Incidence, Prevalence, and Racial and Ethnic Distribution of Inflammatory Bowel Disease in the United States

Enhancing patient representation learning with inferred family pedigrees improves disease risk prediction

BACKGROUND

Machine learning and deep learning are powerful tools for analyzing electronic health records (EHRs) in healthcare research. Although family health history has been recognized as a major predictor for a wide spectrum of diseases, research has so far adopted a limited view of family relations, essentially treating patients as independent samples in the analysis.

METHODS

To address this gap, we present ALIGATEHR, which models inferred family relations in a graph attention network augmented with an attention-based medical ontology representation, thus accounting for the complex influence of genetics, shared environmental exposures, and disease dependencies.

RESULTS

Taking disease risk prediction as a use case, we demonstrate that explicitly modeling family relations significantly improves predictions across the disease spectrum. We then show how ALIGATEHR's attention mechanism, which links patients' disease risk to their relatives' clinical profiles, successfully captures genetic aspects of diseases using longitudinal EHR diagnosis data. Finally, we use ALIGATEHR to successfully distinguish the 2 main inflammatory bowel disease subtypes with highly shared risk factors and symptoms (Crohn's disease and ulcerative colitis).

CONCLUSION

Overall, our results highlight that family relations should not be overlooked in EHR research and illustrate ALIGATEHR's great potential for enhancing patient representation learning for predictive and interpretable modeling of EHRs.

Treatment Persistence Among Anti-Tumor Necrosis Factor-experienced Patients With Ulcerative Colitis Switching to a Biologic With a Different Mode of Action or Cycling to Another Anti-Tumor Necrosis Factor Agent

PURPOSE

In ulcerative colitis (UC), anti-tumor necrosis factor (TNF) agents often are first-line biologic therapy. Switching to a biologic with a different mode of action (ustekinumab and vedolizumab) or cycling to another anti-TNF agent (adalimumab, infliximab, and golimumab) is necessary if an initial anti-TNF fails. This study compared real-world persistence in patients with UC who switched to a biologic with a different mode of action or cycled with another anti-TNF after nonresponse to an anti-TNF.

METHODS

Adults with UC treated with an anti-TNF, who switched or cycled (index date) between October 21, 2019, and March 02, 2022, were selected from the IQVIA PharMetrics® Plus database. Patients had ≥12 months of continuous insurance eligibility before the first anti-TNF without UC-indicated biologics or advanced therapies. During the 12 months before the index date (baseline period), patients had no other immune disorders and discontinued the first anti-TNF. Baseline characteristics were balanced using inverse probability of treatment weights. Persistence on the index biologic was defined as no therapy exposure gaps >120 days (ustekinumab, vedolizumab, and infliximab) or >60 days (adalimumab and golimumab) between days of supply. Composite end points were persistence while corticosteroid-free (<14 consecutive days of corticosteroid supply after day 90 post-index) and persistence while on monotherapy (no immunomodulators/nonindex biologics/advanced therapies). End points were assessed with weighted Kaplan-Meier and Cox proportional hazards models 12 months after the maintenance phase started.

FINDINGS

The switch cohort included 488 patients (mean age: 41.4 years; 44.9% female), and the cycle cohort included 129 patients (mean age: 40.7 years; 43.8% female). At 12 months after the maintenance phase started, the proportions of persistent patients (switch cohort: 79.6%; cycle cohort: 64.9%) and persistent patients on monotherapy (switch cohort: 74.6%; cycle cohort: 48.0%) were significantly higher in the switch versus cycle cohort; the proportions of persistent patients while corticosteroid-free was also higher in the switch (60.1%) versus cycle cohort (49.3%) but was not significant. In the switch cohort, the rate of persistence was 1.92 times higher (hazard ratio [HR] = 1.92; 95% CI, 1.31-2.82), the rate of persistence while on monotherapy was 2.56 times higher (HR = 2.56; 95% CI, 1.86-3.53), and the rate of persistence and being corticosteroid-free was 1.31 times higher (HR = 1.31; 95% CI, 0.98-1.77) than in the cycle cohort.

IMPLICATIONS

Patients with UC who switched from an anti-TNF agent to a biologic with a different mode of action were more persistent on treatment than patients who cycled to another anti-TNF agent. Findings may aid physicians whose patients experience treatment failure on the first anti-TNF agent.

Psychotherapy process variables in implementation of CBT for inflammatory bowel disease:Therapist competence, fidelity, and patient themes

OBJECTIVE

Inflammatory Bowel Diseases (IBD) are a group of chronic immune-mediated digestive disorders that can cause significant psychological distress and disability. IBD-informed cognitive behavioral therapy (CBT) may reduce psychiatric co-morbidity and improve health related quality of life. We herein examine the psychotherapy process variables relevant to implementation of a manualized CBT for IBD protocol delivered by therapists with no prior knowledge of IBD.

METHOD

In the ADEPT Trial (Addressing Disability Effectively with Psychosocial Telemedicine - NCT05635292), 30 patients with IBD received up to 8 sessions of manualized CBT for IBD delivered via telehealth by one of 5 licensed PhD level clinical psychologists skilled in CBT but naïve to IBD prior to the study. All treating psychologists received training in IBD-informed CBT. Videos of the CBT sessions were rated by trained raters for psychotherapy process variables including therapist competence, fidelity to the manual, therapeutic relationship, and the content of patient themes. We also evaluated the association between process variables and outcome, measured as reductions in the IBD-Disability Index.

RESULTS

All general therapists were highly competent in delivering IBD-informed CBT after training and showed fidelity to the treatment manual. Fidelity to teaching deep diaphragmatic breathing was associated with greater reductions in disability. Patient themes were associated with baseline disability and outcome.

CONCLUSIONS

IBD-informed CBT can be delivered successfully by CBT therapists with no prior knowledge of IBD as a flexible modular therapy manual applied to a medically complex patient population.

Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis

BACKGROUND

Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

METHODS

Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

RESULTS

Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

CONCLUSIONS

Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

A Simple Endoscopic Score for Crohn's Disease (SES-CD) ≥ 7 Predicts Disease Progression

BACKGROUND

Up to 30% of patients with Crohn's disease (CD) will experience a mild disease course. However, there is no consensus definition for mild CD.

AIM

To examine the Simple Endoscopic Score for Crohn's disease (SES-CD) thresholds best associated with low likelihood of long-term disease progression.

METHODS

We conducted a multicentre retrospective cohort study at three tertiary care centres in United States and Europe. We analysed data from 177 surgery-naïve patients with CD who had endoscopic assessment while not on immunosuppressive therapy. The primary outcome was disease progression (systemic steroids, biologic or immunomodulator therapy initiation; new stricturing or penetrating complications; or CD-related hospitalisation or surgery). Univariable and multivariable Cox proportional hazards modelling identified predictors of the primary outcome at 2 and 5 years following endoscopy.

RESULTS

Disease progression occurred in 23% and 35% of patients at years two and five, respectively. Endoscopic severity at enrolment independently predicted disease progression. Compared to those with an SES-CD of 0, an SES-CD ≥ 7 had a greater risk of progression at 2 years (HR 2.50, 95% CI 1.09-5.72) and 5 years (HR 2.89, 95% CI 1.41-5.91). SES-CD > 7 remained independently predictive of disease progression among the 129 immunosuppression-naïve patients (HR 5.65, 95% CI 1.49-21.52) and after excluding patients with prior penetrating disease (HR 2.32, 95% CI 1.00-5.45).

CONCLUSIONS

SES-CD ≥ 7 predicts disease progression in mild CD. A score ≤ 6 may help identify patients less likely to progress and be part of the definition of mild CD.

Dissecting the rising tide of inflammatory bowel disease among youth in a changing world: insights from GBD 2021

OBJECTIVES

This study investigates the alarming epidemiological trends of inflammatory bowel disease (IBD) among children and young adults, highlighting the associated disease burden on global health.

MATERIALS AND METHODS

Utilizing data from the Global Burden of Disease (GBD) study 2021, we conducted a comprehensive analysis of age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), disability-adjusted life years (DALYs), and estimated annual percentage changes (EAPC). Future trends were forecasted using the Bayesian age-period-cohort model.

RESULTS

From 1990 to 2021, IBD incidence and DALY rates remained persistently high, with a concerning upward trend noted among children and young adults. While men experienced a decline in DALY rates, women faced increasing burdens. In 2021, high-income regions, particularly North America, reported the highest incidence and DALY rates, contrasting sharply with Central Latin America, which exhibited the lowest ASIR. Southeast Asia presented the most favorable DALY rates. A notable negative correlation was identified between DALY rates and socio-demographic index (SDI) at the national level, with high and high-middle SDI countries continuing to bear a substantial burden, while low and middle SDI nations faced rising challenges.

CONCLUSIONS

The persistent high burden of IBD in children and young adults signifies a critical public health concern. The marked geographical and gender disparities underscore the urgent need for tailored regional and population-based strategies aimed at primary prevention and effective management. This study illuminates the pressing necessity for policy interventions to address the growing epidemic of IBD among vulnerable populations.

Effects of psychological stress on inflammatory bowel disease via affecting the microbiota-gut-brain axis

ABSTRACT

Inflammatory bowel disease (IBD) is an idiopathic intestinal inflammatory condition with chronic and relapsing manifestations and is characterized by a disturbance in the interplay between the intestinal microbiota, the gut, and the brain. The microbiota-gut-brain axis involves interactions among the nervous system, the neuroendocrine system, the gut microbiota, and the host immune system. Increasing published data indicate that psychological stress exacerbates the severity of IBD due to its negative effects on the microbiota-gut-brain axis, including alterations in the stress response of the hypothalamic-pituitary-adrenal (HPA) axis, the balance between the sympathetic nervous system and vagus nerves, the homeostasis of the intestinal flora and metabolites, and normal intestinal immunity and permeability. Although the current evidence is insufficient, psychotropic agents, psychotherapies, and interventions targeting the microbiota-gut-brain axis show the potential to improve symptoms and quality of life in IBD patients. Therefore, further studies that translate recent findings into therapeutic approaches that improve both physical and psychological well-being are needed.

Epidemiology and clinical outcomes of hospitalized Hispanic patients with IBD: results of a large national cohort study

INTRODUCTION

Inflammatory bowel disease (IBD) has historically been seen as predominantly affecting non-Hispanic Whites (NHW). Hispanics are the largest minority group in the USA, yet they remain grossly underrepresented in studies of IBD. With this study, we aimed to better understand the epidemiology of hospitalized Hispanic patients with IBD in the US.

METHODS

This was a retrospective cohort study utilizing the National Inpatient Sample, the largest publicly available all-payer inpatient care database in the United States. We compared demographics, hospitalization characteristics, clinical outcomes, and year-to-year trends from 2016 to 2020 in Hispanic and NHW with a primary diagnosis of inflammatory bowel disease, Crohn's disease, or ulcerative colitis.

RESULTS

NHWs hospitalized with a primary diagnosis of IBD had significantly higher rates of hospitalization than Hispanics (122.67 vs 71.12, P < 0.01). While hospitalized Hispanics with IBD are more likely to be in the lowest quartile for household income (31.6% vs 19.3%, P < 0.01), have a younger median age (37.0 vs 45.0, P < 0.01), and be uninsured (4.3% vs 8.8%, P < 0.01) compared to NHW. Length of admission was similar, yet NHWs had higher rates of mortality (0.3% vs 0.2%, P = 0.01), while total charges for hospitalizations were significantly higher for Hispanic patients (P < 0.01).

DISCUSSION

To our knowledge, this is one of the largest US-based studies of Hispanics with IBD. Our findings suggest that among hospitalized IBD patients, Hispanics are more likely to be younger, uninsured, have a lower household income, and are less likely to undergo surgery while having higher hospital charges.

MK2 Inhibition in CD4+ T Cells Protects Against IFNγ and IL-17A, Chronic Inflammation, and Fibrosis in Inflammatory Bowel Disease Models

BACKGROUND

CD4+ T cells contribute to chronic inflammation and fibrosis in inflammatory bowel disease (IBD), but the cellular mechanisms remain elusive. We have found that the mitogen-activated protein kinase 2 (MK2) pathway plays a major role in inflammation and overall pathology in IBD. Thus, here, we examined the role of MK2 in regulating CD4+ T cell responses in IBD models.

METHODS

Interleukin-10 (IL-10) knockout (KO) mice treated with MK2 inhibitors (MK2i) and CD4-specific MK2 knockdown mice treated with chronic dextran sodium sulfate (DSS) treatments were used to examine inflammation and fibrosis by multiplex array, gene expression, flow cytometry, and histology. Human tissues were treated with MK2i to examine Th1 and Th17 markers.

RESULTS

IL-10 KO mice treated with MK2i therapeutically showed significantly reduced interferon gamma (IFNγ) and interleukin-17A (IL-17A) and a significantly reduced number of IFNγ+ and IL-17A+ producing CD4+ T cells by flow cytometry. To investigate the direct role of MK2 in CD4+ T cells during IBD, we utilized CD4-specific MK2 knockdown mice in chronic DSS colitis. A decrease in colonic inflammation, IFNγ and IL-17, pro-fibrotic genes, and extracellular matrix deposition was observed in mice with MK2 knockdown in CD4+ T cells compared to control mice. Additionally, IL-17A and IFNγ directly regulated the expression of fibrosis genes in colon tissues.

CONCLUSIONS

The MK2 pathway regulates inflammatory CD4+ T cells and fibrosis in IBD models and is a potential therapeutic target.

Gender and Sex Differences in Abdominal Pain, Fatigue, And Psychological Symptoms Among Adults with Inflammatory Bowel Disease: A Network Analysis

BACKGROUND AND AIMS

Individuals with inflammatory bowel disease (IBD) experience a high symptom burden, including abdominal pain, fatigue, anxiety, depression, and sleep disturbances; yet, little is known regarding the relationship between sex and gender on symptoms. We sought to report symptom severity for cisgender men, cisgender women, and transgender and gender-diverse (TGD) individuals. In addition, we used network analysis to identify core symptoms and explore if symptoms and their relationships differ between cisgender men and cisgender women.

METHODS

This was a cross-sectional study. We recruited adults with IBD online through ResearchMatch. Individuals responded to Patient-Reported Outcomes Measurement Information symptom questionnaires, as well as demographic and clinical questionnaires. Network analysis was used to identify the core symptoms driving the symptom structure.

RESULTS

One-hundred and fifty-seven (63.3%) participants identified as cisgender women, 84 (33.9%) as cisgender men, and 7 (2.8%) as TGD. Cisgender men (M = 61.8) and TGD (M = 61.3) groups reported higher abdominal pain levels compared with cisgender women (M = 57.8; P = .02). Transgender and gender-diverse individuals reported higher depression levels (M = 64.8) compared with cisgender men (M = 56.7) and cisgender women (M = 54.4; P = .01). Using a network analysis approach, anxiety and fatigue emerged as core symptoms for the entire sample (clinically active and inactive disease), and among only those with active clinical disease. Fatigue was a top core symptom for cisgender women; anxiety emerged as a top core symptom for cisgender men.

CONCLUSIONS

This study highlights that fatigue and anxiety are core symptoms among individuals with IBD and demonstrates a potential sex and/or gender difference in core symptoms. Replication of this study is needed with further consideration of inclusion of TGD patients.

Equivalent Survivorship of Total Hip Arthroplasty in Patients Who Have Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) can have orthopaedic manifestations related to decreased bone mineral density and increased fracture risk. The impact of IBD-spectrum diseases, including Crohn's disease (CD) and ulcerative colitis (UC), on the overall performance of total hip arthroplasty (THA), is not well understood. The present study sought to evaluate whether patients who have IBD were at an increased risk of THA failure compared to those who did not have IBD.

METHODS

The Statewide Planning and Research Cooperative System was used to compare postoperative outcomes between patients who have IBD (CD and UC) and patients who do not have IBD from 2010 to 2020. A total of 119,094 patients were included in the study, of whom 1,165 had a diagnosis of IBD. Overall, 501 of those had CD, while 664 had UC.

RESULTS

When controlling for comorbidities, patients who had CD had longer hospital length of stay (CD: 3.6 ± 2.5 versus UC: 3.4 ± 2.1 versus control: 3.2 ± 2.3 days, P < 0.001), higher rates of 90-day readmission (CD: 13.6 versus UC: 8.3 versus control: 7.7%, P < 0.001) and 1-year readmission (CD: 20.4 versus UC: 15.1 versus control: 12.8%, P < 0.001), and higher rates of 90-day emergency room visits (CD: 15.4 versus UC: 12 versus control: 11.1%, P = 0.007). There were no differences in all-cause revision or revision for periprosthetic joint infection between CD and UC compared with control patients.

CONCLUSIONS

Patients who have UC had more emergency room visits and hospital readmissions following THA; however, survival analysis demonstrated that IBD patients are not at an increased risk of revision or periprosthetic joint infection after THA.

Trends in Mortality Due to Inflammatory Bowel Disease in the United States: A CDC WONDER Database Analysis (1999-2020)

INTRODUCTION

Inflammatory bowel disease (IBD) is a global health issue profoundly impacting quality of life. The United States accounts for nearly a quarter of the world's IBD patients, with the highest prevalence rates. This study aims to identify the demographic and regional trends of IBD-related mortality in the U.S. from 1999 to 2020.

METHODOLOGY

Our study utilized the CDC Wonder database to gather mortality data for IBD (Crohn's disease and ulcerative colitis) from 1999 to 2020. Results were presented as age-adjusted mortality rates (AAMR) per 100,000 population, with Joinpoint regression used to analyze trend changes and calculate annual percentage change (APC).

RESULTS

A total of 62,310 IBD-related deaths were recorded. From 1999 to 2020, AAMR for Crohn's disease increased from 0.79 to 0.97, declining from 1999 to 2018 (APC: - 0.22) but surging from 2018 onwards (APC: 11.26). Women had a higher AAMR (0.81) compared to men (0.77). The highest rates were among non-Hispanic whites (0.86), followed by non-Hispanic blacks (0.48) and Hispanics (0.21). AAMR varied by state, ranging from 0.29 in Hawaii to 1.42 in Vermont. For ulcerative colitis, AAMR rose from 0.56 in 1999 to 0.63 in 2020, following a similar trend: a decline from 1999 to 2018 (APC: - 0.37) followed by an increase (APC: 12.21). State-specific AAMR ranged from 0.14 in Hawaii to 0.67 in Oregon.

CONCLUSION

This study highlights a decrease in AAMR for both diseases from 1999 to 2018, followed by significant increases from 2018 to 2020, indicating a need for targeted interventions.

Inflammation and aging-related disease: A transdisciplinary inflammaging framework

Inflammaging, a state of chronic, progressive low-grade inflammation during aging, is associated with several adverse clinical outcomes, including frailty, disability, and death. Chronic inflammation is a hallmark of aging and is linked to the pathogenesis of many aging-related diseases. Anti-inflammatory therapies are also increasingly being studied as potential anti-aging treatments, and clinical trials have shown benefits in selected aging-related diseases. Despite promising advances, significant gaps remain in defining, measuring, treating, and integrating inflammaging into clinical geroscience research. The Clin-STAR Inflammation Research Interest Group was formed by a group of transdisciplinary clinician-scientists with the goal of advancing inflammaging-related clinical research and improving patient-centered care for older adults. Here, we integrate insights from nine medical subspecialties to illustrate the widespread impact of inflammaging on diseases linked to aging, highlighting the extensive opportunities for targeted interventions. We then propose a transdisciplinary approach to enhance understanding and treatment of inflammaging that aims to improve comprehensive care for our aging patients.

Black Race is Associated with Decreased Exposure to Advanced Therapies and Worse Outcomes in Individuals with Ulcerative Colitis

BACKGROUND

For people diagnosed with ulcerative colitis (UC), racial disparities exist both in access to medications and clinical outcomes.

METHODS

We used the TriNetX database for two population-based retrospective analyses with Black (n = 22,519) and Asian (n = 8,626) individuals with UC matched for age, sex, and ethnicity. Outcomes included mortality, medication prescriptions, and clinical encounters at 6 months and 10 years.

RESULTS

At 6 months and 10 years after diagnosis, Black people had increased mortality (2.7% vs. 1.9% and 8.1% vs. 6.9%, p < 0.0001), were prescribed fewer UC-specific therapies (21.3% vs. 26.4% and 30% vs. 36%, p < 0.0001), had higher rates of emergency department visits (22.3% vs. 13.6% and 41.2% vs. 31.5%, p < 0.0001), and higher hospitalisation rates (30.1% vs. 25.8% and 42.6% vs. 39.9%, p < 0.0001). At 6 months, they had more opioid prescriptions (18.5% vs. 15.7%, p < 0.0001). Asian people had lower mortality at 10 years (5.6% vs. 7.7%, p < 0.0001), higher rates of UC-specific medications at 6 months (28.6% vs. 26.5%, p = 0.002), and more hospitalizations (38.8% vs. 27.7%, p < 0.0001 at 6 months and 50% vs. 42.2%, p < 0.0001 at 10 years).

CONCLUSION

Black individuals with UC are prescribed fewer disease-specific therapies compared to White individuals and have increased hospitalizations and mortality. Black individuals have higher rates of opioid prescriptions. Opioids have been associated with increased complication rates in inflammatory bowel disease. These trends are not seen in Asian individuals. This reveals critical disparities in the care of Black people with UC with opportunity for targeted interventions.

Sleep Deficiency and Fatigue in Adults with Inflammatory Bowel Disease: A Systematic Review

PURPOSE

Fatigue is one of the most common and disabling symptoms experienced by people with inflammatory bowel disease; however, interventions to treat fatigue are limited. The purpose of this systematic review is to examine the relationship between sleep deficiency and fatigue in adults with inflammatory bowel disease and to describe the demographic and clinical factors associated with fatigue to inform future intervention work.

METHODS

We conducted a systematic review and reported the results using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL on 3/7/24. We included studies with adults (≥18 years of age) who had a diagnosis of inflammatory bowel disease (Crohn's disease, ulcerative colitis, or indeterminate colitis) and measured fatigue and sleep using a validated self-report questionnaire or objective measurement.

RESULTS

Twenty-two studies met inclusion criteria for a total sample of 16 927, of whom 58.7% (n = 9937) had Crohn's disease, and 66.3% (n = 11 226) were female. 56.1% of the participants experienced fatigue and 66.3% experienced sleep deficiency. Sleep quality and insomnia were consistently associated with fatigue. Baseline poor sleep quality was associated with persistent and worsening fatigue over 12 to 24 months. Clinical but not objective assessment of disease activity, anxiety, depression, female gender/sex, and younger age were also associated with more severe fatigue.

CONCLUSIONS

Sleep quality and insomnia represent important modifiable contributors to fatigue. Future research should explore whether sleep interventions can improve fatigue in this population.

Safety and Efficacy of Fecal Microbiota, Live-jslm (REBYOTA®), for the Prevention of Recurrent Clostridioides difficile Infection in Participants With Inflammatory Bowel Disease in PUNCH CD3-OLS

BACKGROUND

Fecal microbiota, live-jslm (RBL; REBYOTA®), is the first single-dose, broad consortia, microbiota-based live biotherapeutic approved by the US Food and Drug Administration to prevent recurrent Clostridioides difficile infection (rCDI) in adults following standard-of-care antimicrobials. Inflammatory bowel disease (IBD) is a common risk factor for rCDI, yet patients with IBD are often excluded from prospective trials. This subgroup analysis of PUNCH CD3-OLS (NCT03931941) evaluated the safety and efficacy of RBL in participants with rCDI and IBD.

METHODS

Participants with IBD (ulcerative colitis [UC], Crohn's disease [CD], or unspecified) who had rCDI were included. Treatment-emergent adverse event (TEAE) data were collected for up to 6 months following RBL administration. Efficacy outcomes included treatment success at 8 weeks and sustained clinical response at 6 months.

RESULTS

Overall, 793 participants were enrolled, and 697 received RBL; 74 had IBD (UC: n = 45; CD: n = 25; unspecified IBD: n = 4). TEAEs within 8 weeks of administration were reported by 45.9% and 47.5% of participants with and without IBD, respectively; most were mild or moderate gastrointestinal symptoms. Serious TEAEs within 8 weeks of administration were reported by 1.4% and 4.2% of participants with and without IBD, respectively. The treatment success rate at 8 weeks was 78.9%, and the sustained clinical response rate at 6 months was 91.1% in participants with IBD, similar to rates in participants without IBD (73.2% and 91.0%, respectively).

CONCLUSIONS

The results of this subgroup analysis of PUNCH CD3-OLS suggest RBL is safe and efficacious in patients with IBD.

Adhesive polyelectrolyte coating through UV-triggered polymerization on PLGA particles for enhanced drug delivery to inflammatory intestinal mucosa

Administering medication precisely to the inflamed intestinal sites to treat ulcerative colitis (UC), with minimized side effects, is of urgent need. In UC, the inflammation damaged mucosa contains a large number of amino groups which are positively charged, providing new opportunities for drug delivery system design. Here, we report an oral drug delivery system utilizing the tacrolimus-loaded poly (lactic-co-glycolic acid) (TAC/PLGA) particles with an adhesion coating by in situ UV-triggered polymerization of polyacrylic acid and N-hydroxysuccinimide (PAA-NHS). The negatively charged carboxyl groups effectively interact with the positively charged focal mucosa, and the NHS ester groups form the covalent bonds with the amino groups, thereby synergically enhancing the adhesion of the PLGA particles to the focal mucosa. Our findings reveal that, compared to the naked particles, the PAA-NHS coating increases the adhesion of particles to the inflammatory intestine. In a dextran sulfate sodium-induced acute colitis mouse model, the TAC/PLGA particles with PAA-NHS coating exhibits substantial retention of TAC within the inflammatory intestine, enhancing drug delivery efficiency and therapeutic effects. This approach holds promise for UC management, minimizing systemic side effects and optimizing therapeutic outcomes.

Identification of circadian rhythm-related biomarkers and development of diagnostic models for Crohn's disease using machine learning algorithms

The global rise in Crohn's Disease (CD) incidence has intensified diagnostic challenges. This study identified circadian rhythm-related biomarkers for CD using datasets from the GEO database. Differentially expressed genes underwent Weighted Gene Co-Expression Network Analysis, with 49 hub genes intersected from GeneCards data. Diagnostic models were constructed using machine learning algorithms, and biologic therapy efficacy was predicted with advanced regression techniques. Single-cell sequencing showed high gene expression in stem cells, immune, and endothelial cells, with validation confirming significant differences between CD patients and controls. These findings suggest circadian rhythm-related genes as promising diagnostic biomarkers for CD.

Alternative Splicing at the Crossroad of Inflammatory Bowel Diseases and Colitis-Associated Colon Cancer

The risk of developing colorectal cancer (CRC) is increased in ulcerative colitis patients compared to the general population. This increased risk results from the state of chronic inflammation, a well-known tumour-promoting condition. This review explores the pathologic and molecular characteristics of colitis-associated colon cancer (CAC), emphasizing the distinct features from sporadic CRC. We focus on the key signalling pathways involved in the transition to CAC, highlighting the emerging role of alternative splicing in these processes, namely on how inflammation-induced alternative splicing can significantly contribute to the increased CRC risk observed among UC patients. This review calls for more transcriptomic studies to elucidate the molecular mechanisms through which inflammation-induced alternative splicing drives CAC pathogenesis. A better understanding of these splicing events is crucial as they may reveal novel biomarkers for disease progression and have the potential to target changes in alternative splicing as a therapeutic strategy.

Deep Learning for Classification of Inflammatory Bowel Disease Activity in Whole Slide Images of Colonic Histopathology

Grading activity of inflammatory bowel disease (IBD) using standardized histopathological scoring systems remains challenging due to limited availability of pathologists with IBD expertise and interobserver variability. In this study, a deep learning model was developed to classify activity grades in hematoxylin and eosin-stained whole slide images (WSIs) from patients with IBD, offering a robust approach for general pathologists. This study utilized 2077 WSIs from 636 patients who visited Dartmouth-Hitchcock Medical Center in 2018 and 2019, scanned at ×40 magnification (0.25 μm/pixel). Board-certified gastrointestinal pathologists categorized the WSIs into four activity classes: inactive, mildly active, moderately active, and severely active. A transformer-based model was developed and validated using five-fold cross-validation to classify IBD activity. Using HoVer-Net, neutrophil distribution across activity grades was examined. Attention maps from the model highlighted areas contributing to its prediction. The model classified IBD activity with weighted averages of 0.871 (95% CI, 0.860-0.883) for the area under the curve, 0.695 (95% CI, 0.674-0.715) for precision, 0.697 (95% CI, 0.678-0.716) for recall, and 0.695 (95% CI, 0.674-0.714) for F1 score. Neutrophil distribution was significantly different across activity classes. Qualitative evaluation of attention maps by a gastrointestinal pathologist suggested their potential for improved interpretability. The model demonstrates robust diagnostic performance and could enhance consistency and efficiency in IBD activity assessment.

Crohn's Disease Phenotypes and Associations With Comorbidities, Surgery Risk, Medications and Nonmedication Approaches: The MAGIC in IMAGINE Study

BACKGROUND

We aimed to establish a cohort of persons with Crohn's disease (CD) enrolled from 14 Canadian centers to describe the contemporary presentation of CD in Canada.

METHODS

All enrollees were at least 18 years old and underwent chart review for phenotype documentation by Montreal Classification at time of enrollment, comorbidities, inflammatory bowel disease (IBD) and other surgeries, and use IBD and other therapies.

RESULTS

Of 2112 adults, 59% were female, and the mean age was 44.1 (+/-14.9SD) years. The phenotype distribution was B1 = 50.4%, B2 = 22.4%, B3 = 17.3%, and missing information = 9.9%. Perineal disease was present in 14.2%. Pertaining to disease location, 35.2% of patients had disease in L1, 16.8% in L2, 48% in L3, and 0.4% in L4. There was no difference in phenotype by gender, anxiety score, depression score. Disease duration was significantly different depending on disease behavior type (B1 = 12.2 ± 10.1; B2 = 19.4 ± 12.9; B3 = 18.9 ± 11.8, P < .0001). Isolated colonic disease was much less likely to be fibrostenotic or penetrating than inflammatory disease. Penetrating disease was more likely to be associated with ileocolonic location than other locations. Perineal disease was most commonly seen in persons with B3 disease behavior (24%) than other behaviors (11% B1; 20% B2 disease, P < .0001) and more likely to be seen in ileocolonic disease (L3;19%) vs L2 (17%) and L1 (11%; P < .0001). Surgery related to IBD occurred across each behavior types at the following rates: B1 = 23%, B2 = 64%, and B3 = 74%. Inflammatory bowel disease-related surgery rates by location of disease were L1 = 48%, L2 = 21%, and L3 = 51%.

CONCLUSIONS

In exploring this large contemporary CD cohort we have determined that inflammatory disease is the main CD phenotype in Canada and that CD-related surgery remains very common.

Impact of pericarditis on cardiovascular complications and healthcare utilization in patients with inflammatory bowel disease: a National Inpatient Sample study

Background

Inflammatory bowel disease (IBD), which affects over 2.3 million people in the USA, involves chronic gut inflammation and can lead to cardiovascular complications, including pericarditis. Whether pericarditis in IBD patients is caused by medication, or by the disease itself, remains unclear. Our study aimed to determine the prevalence of pericarditis in IBD and its impact on cardiac complications, outcomes and resource utilization.

Methods

NIS data were obtained for IBD patients from 2016-2020. Outcomes were assessed using multivariate logistic regression, adjusting for demographics, hospital characteristics, comorbidities, and IBD etiology.

Results

In our study of 1.52 million IBD patients, 0.6% had pericarditis, of whom a majority were women (54.1%) and white (76.3%), over 65 years old (43.1%), enrolled in Medicare (51.7%), and living in urban areas (96.3%). Adjusting for confounding factors, IBD patients with pericarditis had higher odds of cardiac arrest (adjusted odds ratio [aOR] 2.73, 95% confidence interval [CI] 1.90-3.91), cardiogenic shock (aOR 6.42, 95%CI 4.77-8.64), and ventricular arrhythmia (aOR 2.13, 95%CI 1.63-2.78 (P<0.001 for all).

Conclusions

Our study found that pericarditis, though rare at 0.6%, significantly impacts cardiovascular health and healthcare utilization in IBD patients, with higher prevalence of pericarditis in older individuals, females, and those with comorbidities such as diabetes, hypertension or chronic kidney disease highlighting the need for further research to enhance therapeutic approaches and patient care.

Dual Biologic Therapy Induces Remission in Refractory Crohn's Disease With Vedolizumab and Ustekinumab

Background

Despite advancements in the therapeutic armamentarium for Crohn's disease (CD), biologic and small molecule monotherapies are associated with sub-optimal response and remission rates. Utilizing dual biologic therapy (DBT) holds the potential to increase efficacy in the treatment of refractory or partially responsive CD. Evidence pertaining to this strategy remains limited.

Methods

We retrospectively examined refractory CD patients treated with a combination of ustekinumab and vedolizumab. Outcomes to DBT at week (wk) 52 were compared to monotherapy. The primary outcome constituted corticosteroid-free remission. Secondary outcomes included adverse events, infections, hospitalizations, surgeries, treatment persistence, and disease clearance.

Results

Sixteen of 21 active refractory CD patients (76%) on DBT achieved disease remission at wk 52. Mucosal healing was observed in 38% (n = 6), biochemical remission in 25% (n = 4), and both clinical and biochemical remission in 38% (n = 6). Of these patients, 50% (n = 8) achieved corticosteroid-free remission. Three patients (37.5%) with corticosteroid-free remission achieved complete disease clearance. Paired median fecal calprotectin decreased from 508 to 118 µg/g (P < .0001). Paired C-reactive protein median decreased from 1.04 to 0.50 mg/dL (P < .0001). Median Harvey Bradshaw Index score reduced from 7 to 2 (P = .003). Endoscopic healing was achieved with a paired simple endoscopic score for CD decrease from 6 to 3 (P = .013). Corticosteroid dependency reduced from 17 to 8 patients discontinuing altogether. Patients still requiring corticosteroids experienced a decrease in average daily dose from 9 to 6 mg (P = .045). At wk 52, 5 patients (24%) did not meet the criteria for remission with 4 requiring CD-related surgical intervention. Mean CD-related hospitalizations reduced from 2.95 ± 2.33 to 0.52 ± 1.12 (P < .001) and surgeries from 1.76 ± 1.3 to 0.14 ± 0.4 (P < .001). Three infections with 1 requiring hospitalization and 1 report of headache were noted. Two patients discontinued DBT.

Conclusions

Dual biologic therapy with ustekinumab and vedolizumab is a safe and effective strategy to induce disease remission in refractory CD. Large-scale studies are necessary to validate findings in a prospective setting.

Immunogenicity of Therapeutic Antibodies Used for Inflammatory Bowel Disease: Treatment and Clinical Considerations

The introduction of tumor necrosis factor inhibitors has led to a paradigm shift in the management of inflammatory bowel disease (IBD). The subsequent introduction of both anti-integrins and cytokine blockers has since expanded the biologic armamentarium. However, immunogenicity, defined as the production of anti-drug antibodies (ADAs) to the prescribed biopharmaceutical, means a significant fraction of patients exposed to biologic agents will experience a secondary loss of response to one or more of the drugs. In clinical settings, immunogenicity may be caused by several factors, both patient related (e.g., underlying chronic disease, systemic immune burden, including previous biologic therapy failure, and [epi]genetic background) and treatment related (e.g., dose and administration regimens, drug physical structure, photostability, temperature, and agitation). Here, we outline these elements in detail to enhance biopharmaceutical delivery and therapy for patients with IBD. Moreover, concurrent immunomodulator medication may reduce the risks of ADA generation, especially when using the chimeric drug infliximab. Summarizing the latest developments and knowledge in the field, this review aims to provide strategies to prevent ADA production and information on managing non-responsiveness or loss of response to biologics. Better understanding of the molecular mechanisms underlying the formation of ADAs and the critical factors influencing the immunogenicity of biopharmaceuticals may lead to improved health outcomes in the IBD community that may benefit both the individual patient and society through lower healthcare expenses.

Polystyrene nanoplastics promote colitis-associated cancer by disrupting lipid metabolism and inducing DNA damage

Nanoplastics (NPs) have attracted widespread attention owing to their presence in the body. Recent studies highlighted the detrimental effects of NPs on the digestive tract. However, no studies have reported an association between NPs exposure and colitis-associated cancer (CAC). An azoxymethane/dextran sodium sulfate-induced CAC model was used, and polystyrene nanoparticles (PS-NPs) were selected for long-term exposure. Non-targeted metabolomics and 16S rRNA sequencing were used to detect changes in colonic metabolites and gut microbes following PS-NPs exposure. A lipopolysaccharide (LPS)-treated cancer cell model (Caco-2) exposed to PS-NPs was used to investigate the underlying molecular mechanism. Compared to the normal control group, mice in the PS-NPs group exhibited more tumor nodes and reactive oxygen species (ROS), higher expression of pan-CK and Ki-67, and more severe DNA damage. 16S rRNA sequencing revealed that exposure to PS-NPs altered the abundance of Allobaculum and Lactobacillus, whereas metabolic analysis showed that the most significant metabolites were enriched mostly in fatty acid metabolism. Experiments in LPS intervened Caco-2 cells showed that exposure to PS-NPs led to lipid peroxidation, oxidative stress, and DNA damage in Caco-2. Exposure to PS-NPs activated the phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) signaling pathway both in the AOM/DSS mouse model and cellular model. Key proteins involved in fatty acid metabolism were downregulated in Caco-2 cells exposed to PS-NPs. The metabolic effects of cancer cells exposed to PS-NPs were significantly inhibited by the activation of the fatty acid metabolism pathway by fenofibrate. PS-NPs exposure disturbed lipid metabolism and induced DNA damage via the activation of PI3K/AKT/mTOR to promote CAC progression. Inhibition of fatty acid metabolism is a therapeutic target for controlling PS-NP-induced CAC. Our study provides an important reference for the prevention and treatment of CAC from the perspective of the environment and enhances awareness of the necessity of plastic control.

The Role of Diet in Inflammatory Bowel Disease Onset, Disease Management, and Surgical Optimization

The concept of using diet as therapy in inflammatory bowel disease is of interest to clinicians and patients. Once considered to play a minor role, diet is now known to not only affect disease onset but may also serve as a therapeutic tool for inducing and maintaining remission and improving surgical outcomes. Further research is needed to fully elucidate how, when, and in whom diet therapies may be best applied to improve clinical and disease outcomes. The aim of this review was to summarize current research findings and serve as a tool to help facilitate patient-clinician conversations.

Geographical and sociodemographic epidemiology of inflammatory bowel disease in young females from 2010 to 2019

BACKGROUND AND AIMS

Inflammatory Bowel Disease (IBD) represents a significant health threat worldwide. However, there are deficiencies in large-scale epidemiological research focusing on these issues, especially among young women. We aim to examine the trend of IBD in young females globally.

METHODS

We utilized data from the Global Burden of Disease (GBD) study between 2010 and 2019 to conduct a comprehensive analysis of the prevalence, mortality, and disability-adjusted life years (DALYs) from IBD in young females (15-49 years), stratified by region, nation, and sociodemographic index (SDI).

RESULTS

Globally, there were 1.27 million (95 % UI 1.10 to 1.45 million) cases and 314,120 (95 % UI 240,880 to 395,420) DALYs from IBD in young females in 2019. Geographically, Europe had the highest burden of IBD in young females (n = 421,320). From 2010 to 2019, the prevalence rate increased in Africa (APC 0.34 %, 95 % CI 0.25 to 0.44 %), the Eastern Mediterranean (APC 0.77 %, 95 % CI 0.74 to 0.81 %), Europe (APC 0.48 %, 95 % CI 0.44 to 0.51 %) and the Western Pacific region (APC 1.01 %, 95 % CI 0.89 to 1.14 %). Countries with lower SDI exhibited higher DALYs to prevalence ratio. Over the study period, the percentage of young women with IBD compared to young adults increased by 0.24 %. This percentage varies significantly between countries, from 26 % to 62 %.

CONCLUSION

The burden of IBD in young females is high and increasing. Countries with lower SDIs generate higher disability per case. This necessitates immediate and inclusive measures to tackle the rising burden of IBD in this vulnerable group.

LAY SUMMARY

From 2010 to 2019, in the largest global epidemiology database, prevalence rates of inflammatory bowel disease in young females increased in many regions. Countries with lower socioeconomic development, as indicated by sociodemographic index, generated a higher burden compared to countries with higher development.

Greater Fatigue and Reduced Neurocognitive Speed With Symptomatic Crohn's Disease

Background

While patients with Crohn's disease commonly report fatigue, an association of Crohn's disease with mild neurocognitive impairment has also been suggested. This study investigated the relationship between Crohn's disease activity, fatigue, and neurocognitive functioning.

Methods

In this cross-sectional study, adults with Crohn's disease (n = 25) and healthy controls (n = 26) completed the PROMIS Fatigue 7a form and Multidimensional Fatigue Inventory and neurocognitive testing across 6 domains. Symptomatic and endoscopic remission were assessed with a short Crohn's Disease Activity Index and Simple Endoscopic Score for Crohn's Disease. Linear regression adjusting for age and sex was used to compare fatigue and neurocognition among patients with Crohn's disease versus controls and those with active Crohn's disease versus those in remission.

Results

Compared to controls, adults with Crohn's disease reported greater overall and domain-specific fatigue (general, physical, and mental) (P < .05 for all comparisons). Patients in symptomatic remission had significantly less fatigue (P < .05). No differences were found in neurocognitive accuracy or speed between Crohn's disease and controls. Disease activity was not associated with accuracy on neurocognitive testing; however, patients with symptomatic Crohn's disease had longer correct response times for social cognition and episodic memory compared to asymptomatic patients (P < .05). Endoscopic disease activity was associated with longer correct response times for tasks linked to social cognition, episodic memory, and complex cognition (P < .05). These differences persisted after adjusting for fatigue.

Conclusions

Patients with symptomatic Crohn's disease experience greater fatigue and have slower response times on neurocognitive testing. However, fatigue does not appear to mediate the slower response times.

Upadacitinib is associated with clinical response and steroid-free remission for children and adolescents with inflammatory bowel disease

OBJECTIVE

Upadacitinib, an oral Janus kinase inhibitor (JAKi), is approved for inflammatory bowel disease (IBD) in adults. As on-label use will face significant delay in pediatrics, a real-world understanding of safety and efficacy in children is critical.

METHODS

This is a single-center retrospective cohort of pediatric subjects (ages 9-20 years) with a diagnosis of IBD initiated on upadacitinib. The primary outcome was clinical response following induction (decrease of ≥20 points in the Pediatric Ulcerative Colitis Activity Index [PUCAI] or ≥12.5 points for the Pediatric Crohn's Disease Activity Index [PCDAI]). Secondary outcomes included steroid-free clinical remission (SF-CR) following induction and at Week 24 (PUCAI or PCDAI ≤10), post-induction mucosal response and remission (Mayo for ulcerative colitis [UC]/IBD-unclassified [IBD-U] and simple-endoscopic scoring for CD), and improvement in calprotectin and C-reactive protein (CRP) post-induction. Monitoring for adverse events was recorded.

RESULTS

Twenty subjects (40% female with a median age of 16.3 years; 3 CD, 13 UC, 4 IBD-U) were initiated on upadacitinib. Clinical response at Week 8 (UC/IBD-U) and Week 12 (CD), was achieved in 90% (18/20). SF-CR was seen in 75% (16/20) following induction and maintained in 65% (11/17) reaching Week 24 of therapy. In subjects with UC/IBD-U (17), PUCAI was significantly improved at Weeks 8 and 24. Calprotectin post-induction showed a significant downtrend, whereas CRP did not. Endoscopic response was noted in seven of the eight cases, with three achieving endoscopic remission. One patient underwent subtotal colectomy after 2 weeks of upadacitinib induction. Another patient stopped therapy following the creation of a diverting ileostomy secondary to rectal perforation experienced following manual dilation of a rectal stricture. No new safety signals were reported.

CONCLUSION

Therapeutic options for children with IBD remain limited. In cases refractory to approved agents, our experience suggests that upadacitinib is effective with no new safety signals in a small subset of patients with IBD (ages 9-20 years) treated at a children's hospital.

Racial, Ethnic, and Geographic Disparities in Digestive Diseases Mortality in the United States, 2000-2019

BACKGROUND AND AIMS

The global burden of digestive diseases mortality has been increasing over the last 3 decades. However, little is known about disparities in digestive diseases-specific mortality in the United States. This study aimed to examine racial, ethnic, and state- and county-level disparities in digestive diseases mortality rate in the United States between 2000 and 2019.

METHODS

We used the Institute of Health Metrics and Evaluation Global Health Data Exchange to gather digestive diseases age-standardized mortality rates for 5 racial and ethnic groups (White, Black, Latino, American Indian/Alaska Native [AI/AN], and Asian/Pacific Islander [API]) by sex, state, and county between 2000 and 2019. We used joinpoint regression analysis to evaluate the overall temporal trends by demography.

RESULTS

The overall cause-specific mortality rate decreased from 36.0 to 34.5 deaths per 100,000 population across all groups (2000-2019). In 2019, AI/AN individuals had the highest mortality rate (86.2), followed by White (35.5), Latino and Black (both at 33.6), and API (15.6) individuals. Significant increases occurred across some of the racial and ethnic groups, with an increased average annual percentage change for 2000-2019 among AI/AN (0.87%; 95% confidence interval, 0.77%-0.97%) and White individuals (0.12%; 95% confidence interval, 0.02%-0.22%) particularly among females, while Latino, Black, and API individuals showed reduced average annual percentage change for 2000-2019. AI/AN constitutes the main race affected in the top 10 counties. Substantial state-level variation emerged, with the highest mortality rates in 2019 seen in West Virginia.

CONCLUSIONS

Despite an overall decrease in digestive diseases mortality, significant disparities persist across racial and ethnic groups. AI/AN and White individuals experienced increased mortality rates, particularly among females. Targeted interventions and further research are needed to address these disparities and improve digestive health equity.

The effect of minimally invasive surgery on thirty-day postoperative outcomes of frail patients undergoing emergency colon resections

BACKGROUND

Frail patients have poor outcomes after emergent colon surgery. While minimally invasive surgery has shown improved outcomes in the general patient population undergoing colectomy, the benefits in frail patients are unknown.

METHODS

We identified frail patients who underwent urgent or emergent colon resections from 2017 to 2021 in the National Surgical Quality Improvement Program database. We defined frail as a score of 2 or greater on the modified frailty index. We used inverse probability of treatment weighted analysis to determine the association of surgical technique with 30-day postoperative outcomes independent of confounding variables.

RESULTS

Of the 11,976 frail patients, 10,293 (87.2%) underwent open surgery and 1,503 (12.7%) underwent minimally invasive surgery. Patients who underwent open surgery had significantly more comorbid conditions. The most common diagnosis for patients who underwent open surgery was intra-abdominal sepsis (59.6%) and neoplasms for patients who underwent minimally invasive surgery (42%). After the inverse probability of treatment weighted analysis, the standardized difference was reduced to 1.7% or less. At 30 days from surgery, minimally invasive surgery was independently associated with reduced risk of death: 4.6% (odds ratio, 0.95; 95% confidence interval, 0.93-0.97; P < .001), severe complications: 6.9% (odds ratio, 0.93; 95% confidence interval, 0.90-0.95, P < .001), any complication: 8.8% (odds ratio, 0.91; 95% confidence interval, 0.88-0.94, P < .001), septic shock: 5.9% (odds ratio, 0.94; 95% confidence interval, 0.92-0.96 P < .001), postoperative bleeding: 4% (odds ratio, 0.95; 95% confidence interval, 0.93-0.98, P < .001), hospital stay >14 days: 4.2% (odds ratio, 0.95; 95% confidence interval, 0.92-0.99, P = .02).

CONCLUSION

In this vulnerable population of frail patients, minimally invasive surgery was associated with reduced risk of morbidity and mortality in the 30 days after emergency colectomy. A minimally invasive surgery approach should be considered in emergency colon surgeries, provided proficient resources are available.

Oral Pathogens' Substantial Burden on Cancer, Cardiovascular Diseases, Alzheimer's, Diabetes, and Other Systemic Diseases: A Public Health Crisis-A Comprehensive Review

This review synthesizes the findings from 252 studies to explore the relationship between the oral pathogens associated with periodontitis, dental caries, and systemic diseases. Individuals with oral diseases, such as periodontitis, are between 1.7 and 7.5 times (average 3.3 times) more likely to develop systemic diseases or suffer adverse pregnancy outcomes, underscoring the critical connection between dental and overall health. Oral conditions such as periodontitis and dental caries represent a significant health burden, affecting 26-47% of Americans. The most important oral pathogens, ranked by publication frequency, include the herpes virus, C. albicans, S. mutans, P. gingivalis, F. nucleatum, A. actinomycetemcomitans, P. intermedia, T. denticola, and T. forsythia. The systemic diseases and disorders linked to oral infections, ranked similarly, include cancer, respiratory, liver, bowel, fever, kidney, complications in pregnancy, cardiovascular bacteremia, diabetes, arthritis, autoimmune, bladder, dementia, lupus, and Alzheimer's diseases. Evidence supports the efficacy of dental and periodontal treatments in eliminating oral infections and reducing the severity of systemic diseases. The substantial burden that oral pathogens have on cancer, cardiovascular diseases, Alzheimer's, diabetes, and other systemic diseases poses a significant public health crisis.

Composition of Human-Associated Gut Microbiota Determines 3-DF and 3-HF Anti-Colitic Activity in IL-10 -/- Mice

BACKGROUND

Gut bacterial dysbiosis along with intestinal mucosal disruption plays a critical role in inflammatory disorders like ulcerative colitis. Flavonoids and other food bioactives have been studied in mice models as alternative treatments with minimal side effects. However, most of the research has been carried out with mice-native microbiota, which limits the comprehension of the interaction between flavonoids and human-associated bacteria. Hence, the objective of our study was to determine the effect of healthy human-associated microbiota on the anti-colitic activity of diets rich in anthocyanins (3-HF) and phlobaphenes (3-DF).

METHODS

In this regard, the interleukin (IL)-10 -/- mice model was utilized. Mice were divided into three groups for inoculation with human gut bacteria from three different healthy donors and assigned to four diets. A purified diet (Diet P) and three diets containing 25% near-isogenic lines (NILs) of corn were evaluated. Diets were substituted with NILs expressing only 3-DFs (diet B), only 3-HFs (diet C), and both 3-DF and 3-HF (diet D).

RESULTS

In an overall analysis, flavonoid-rich diets did not affect inflammatory markers, microbiota diversity, or gut metabolites, but diets containing anthocyanins improved barrier function parameters. However, when data was segmented by the recipient's microbiota from different human donors, the diet effects became significant. Furthermore, 3-HFs showed more beneficial effects than 3-DFs across the recipient's microbiota.

CONCLUSIONS

Our study suggests that the anti-colitic activity of 3-DF and 3-HF and their gut metabolites depends on the donor's microbial composition.

AI-luminating Artificial Intelligence in Inflammatory Bowel Diseases: A Narrative Review on the Role of AI in Endoscopy, Histology, and Imaging for IBD

Endoscopy, histology, and cross-sectional imaging serve as fundamental pillars in the detection, monitoring, and prognostication of inflammatory bowel disease (IBD). However, interpretation of these studies often relies on subjective human judgment, which can lead to delays, intra- and interobserver variability, and potential diagnostic discrepancies. With the rising incidence of IBD globally coupled with the exponential digitization of these data, there is a growing demand for innovative approaches to streamline diagnosis and elevate clinical decision-making. In this context, artificial intelligence (AI) technologies emerge as a timely solution to address the evolving challenges in IBD. Early studies using deep learning and radiomics approaches for endoscopy, histology, and imaging in IBD have demonstrated promising results for using AI to detect, diagnose, characterize, phenotype, and prognosticate IBD. Nonetheless, the available literature has inherent limitations and knowledge gaps that need to be addressed before AI can transition into a mainstream clinical tool for IBD. To better understand the potential value of integrating AI in IBD, we review the available literature to summarize our current understanding and identify gaps in knowledge to inform future investigations.

AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis

BACKGROUND & AIMS

This American Gastroenterological Association (AGA) living guideline is intended to support practitioners in the pharmacological management of moderate-to-severe ulcerative colitis (UC).

METHODS

A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations on the pharmacological management of moderate-to-severe UC.

RESULTS

The AGA guideline panel made 14 recommendations. In adult outpatients with moderate-to-severe UC, the AGA recommends the use of infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab, and suggests the use of adalimumab, filgotinib, and mirikizumab over no treatment. In patients who are naïve to advanced therapies, the AGA suggests using a higher-efficacy medication (eg, infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, and guselkumab) or an intermediate-efficacy medication (eg, golimumab, ustekinumab, tofacitinib, filgotinib, and mirikizumab) rather than a lower-efficacy medication (eg, adalimumab). In patients who have previously been exposed to 1 or more advanced therapies, particularly tumor necrosis factor (TNF)-α antagonists, the AGA suggests using a higher-efficacy medication (eg, tofacitinib, upadacitinib, and ustekinumab) or an intermediate-efficacy medication (eg, filgotinib, mirikizumab, risankizumab, and guselkumab) rather than a lower-efficacy medication (eg, adalimumab, vedolizumab, ozanimod, and etrasimod). In adult outpatients with moderate-to-severe UC, the AGA suggests against using thiopurine monotherapy for induction of remission, but suggests using thiopurine monotherapy over no treatment for maintenance of (typically corticosteroid-induced) remission. The AGA suggests against using methotrexate monotherapy, for induction or maintenance of remission. In adult outpatients with moderate-to-severe UC, the AGA suggests the use of infliximab, adalimumab, and golimumab in combination with an immunomodulator over corresponding monotherapy. However, the AGA makes no recommendation in favor of, or against, the use of non-TNF antagonist biologics in combination with an immunomodulator over non-TNF biologic alone. In patients with UC who are in corticosteroid-free clinical remission for at least 6 months on combination therapy of TNF antagonists and an immunomodulator, the AGA suggests against withdrawal of TNF antagonists, but makes no recommendation in favor of, or against, withdrawing immunomodulators. In adult outpatients with moderate-to-severe UC, who have failed 5-aminosalicylates, and have escalated to therapy with immunomodulators or advanced therapies, the AGA suggests stopping 5-aminosalicylates. Finally, in adult outpatients with moderate-severe UC, the AGA suggests early use of advanced therapies and/or immunomodulator therapy, rather than gradual step-up after failure of 5-aminosalicylates. The panel also proposed key implementation considerations for optimal use of these medications and identified several knowledge gaps and areas for future research.

CONCLUSIONS

This guideline provides a comprehensive, patient-centered approach to the pharmacological management of patients with moderate-to-severe UC.

Provider Specialization in Inflammatory Bowel Diseases: Quality of Care and Outcomes

BACKGROUND & AIMS

Management of inflammatory bowel diseases (IBD) is complex and variation in care has been well-documented. However, the drivers of practice variation remain unexplored. We examined variation based on the treating gastroenterologist's IBD focus (proportion of outpatient visits for IBD).

METHODS

We conducted a retrospective cohort of newly diagnosed patients with IBD using data from Optum's deidentified Clinformatics Data Mart Database (2000-2020). The exposure variable was whether the treating gastroenterologist had an IBD focus (>90th percentile of IBD visits/total outpatient visits). We used adjusted regression models to evaluate associations between provider IBD focus and process measures (use of mesalamine, corticosteroid, biologic, and narcotic medications and endoscopic or radiographic imaging) and clinical outcomes (time to IBD-related hospitalization and bowel resection surgery). We tested for change in treatment patterns over time by including an interaction term for study era (2004-2012 vs 2013-2020).

RESULTS

The study included 772 children treated by 493 providers and 2864 adults treated by 2076 providers. In children, none of the associations between provider focus and process or outcome measures were significant. In adults, care from an IBD-focused provider was associated with more use of biologics, combination therapy, and imaging and endoscopy, and less mesalamine use for Crohn's disease (P < .05 for all comparisons) but not with other process measures. Biologics were prescribed more frequently and narcotics less frequently during the later era (P < .05 for both). Hospitalization and surgery rates were not associated with IBD focus or era.

CONCLUSIONS

IBD care for adults varies by provider specialization. Given the evolving complexity, novel methods may be needed to standardize care.

Comparative Efficacy of Advanced Therapies for Management of Moderate-to-Severe Ulcerative Colitis: 2024 American Gastroenterological Association Evidence Synthesis

BACKGROUND & AIMS

We performed an updated systematic review and network meta-analysis to inform the 2024 American Gastroenterological Association (AGA) Clinical Guidelines on the management of moderate-to-severe ulcerative colitis (UC).

METHODS

We searched multiple electronic databases through November 21, 2023, to identify randomized controlled trials in adults with moderate-to-severe UC, comparing different advanced therapies (tumor necrosis factor antagonists, vedolizumab, sphingosine-1-phosphate receptor modulators, interleukin 12/23 or selective interleukin 23 antagonists, and Janus kinase [JAK] inhibitors) against placebo or another active comparator. Our primary outcomes were induction and maintenance of clinical remission, and our secondary outcome was endoscopic improvement. We performed a network meta-analysis using a frequentist approach and applied Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to appraise certainty of evidence.

RESULTS

After excluding JAK inhibitors as potential first-line treatment (in accordance with the United States Food and Drug Administration), low-certainty evidence supports clinically important benefit with infliximab, ozanimod, risankizumab, and guselkumab over adalimumab and mirikizumab for achieving remission with induction therapy in biologically naïve patients with moderate-to-severe UC, with risankizumab and ozanimod being ranked the highest for induction of clinical remission. With the inclusion of JAK inhibitors as first-line therapy, upadacitinib was more efficacious compared with all other medications except ozanimod and risankizumab, with low- to moderate-certainty evidence. In patients with prior biologic exposure, upadacitinib, tofacitinib, and ustekinumab were ranked highest for achieving remission.

CONCLUSIONS

Using Grading of Recommendations, Assessment, Development and Evaluation to appraise quality of evidence, this updated network meta-analysis will be used to inform comparative efficacy and positioning of advanced therapies for the treatment of biologic-naïve and biologic-exposed patients with moderate-to-severe UC.

Bidirectional associations between periodontitis and inflammatory bowel disease: A systematic review of longitudinal studies with meta-analysis and trial sequential analysis

The bidirectional associations between periodontitis and inflammatory bowel disease (IBD) with temporal directionality remain inconclusive. This study aims to evaluate the bidirectional associations between periodontitis and IBD through a systematic review and meta-analysis. Five databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library) were systematically searched from inception to 27 February 2024. Two independent reviewers performed a review of the retrieved studies. Longitudinal studies, including cohort and nested case-control studies, were considered eligible for the study design. The pooled risk ratio (RR) and hazard ratio (HR) derived from the meta-analysis were used to assess whether periodontitis (or IBD) was a risk factor for IBD (or periodontitis). Trial sequential analysis (TSA) was performed to evaluate the reliability of the results. Four studies (n = 10 270 912) on the risk of IBD in patients with periodontitis and two (n = 33 420) on the risk of periodontitis in patients with IBD were included. The result suggested that periodontitis did not increase the risk of IBD (pooled RR = 1.04, 95% confidence interval [CI]: 0.99-1.09; p = .164; I-squared statistic [I2] = 27%). For subtypes of IBD, periodontitis was associated with the occurrence of ulcerative colitis (UC) (pooled RR = 1.12, 95% CI: 1.04-1.21; p = .003; I2 = 38%), but not with Crohn's disease (CD) (pooled RR = 0.98, 95% CI: 0.92-1.04; p = .475; I2 = 0%). Specifically, the risk of UC was higher among men (pooled HR = 1.11, 95% CI: 1.01-1.22; p = .025; I2 = 0%) and smokers (pooled HR = 1.23, 95% CI: 1.07-1.42; p = .004; I2 = 0%) with periodontitis than their counterparts without periodontitis. Patients with IBD may have a higher risk of developing periodontitis (pooled HR = 1.37, 95% CI: 1.26-1.49; p < .001; I2 = 18%); however, whether IBD subtypes increased the occurrence of periodontitis remained uncertain. The TSA results confirmed the reliability of the primary findings. Based on limited longitudinal evidence, patients with periodontitis do not exhibit an increased risk of developing IBD overall, but they are at increased risk of UC (not CD). On the contrary, patients with IBD have a higher risk of developing periodontitis over time. More high-quality longitudinal studies are needed to determine the effect of specific subtypes of IBD on periodontitis.

The Impact of Inflammatory Bowel Diseases on Patients' Quality of Life and Work Functionality: An Observational Study

BACKGROUND

This study aimed to assess the employment status, quality of life, and work functionality in patients affected by inflammatory bowel diseases (IBDs).

METHODS

Patients (N = 216) were enrolled between June 2020 and October 2021. Personal, clinical, and occupational features were investigated. The Short Inflammatory Bowel Disease Questionnaire and the Work Productivity and Activity Impairment questionnaire were administered.

RESULTS

Among the enrolled patients, 114 (53%) were employed. The mean absenteeism and presenteeism percentages of 10% and 37% were determined, with 44% and 39% of daily and work activity impairment, respectively. A poor Health-Related Quality of Life (HRQoL) was retrieved (47 ± 12). Extraintestinal manifestations, disease activity, and HRQoL were associated with occupational outcomes.

CONCLUSIONS

IBD can impact patients' work functionality. The association between clinical, psychological, and occupational issues suggests the relevance for a multidisciplinary management of the disease.

Pharmacokinetics and Exposure-Response Analyses to Support Dose Selection of Upadacitinib in Crohn's Disease

Upadacitinib, a selective Janus kinase inhibitor, is the first orally administered therapy approved for the treatment of Crohn's disease (CD). This work characterized the pharmacokinetics of upadacitinib in CD patients and evaluated the relationships between upadacitinib steady-state plasma exposures and efficacy as well as safety parameters during the 12-week induction and the 52-week maintenance periods, to provide dosing recommendations for the treatment of CD. Upadacitinib pharmacokinetics in CD patients administered the extended-release formulation were consistent with patient populations in other approved indications. None of the evaluated CD-specific patient characteristics (e.g., disease location and prior gastrointestinal surgeries) had a meaningful impact on upadacitinib pharmacokinetics. Exposure-response analyses during 12-week induction treatment showed that response across all evaluated efficacy end points were approaching a plateau at median plasma exposures associated with 45 mg QD. Analyses for the maintenance period demonstrated that 30 mg QD is predicted to provide an additional 8% to 10% benefit for endoscopic response and endoscopic remission compared with 15 mg QD in patients who failed biologics. The analyses for safety showed a statistically significant relationship between increasing upadacitinib plasma exposures and the percentage of patients experiencing >2 g/dL decrease in hemoglobin from Baseline during induction and showed shallow relationships for serious infections and herpes zoster during the maintenance period. These results demonstrated adequate absorption of the extended-release formulation of upadacitinib in CD patients. The exposure-response analyses confirmed that 45 mg QD dose maximized efficacy as induction treatment and supported the selection of 15 mg QD or 30 mg QD as the maintenance doses.

Sex and gender in inflammatory bowel disease outcomes and research

Extensive patient heterogeneity is a challenge in the management of inflammatory bowel disease (IBD). Sex and gender, as well as the interaction of sex and gender with other social identities, referred to as intersectionality, contribute to this heterogeneity and might affect IBD outcomes. An interdisciplinary team of clinicians, researchers, patients, and sex and gender experts reviewed current literature on the effect of sex and gender dimensions on IBD outcomes. The team also investigated the role that stakeholders have in advancing sex-based and gender-based IBD knowledge, as comprehensive studies are scarce. Acknowledging and integrating sex and gender into the organisation and content of research (eg, study design, participant recruitment, data analysis, data interpretation, data dissemination, and impact evaluation) could enhance the validity, relevance, and applicability of research. Such gendered innovation has potential for advancing personalised medicine and improving the quality of life for people with IBD.

Regional specialization within the mammalian respiratory immune system

The respiratory tract is exposed to infection from inhaled pathogens, including viruses, bacteria, and fungi. So far, a comprehensive assessment that integrates common and distinct aspects of the immune response along different areas of the respiratory tract has been lacking. Here, we discuss key recent findings regarding anatomical, functional, and microbial factors driving regional immune adaptation in the mammalian respiratory system, how they differ between mice and humans, and the similarities and differences with the gastrointestinal tract. We demonstrate that, under evolutionary pressure, mammals evolved spatially organized immune defenses that vary between the upper and lower respiratory tract. Overall, we propose that the functional specialization of the immune response along the respiratory tract has fundamental implications for the management of infectious or inflammatory diseases.