is increased in several systemic inflammatory diseases. The purpose of this study was to examine whether inflammatory bowel disease (IBD) increases CV mortality, an indirect surrogate for CV disease incidence.

METHODS

A systematic review of studies on CV mortality rates in patients with IBD published between 1965 and 2006 was performed. Studies were included for analysis if they reported data on CV-disease-specific standardized mortality ratios (SMRs) for Crohn's disease (CD) and/or ulcerative colitis (UC). A meta-analysis of SMRs from included studies was performed.

RESULTS

The review ultimately included 11 studies. Overall there were 4,532 patients with CD and 9,533 patients with UC. SMR point estimates ranged from 0.7 to 1.5 for patients with CD and 0.6-1.1 for patients with UC. There was not a statistically significant increase in CV SMR for either CD or UC in any study. However, two studies demonstrated a statistically significant decrease in CV SMR for UC. Finally, the meta-SMR for CD was 1.0 (95% CI 0.8-1.1) and the meta-SMR for UC was 0.9 (95% CI 0.8-1.0).

CONCLUSIONS

IBD is not associated with increased CV mortality. Although CV mortality is a suboptimal surrogate for CV disease incidence, this finding provides indirect evidence against an association between IBD and CV disease.

Molecular profiling of ulcerative colitis-associated neoplastic progression

Fundamental differences exist between ulcerative colitis (UC)-associated and sporadic forms of colorectal cancer, including preexisting inflammation, type of dysplasia, and timing of molecular events in carcinogenesis. Transcriptional alterations that occur in UC-associated neoplasia in the progression from normal mucosa through dysplastic epithelium to invasive cancer have not been described. We used Affymetrix U95Av2 microarrays to assess differential gene expression in the neoplastic progression of UC tissue from the colonic mucosa of individuals with benign UC, UC-dysplasia-associated lesions or masses, and UC adenocarcinoma. By correlating transcript alterations across tissue types using a mixed statistical model, we identified 699 genes exhibiting altered expression with dysplasia development. A different expression profile was observed in progression to adenocarcinoma with 392 transcripts exhibiting differential expression. There were 224 transcripts common to both dysplasia and adenocarcinoma. Most of the differentially expressed genes described herein were not previously known to play a role in neoplastic progression in UC, including transcripts affecting cell proliferation and apoptosis, signal transduction and signaling, and DNA repair. The altered expression of five transcripts was confirmed by quantitative real-time reverse-transcription polymerase chain reaction. Based on comparisons with previous studies on sporadic colorectal carcinoma, several similarities were found. There were, however, important differences that suggest that different molecular events may occur in the development of UC-associated neoplasia. Several of these genes demonstrated similar changes in dysplastic and cancerous tissue and may be involved in early cancer formation. Identification of these genes as potential clinical biomarkers may lead to improved early disease diagnosis.

Outcome of a conservative approach in severe ulcerative colitis

BACKGROUND

Severe ulcerative colitis is potentially life threatening even though a policy of intensive medical management and early colectomy in recent years reduced mortality to almost zero. However, colectomy, with or without ileal-anal anastomosis, has its own problems (morbidity, pouchitis, cuffitis) and no reliable prognostic index of surgical outcome has been developed. Intravenous steroids are still the mainstay of medical therapy but their maximal duration before stating a 'treatment failure' has not been defined.

AIM OF THE STUDY

To evaluate the effectiveness, safety and outcome of an intensive medical approach in a series of patients with severe ulcerative colitis.

PATIENTS AND METHODS

One hundred and forty-nine episodes of severe ulcerative colitis in 115 patients admitted to a Gastroenterology Unit in a 7-year period were retrospectively evaluated. Intravenous glucocorticosteroids--methylprednisolone 1 mg/kg/day--and topical steroids were administered, and supportive treatments with intensive monitoring were extended to all the patients. Second-line strategies for steroid-refractoriness were prolonged glucocorticosteroids treatment, oral ciclosporin, infliximab or surgery.

RESULTS

The median number of Truelove criteria at admission was 3 (range 2-5), median CRP 34 mg/l (range 10-196). Median follow-up after discharge was 49 months. In 84 (57%) episodes an early response was noted, while 65 (43%) did not respond within 10 days to the standard steroid treatment. In the non-responders group, 28 patients went into remission with a prolonged steroid treatment (slow responders); 15 patients were treated with ciclosporin (eight responders) and 6 with infliximab (four responders). A total of 24 colectomies was performed in this group of patients (in 21 cases within 30 days from admission). Slow responders showed lower albumin levels (P = 0.02), higher cumulative dose of glucocorticosteroids in the year prior to admission (P = 0.02) and higher age (P = 0.03), in comparison with early responders. Major complications were noted in four episodes which responded to medical treatment. Disease-related mortality was zero.

CONCLUSIONS

Medical treatment and use of second-line therapies were effective in the present series of patients. A group of slow responders has been identified and, if an intensive medical monitoring is guaranteed, steroids can be safely prolonged after the first 10 days of treatment. Cumulatively, about 80% of the patients responded to short-term medical treatment, only 5% of the patients underwent colectomy in the follow-up period. Major adverse events were recorded in four patients, who had recovered completely after adequate medical treatment.

Mortality in inflammatory bowel disease: a population-based cohort study

BACKGROUND & AIMS

There is no consensus regarding any increase in mortality with inflammatory bowel disease (IBD). In general, previous studies were not contemporary and were unable to correct for likely confounders. We have performed a large cohort study to examine contemporary IBD related mortality in the United Kingdom.

METHODS

We selected subjects within the General Practice Research Database with a coded diagnosis of inflammatory bowel disease and up to 5 matched controls for each. We derived the date of recorded deaths and information on smoking and a variety of medical conditions. We calculated both the absolute risk of death and the relative risk as a hazard ratio corrected for available confounders by Cox regression.

RESULTS

We included 16,550 IBD cases with 1047 deaths and 82,917 controls with 3758 deaths. The mortality rate was 17.1 per 1000 person-years overall for IBD cases and 12.3 for controls; this difference was greatest in the elderly. Conversion of these figures to hazard ratios by Cox regression gave hazard ratios of 1.54 (1.44-1.65) for all IBD, 1.44 (1.31-1.58) for ulcerative colitis (UC), and 1.73 (1.54-1.96) for Crohn's disease. The greatest hazard ratio for UC was among the 40-59-year age group (1.79 [1.42-2.27]) and for Crohn's disease among 20-39-year-olds (3.82 [2.17-6.75]).

CONCLUSIONS

IBD is associated with an overall small increase in mortality rate greatest in relative terms in younger subjects but in absolute terms in the elderly.

A case of Evans' syndrome in a patient with ulcerative colitis

The case of a 37-year-old male diagnosed 16 years previously with ulcerative colitis, admitted on account of hemolytic anaemia and thrombocytopaenia that responded to immunosuppressive therapy, is reported. Despite various peculiarities discussed, this may be the first reported case of Evans' syndrome associated with ulcerative colitis.

Continuing low incidence of Crohn's disease in Northwest Greece

AIM OF STUDY

The largest population-based study for inflammatory bowel disease in Northwest Greece.

MATERIALS AND METHODS

A retrospective survey for the years 1982-1997.

RESULTS

Of 400 patients, 334 had ulcerative colitis, 43 Crohn's disease and 23 indeterminate colitis.

CONCLUSIONS

Crohn's disease still remains rare in Northwest Greece.

Epidemiology of inflammatory bowel disease

Despite the apparent continuous increase of the incidence of inflammatory bowel disease (IBD) in some populations, or some sections of populations such as British children, the origin of these conditions remains obscure. Epidemiological studies of specific risk factors continue to yield contradictory and inconclusive results. However, studies of exposure and comorbidity, coupled with genetic and molecular studies, expand our knowledge and will facilitate more sophisticated research in the near future. Our understanding of the genetic basis of IBD is improving, but genetic anticipation as an explanation for increasing incidence rates appears less probable. The benefit of giving up smoking has been demonstrated in Crohn's disease patients, because smoking influences disease activity. The increased cancer risk in IBD is a concern, but despite this, the overall mortality in IBD is no higher than that of the general population.