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Chen D, Woo JMP, Parks CG, Lawrence KG, O'Brien KM, Sandler RS, Sandler DP. Childhood and adolescent residential and farm pesticide exposures and inflammatory bowel disease incidence in a U.S. cohort of women. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 946:174475. [PMID: 38964382 PMCID: PMC11296211 DOI: 10.1016/j.scitotenv.2024.174475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND AIMS There are few known risk factors for inflammatory bowel disease (IBD), an autoimmune disease characterized by chronic intestinal inflammation. Use of specific pesticides has been associated with higher incidence of IBD among pesticide applicators and their spouses, but no study has examined pesticide exposure in early life, a period where the human immune system undergoes rapid changes. We evaluated pesticide use during childhood and adolescence and incidence of IBD among US women enrolled in the Sister Study. METHODS Incident IBD diagnoses between enrollment (2003-2009) and 2021 were identified and validated with medication use and colectomy/colostomy surgery. We estimated hazard ratios (HR) and 95 % confidence intervals (CI) for the relationship of childhood/adolescent residential and farm pesticide exposures with IBD incidence using Cox models, accounting for age, race and ethnicity, education, smoking, and birth year. RESULTS We identified 277 incident IBD cases among 48,382 eligible participants. IBD hazard was elevated among those whose childhood residence was regularly treated with pesticides, especially among those who ever personally applied pesticides (HR = 1.39, 95%CI: 0.65, 2.99). We observed a positive association between IBD and exposure to broadcast pesticide sprays before DDT was banned (>6 times vs. never HR = 1.56, 95%CI: 1.06, 2.31). Among participants who lived on a farm during childhood/adolescence for ≥1 year (N = 9162), IBD hazards were higher among those who were in crop fields during pesticide application (HR = 2.06, 95%CI: 0.94, 4.51) and who ever personally applied pesticides on crops (HR = 1.85, 95%CI: 0.81, 4.18) or livestock (HR = 2.58, 95%CI: 1.14, 5.83). CONCLUSION Early-life pesticide exposure may be a novel risk factor for IBD. Practices that reduce pesticide exposure during early life may help reduce the burden of this disease.
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Affiliation(s)
- Dazhe Chen
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Jennifer M P Woo
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Christine G Parks
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Kaitlyn G Lawrence
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Katie M O'Brien
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
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Thacker N, Duncanson K, Eslick GD, Dutt S, O'Loughlin EV, Hoedt EC, Collins CE. Antibiotics, passive smoking, high socioeconomic status and sweetened foods contribute to the risk of paediatric inflammatory bowel disease: A systematic review with meta-analysis. J Pediatr Gastroenterol Nutr 2024. [PMID: 39020449 DOI: 10.1002/jpn3.12303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVE Genetic and environmental factors influence pathogenesis and rising incidence of paediatric inflammatory bowel disease (PIBD). The aim was to meta-analyse evidence of diet and environmental factors in PIBD. METHODS A systematic search was conducted to identify diet and environmental factors with comparable risk outcome measures and had been reported in two or more PIBD studies for inclusion in meta-analyses. Those with ≥2 PIBD risk estimates were combined to provide pooled risk estimates. RESULTS Of 4763 studies identified, 36 studies were included. PIBD was associated with higher risk with exposure to ≥/=4 antibiotic courses (includes prescriptions/purchases/courses), passive smoking, not being breastfed, sugary drink intake, being a non-Caucasian child living in a high-income country and infection history (odds ratio [OR] range: 2-3.8). Paediatric Crohn's disease (CD) was associated with higher risk with exposure to antibiotics during early childhood, ≥/=4 antibiotic courses, high socioeconomic status (SES), maternal smoking, history of atopic conditions and infection history (OR range: 1.6-4.4). A history of infection was also associated with higher risk of paediatric ulcerative colitis (UC) (OR: 3.73). Having a higher number of siblings (≥2) was associated with lower risk of paediatric CD (OR: 0.6) and paediatric UC (OR: 0.7). Pet exposure was associated with lower risk of paediatric UC (OR: 0.5). CONCLUSION Several factors associated with PIBD risk were identified that could potentially be used to develop a disease screening tool. Future research is needed to address risk reduction in PIBD.
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Affiliation(s)
- Nisha Thacker
- School of Health Sciences, College of Health Medicine and Wellbeing, The University of Newcastle, Sydney, New South Wales, Australia
- Food and Nutrition Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kerith Duncanson
- Food and Nutrition Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Sydney, New South Wales, Australia
- NHMRC Centre of Research Excellence in Digestive Health, The University of Newcastle, Sydney, New South Wales, Australia
| | - Guy D Eslick
- NHMRC Centre of Research Excellence in Digestive Health, The University of Newcastle, Sydney, New South Wales, Australia
| | - Shoma Dutt
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Westmead, New South Wales, Australia
- Children's Hospital at Westmead Clinical School, Sydney Medical Program, University of Sydney, Sydney, New South Wales, Australia
| | - Edward V O'Loughlin
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney Children's Hospital Network, Westmead, New South Wales, Australia
| | - Emily C Hoedt
- NHMRC Centre of Research Excellence in Digestive Health, The University of Newcastle, Sydney, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Sydney, New South Wales, Australia
| | - Clare E Collins
- School of Health Sciences, College of Health Medicine and Wellbeing, The University of Newcastle, Sydney, New South Wales, Australia
- Food and Nutrition Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Chang C, Louie A, Zhou Y, Gupta R, Liang F, Xanthou G, Ereso J, Koletic C, Yang JC, Sedighian F, Lagishetty V, Arias-Jayo N, Altuwayjiri A, Tohidi R, Navab M, Reddy ST, Sioutas C, Hsiai T, Araujo JA, Jacobs JP. Ambient Particulate Matter Induces In Vitro Toxicity to Intestinal Epithelial Cells without Exacerbating Acute Colitis Induced by Dextran Sodium Sulfate or 2,4,6-Trinitrobenzenesulfonic Acid. Int J Mol Sci 2024; 25:7184. [PMID: 39000289 PMCID: PMC11241079 DOI: 10.3390/ijms25137184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/14/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Inflammatory bowel disease (IBD) is an immunologically complex disorder involving genetic, microbial, and environmental risk factors. Its global burden has continued to rise since industrialization, with epidemiological studies suggesting that ambient particulate matter (PM) in air pollution could be a contributing factor. Prior animal studies have shown that oral PM10 exposure promotes intestinal inflammation in a genetic IBD model and that PM2.5 inhalation exposure can increase intestinal levels of pro-inflammatory cytokines. PM10 and PM2.5 include ultrafine particles (UFP), which have an aerodynamic diameter of <0.10 μm and biophysical and biochemical properties that promote toxicity. UFP inhalation, however, has not been previously studied in the context of murine models of IBD. Here, we demonstrated that ambient PM is toxic to cultured Caco-2 intestinal epithelial cells and examined whether UFP inhalation affected acute colitis induced by dextran sodium sulfate and 2,4,6-trinitrobenzenesulfonic acid. C57BL/6J mice were exposed to filtered air (FA) or various types of ambient PM reaerosolized in the ultrafine size range at ~300 μg/m3, 6 h/day, 3-5 days/week, starting 7-10 days before disease induction. No differences in weight change, clinical disease activity, or histology were observed between the PM and FA-exposed groups. In conclusion, UFP inhalation exposure did not exacerbate intestinal inflammation in acute, chemically-induced colitis models.
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Affiliation(s)
- Candace Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- Molecular Toxicology Interdepartmental Program, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Allen Louie
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- Molecular Toxicology Interdepartmental Program, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Yi Zhou
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
- West China Medical Center, Sichuan University, Chengdu 610017, China
| | - Rajat Gupta
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- Molecular Toxicology Interdepartmental Program, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Fengting Liang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Georgina Xanthou
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Jason Ereso
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Carolina Koletic
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Julianne Ching Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Farzaneh Sedighian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Venu Lagishetty
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Nerea Arias-Jayo
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
| | - Abdulmalik Altuwayjiri
- USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA; (A.A.); (R.T.); (C.S.)
- Department of Civil and Environmental Engineering, College of Engineering, Majmaah University, Al-Majmaah 11952, Saudi Arabia
| | - Ramin Tohidi
- USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA; (A.A.); (R.T.); (C.S.)
- Air Quality Planning and Science Division, California Air Resources Board, 4001 Iowa Avenue, Riverside, CA 92507, USA
| | - Mohamad Navab
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
| | - Srinivasa Tadiparthi Reddy
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- West China Medical Center, Sichuan University, Chengdu 610017, China
- Molecular & Medical Pharmacology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Constantinos Sioutas
- USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA; (A.A.); (R.T.); (C.S.)
| | - Tzung Hsiai
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- Henry Samueli School of Engineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Jesus A. Araujo
- Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (A.L.); (R.G.); (M.N.); (S.T.R.); (T.H.)
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA
- Molecular Toxicology Interdepartmental Program, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Jonathan P. Jacobs
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (C.C.); (Y.Z.); (F.L.); (G.X.); (J.E.); (C.K.); (J.C.Y.); (F.S.); (V.L.); (N.A.-J.)
- Molecular Toxicology Interdepartmental Program, University of California Los Angeles, Los Angeles, CA 90095, USA
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Goodman-Luskin Microbiome Center, University of California Los Angeles, Los Angeles, CA 90095, USA
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Chen D, Parks CG, Hofmann JN, Beane Freeman LE, Sandler DP. Pesticide use and inflammatory bowel disease in licensed pesticide applicators and spouses in the Agricultural Health Study. ENVIRONMENTAL RESEARCH 2024; 249:118464. [PMID: 38354883 PMCID: PMC11065595 DOI: 10.1016/j.envres.2024.118464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Pesticide exposure has been linked to some autoimmune diseases and colorectal cancer, possibly via alteration of gut microbiota or other mechanisms. While pesticides have been linked to gut dysbiosis and inflammation in animal models, few epidemiologic studies have examined pesticides in relation to inflammatory bowel disease (IBD). OBJECTIVES We evaluated use of pesticides and incident IBD in 68,480 eligible pesticide applicators and spouses enrolled in the Agricultural Health Study. METHODS Self-reported IBD cases were identified from follow-up questionnaires between enrollment (1993-1997) and 2022. We evaluated IBD incidence in relation to self-reported ever use of 50 pesticides among applicators and spouses. We also explored associations with intensity-weighted lifetime days (IWLD) of pesticide use among male applicators. Covariate-adjusted hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression. RESULTS We identified 454 IBD cases, including 227 among male applicators. In analyses with applicators and spouses combined, associations were positive (HR > 1.2) for ever vs. never use of five organochlorine insecticides, three organophosphate insecticides, one fungicide, and five herbicides. HRs were highest for dieldrin (HR = 1.59, 95%CI: 1.03, 2.44), toxaphene (HR = 1.61, 95%CI: 1.17, 2.21), parathion (HR = 1.42, 95%CI: 1.03, 1.95), and terbufos (HR = 1.53, 95%CI: 1.19, 1.96). We had limited power in many IWLD of pesticide use analyses and did not find clear evidence of exposure-response trends; however, we observed elevated HRs in all tertiles of IWLD use of terbufos compared to never use (T1 vs. never use HR = 1.52, 95%CI: 1.03, 2.24; T2 vs. never use HR = 1.53, 95%CI: 1.04, 2.26; T3 vs. never use HR = 1.51, 95%CI: 1.03, 2.23). CONCLUSIONS Exposure to specific pesticides was associated with elevated hazards of IBD. These findings may have public health importance given the widespread use of pesticides and the limited number of known modifiable environmental risk factors for IBD.
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Affiliation(s)
- Dazhe Chen
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Christine G Parks
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Jonathan N Hofmann
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
| | - Laura E Beane Freeman
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Rockville, MD, USA
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA.
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Guo A, Östensson M, Størdal K, Ludvigsson J, Mårild K. Early-Life Hygiene-Related Factors and Risk of Inflammatory Bowel Disease: A Scandinavian Birth Cohort Study. Inflamm Bowel Dis 2023:izad257. [PMID: 37921331 DOI: 10.1093/ibd/izad257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We aimed to investigate whether early-life hygiene-related factors influenced the risk of inflammatory bowel disease (IBD) in a Scandinavian population and test the association's consistency across cohorts. METHODS This study followed 117 493 participants in the All Babies in Southeast Sweden study and the Norwegian Mother, Father, and Child Cohort Study. IBD diagnoses were defined by national registers. Comprehensive data on hygiene-related exposures, such as having pets, rural living, daycare attendance, and siblings, were retrieved from questionnaires administered from pregnancy until child's age of 36 months. A multivariable Cox regression model yielded adjusted hazard ratios (aHRs) for IBD accounting for socioeconomic status and perinatal factors. Cohort-specific estimates were pooled using a random-effects model. RESULTS In over 2 024 299 person-years of follow-up 451 participants developed IBD. In pooled estimates children attending daycare up to 36 months of life vs not attending daycare were less likely to develop Crohn's disease (aHR, 0.60; 95% confidence interval [CI], 0.37- 0.98). Children having 1 or more siblings had a modestly increased risk of IBD (aHR, 1.17; 95% CI, 0.96-1.42; aHR for each sibling, 1.12; 95% CI, 1.01-1.24). The other hygiene factors were not significantly linked to later IBD. In the Norwegian Mother, Father, and Child Cohort Study cohort, bed sharing was associated with an increased risk of IBD, most notably for ulcerative colitis (aHR, 1.67; 95% CI, 1.01-2.78). CONCLUSIONS In this birth cohort study from 2 high-income Scandinavian countries, some early-life hygiene-related exposures were associated with IBD risk. The generalizability of these results to countries of other socioeconomic level is unknown.
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Affiliation(s)
- Annie Guo
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Malin Östensson
- Bioinformatics and Data Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ketil Størdal
- Department of Pediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
- Children's Center, Oslo University Hospital, Oslo, Norway
| | - Johnny Ludvigsson
- Crown Princess Victoria Children's Hospital and Div of Pediatrics, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Division of Pediatrics, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Karl Mårild
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
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Wetwittayakhlang P, Gonczi L, Golovics PA, Kurti Z, Pandur T, David G, Erdelyi Z, Szita I, Lakatos L, Lakatos PL. Time Trends of Environmental and Socioeconomic Risk Factors in Patients with Inflammatory Bowel Disease over 40 Years: A Population-Based Inception Cohort 1977-2020. J Clin Med 2023; 12:jcm12083026. [PMID: 37109362 PMCID: PMC10147007 DOI: 10.3390/jcm12083026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Data from population-based studies investigating trends in environmental factors associated with inflammatory bowel disease (IBD) is lacking. We aimed to assess long-term time trends of environmental and socioeconomic factors in IBD patients from a well-defined population-based cohort from Veszprem, Hungary. METHODS Patients were included between 1 January 1977, and 31 December 2020. Trends of environmental and socioeconomic factors were evaluated in three periods based on the decade of diagnosis, representing different therapeutic eras: cohort-A,1977-1995; cohort-B,1996-2008 (immunomodulator era); and cohort-C, 2009-2020 (biological era). RESULTS A total of 2240 incident patients with IBD were included (ulcerative colitis (UC) 61.2%, male 51.2%, median age at diagnosis: 35 years (IQR 29-49)). Rates of active smoking significantly decreased over time in Crohn's disease (CD): 60.2%, 49.9%, and 38.6% in cohorts A/B/C (p < 0.001). In UC, the rates were low and stable: 15.4%, 15.4%, and 14.5% in cohorts A/B/C (p = 0.981). Oral contraceptive use was more common in CD compared to UC (25.0% vs. 11.6%, p < 0.001). In UC, prevalence of appendectomy before diagnosis decreased over time: 6.4%, 5.5%, and 2.3% in cohorts A/B/C (p = 0.013). No significant changes were found in the socio-geographic characteristics of the IBD population (urban living: UC, 59.8%/64.8%/ 62.5% (p = 0.309) and CD, 62.5%/ 62.0%/ 59.0% (p = 0.636), in cohorts A/B/C). A greater percentage of patients had completed secondary school as the highest education level in later cohorts in both UC (42.9%/50.2%/51.6%, p < 0.001) and CD (49.2%/51.7%/59.5%, p = 0.002). A higher percentage of skilled workers (34.4%/36.2%/38.9%, p = 0.027) was found in UC, but not in CD (p = 0.454). CONCLUSION The association between trends of known environmental factors and IBD is complex. Smoking has become less prevalent in CD, but no other major changes occurred in socioeconomic factors over the last four decades that could explain the sharp increase in IBD incidence.
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Affiliation(s)
- Panu Wetwittayakhlang
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand
| | - Lorant Gonczi
- Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Petra A Golovics
- Department of Gastroenterology, Hungarian Defence Forces Medical Centre, 1062 Budapest, Hungary
| | - Zsuzsanna Kurti
- Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Tunde Pandur
- Department of Gastroenterology, Grof Eszterhazy Hospital, 8500 Papa, Hungary
| | - Gyula David
- Department of Gastroenterology, Ferenc Csolnoky Hospital, 8200 Veszprem, Hungary
| | - Zsuzsanna Erdelyi
- Department of Gastroenterology, Ferenc Csolnoky Hospital, 8200 Veszprem, Hungary
| | - Istvan Szita
- Department of Gastroenterology, Ferenc Csolnoky Hospital, 8200 Veszprem, Hungary
| | - Laszlo Lakatos
- Department of Gastroenterology, Ferenc Csolnoky Hospital, 8200 Veszprem, Hungary
| | - Peter L Lakatos
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada
- Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
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Alimam W, Nikkilä A, Raitanen J, Kolho KL, Auvinen A. Residential mobility and childhood inflammatory bowel disease: a nationwide case-control study. Ann Epidemiol 2023; 80:53-61. [PMID: 36764587 DOI: 10.1016/j.annepidem.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE To examine the association of residential mobility, as a proxy for environmental influences, with childhood inflammatory bowel disease (IBD) risk. METHODS Using nationwide register-based dataset, all 2038 IBD cases in Finland diagnosed at ages less than 15 years in 1992-2016 were individually matched by sex and age with five controls employing risk set sampling. Complete residential histories of the subjects were constructed from birth until the index date (diagnosis date of the case). Movement patterns were assessed by age, distance, and demographics of the departure and destination municipalities. Conditional logistic regression was employed to estimate the association between movements and IBD risk. RESULTS Overall, residential movement was associated with a slightly decreased odds ratio (OR) for childhood IBD (OR 0.97, 95% confidence interval (CI) 0.95-1.00 for each movement). Further examination showed reduced ORs for moving to rural municipalities (OR 0.94, 95% CI 0.90-0.98) and to distances less than 50 km (OR 0.96, 95% CI 0.93-0.99). In disease subtype analyses, the effect mainly persisted in ulcerative colitis. CONCLUSIONS Our findings suggest lower childhood IBD risk associated with residential mobility. The effect was found in ulcerative colitis, but not in Crohn's disease. Movements to nearby and rural areas may reduce IBD risk, though this requires further investigation.
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Affiliation(s)
- Wafa Alimam
- The Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland; Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Atte Nikkilä
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Jani Raitanen
- The Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland; UKK Institute for Health Promotion Research, Tampere, Finland; Special Services Unit, Finnish Institute for Health and Welfare, Helsinki, Finland.
| | - Kaija-Leena Kolho
- Children's Hospital, University of Helsinki, Helsinki, Finland; Tampere University Hospital, Department of Pediatrics, Tampere, Finland.
| | - Anssi Auvinen
- The Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland; Tampere University Hospital, Department of Pediatrics, Tampere, Finland.
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8
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Singh N, Bernstein CN. Environmental risk factors for inflammatory bowel disease. United European Gastroenterol J 2022; 10:1047-1053. [PMID: 36262056 PMCID: PMC9752273 DOI: 10.1002/ueg2.12319] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/17/2022] [Indexed: 01/13/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, progressive immune-mediated inflammatory condition of the gastrointestinal tract. Environmental risk factors play a role in developing either type of IBD, Crohn's disease and ulcerative colitis; although the exact mechanism is still unknown. Herein, we review environmental risks from early life exposures, lifestyle and hygiene, vaccinations, surgeries, exposure to drugs and gastrointestinal pathogens that may increase the risk of developing IBD.
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Affiliation(s)
- Noreen Singh
- Department of Internal MedicineMax Rady College of MedicineRady Faculty of MedicineUniversity of ManitobaWinnipegManitobaCanada
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9
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Zhao M, Feng R, Ben-Horin S, Zhuang X, Tian Z, Li X, Ma R, Mao R, Qiu Y, Chen M. Systematic review with meta-analysis: environmental and dietary differences of inflammatory bowel disease in Eastern and Western populations. Aliment Pharmacol Ther 2022; 55:266-276. [PMID: 34820868 DOI: 10.1111/apt.16703] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/16/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND While the incidence of inflammatory bowel disease (IBD) has stabilised in the West, it is still increasing in several newly industrialised countries. AIMS To investigate whether the environmental and dietary risk factors for IBD differ between Eastern and Western populations METHODS: We systematically searched PubMed, Embase, and Web of Science for studies published from inception through June 30, 2020. Data were pooled using a random effects model. RESULTS Overall, 255 studies were assessed. We identified 25 risk factors for IBD, seven of which were noted in both Eastern and Western populations: family history of Crohn's disease [CD] or ulcerative colitis [UC], former smoking (CD/UC), smoking (CD), appendicectomy (CD), tonsillectomy (CD), meat and meat products (CD), and vitamin D deficiency (UC). The remaining factors, including urban living, current smoking, antibiotics, oral contraceptives, caesarean section, isotretinoin, total energy, fat, cholesterol, fatty acids and their sub-classifications, eggs, and soft drinks, were associated with an increased risk of IBD in Western or Eastern populations only. We identified 21 protective factors for IBD, among which eight were common in the East and West: farm animals (CD/UC), Helicobacter pylori infection (CD/UC), multiple births (CD), physical activity (CD), history of breastfeeding (CD), pets (UC), current smoking (UC), and coffee intake (UC). Ten factors conferred protection against IBD in Western populations only, whereas eight factors conferred protection against IBD in Eastern populations only. CONCLUSIONS Numerous environmental and dietary factors influenced the development of IBD in both Western and Eastern populations, whereas certain factors influenced IBD risk differently in these populations.
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Affiliation(s)
- Min Zhao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Gastroenterology Department, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhenyi Tian
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaozhi Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ruiqi Ma
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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10
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Maronek M, Gromova B, Liptak R, Konecna B, Pastorek M, Cechova B, Harsanyova M, Budis J, Smolak D, Radvanszky J, Szemes T, Harsanyiova J, Kralova Trancikova A, Gardlik R. Extracellular DNA Correlates with Intestinal Inflammation in Chemically Induced Colitis in Mice. Cells 2021; 10:E81. [PMID: 33418977 PMCID: PMC7825321 DOI: 10.3390/cells10010081] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/25/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022] Open
Abstract
Circulating extracellular DNA (ecDNA) is known to worsen the outcome of many diseases. ecDNA released from neutrophils during infection or inflammation is present in the form of neutrophil extracellular traps (NETs). It has been shown that higher ecDNA concentration occurs in a number of inflammatory diseases including inflammatory bowel disease (IBD). Enzymes such as peptidyl arginine deiminases (PADs) are crucial for NET formation. We sought to describe the dynamics of ecDNA concentrations and fragmentation, along with NETosis during a mouse model of chemically induced colitis. Plasma ecDNA concentration was highest on day seven of dextran sulfate sodium (DSS) intake and the increase was time-dependent. This increase correlated with the percentage of cells undergoing NETosis and other markers of disease activity. Relative proportion of nuclear ecDNA increased towards more severe colitis; however, absolute amount decreased. In colon explant medium, the highest concentration of ecDNA was on day three of DSS consumption. Early administration of PAD4 inhibitors did not alleviate disease activity, but lowered the ecDNA concentration. These results uncover the biological characteristics of ecDNA in IBD and support the role of ecDNA in intestinal inflammation. The therapeutic intervention aimed at NETs and/or nuclear ecDNA has yet to be fully investigated.
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Affiliation(s)
- Martin Maronek
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, 81108 Bratislava, Slovakia; (M.M.); (B.G.); (B.K.); (M.P.)
| | - Barbora Gromova
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, 81108 Bratislava, Slovakia; (M.M.); (B.G.); (B.K.); (M.P.)
| | - Robert Liptak
- Institute of Physiology, Faculty of Medicine, Comenius University in Bratislava, 81372 Bratislava, Slovakia;
| | - Barbora Konecna
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, 81108 Bratislava, Slovakia; (M.M.); (B.G.); (B.K.); (M.P.)
| | - Michal Pastorek
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, 81108 Bratislava, Slovakia; (M.M.); (B.G.); (B.K.); (M.P.)
| | - Barbora Cechova
- Department of Physiology, Third Faculty of Medicine, Charles University, 10000 Prague, Czech Republic;
| | - Maria Harsanyova
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University in Bratislava, 84215 Bratislava, Slovakia; (M.H.); (D.S.); (T.S.)
- Geneton Ltd., 84104 Bratislava, Slovakia; (J.B.); (J.R.)
| | - Jaroslav Budis
- Geneton Ltd., 84104 Bratislava, Slovakia; (J.B.); (J.R.)
- Comenius University Science Park, Univerzita Komenského, 84104 Bratislava, Slovakia
- Slovak Centre of Scientific and Technical Information, 81104 Bratislava, Slovakia
| | - David Smolak
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University in Bratislava, 84215 Bratislava, Slovakia; (M.H.); (D.S.); (T.S.)
- Geneton Ltd., 84104 Bratislava, Slovakia; (J.B.); (J.R.)
| | - Jan Radvanszky
- Geneton Ltd., 84104 Bratislava, Slovakia; (J.B.); (J.R.)
- Comenius University Science Park, Univerzita Komenského, 84104 Bratislava, Slovakia
- Institute of Clinical and Translational Research, Biomedical Research Center, Slovak Academy of Sciences, 84505 Bratislava, Slovakia
| | - Tomas Szemes
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University in Bratislava, 84215 Bratislava, Slovakia; (M.H.); (D.S.); (T.S.)
- Geneton Ltd., 84104 Bratislava, Slovakia; (J.B.); (J.R.)
- Comenius University Science Park, Univerzita Komenského, 84104 Bratislava, Slovakia
| | - Jana Harsanyiova
- Department of Pathophysiology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 03601 Martin, Slovakia;
| | - Alzbeta Kralova Trancikova
- Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, 03601 Martin, Slovakia;
| | - Roman Gardlik
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University in Bratislava, 81108 Bratislava, Slovakia; (M.M.); (B.G.); (B.K.); (M.P.)
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Zou Y, Wu L, Xu W, Zhou X, Ye K, Xiong H, Song C, Xie Y. Correlation between antibiotic use in childhood and subsequent inflammatory bowel disease: a systematic review and meta-analysis. Scand J Gastroenterol 2020; 55:301-311. [PMID: 32180472 DOI: 10.1080/00365521.2020.1737882] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Antibiotic use leads to a cascade of inflammatory reaction in the gastrointestinal tract due to its association with a temporary disruption of human microbiome.Objectives: To explore the undetermined correlation between antibiotic use in childhood and subsequent inflammatory bowel disease (IBD).Methods: PUBMED, EMBASE and Cochrane Central Register of Controlled Trials were searched to identify related articles. We extracted and pooled the (adjusted) odds ratio (OR) and (adjusted) risk ratio (RR).Results: This systematic review and meta-analysis included 11 studies. The pooled OR of all 11 studies was 1.5 (95% confidence interval (CI): 1.22-1.85). The pooled ORs of the subsequent Crohn's disease and ulcerative colitis after antibiotic use in childhood were 1.59 (95% CI: 1.06-2.4) and 1.22 (95% CI: 0.82-1.8). The sensitivity analysis showed no change. The meta-regression showed there was not statistical significance for the publication year, research area and research methods. Egger's test showed publication bias in the IBD studies (p = .006 < .05) but no publication bias for the CD (p = .275>.05) and UC studies (p = .537>.05).Conclusions: There was a positive association between antibiotic use in childhood and the subsequently risk of Crohn's disease in non-European countries in the west during 2010-2013. Children in the United States taking antibiotics will have a higher risk of subsequently IBD than Europe, Asia and Australia. Registration number: CRD42019147648 (PROSPERO).
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Affiliation(s)
- Yunzhi Zou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Medical College of Nanchang University, Nanchang, Jiangxi, China.,Queen Mary School, Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Lizhi Wu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Wencai Xu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Xiong Zhou
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Kun Ye
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Huifang Xiong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Gastroenterology Institute of Jiangxi Province, Nanchang, Jiangxi, China.,Key Laboratory of Digestive Diseases of Jiangxi Province, Nanchang, Jiangxi, China
| | - Conghua Song
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Gastroenterology Institute of Jiangxi Province, Nanchang, Jiangxi, China.,Key Laboratory of Digestive Diseases of Jiangxi Province, Nanchang, Jiangxi, China
| | - Yong Xie
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Gastroenterology Institute of Jiangxi Province, Nanchang, Jiangxi, China.,Key Laboratory of Digestive Diseases of Jiangxi Province, Nanchang, Jiangxi, China
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12
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Piovani D, Danese S, Peyrin-Biroulet L, Nikolopoulos GK, Lytras T, Bonovas S. Environmental Risk Factors for Inflammatory Bowel Diseases: An Umbrella Review of Meta-analyses. Gastroenterology 2019; 157:647-659.e4. [PMID: 31014995 DOI: 10.1053/j.gastro.2019.04.016] [Citation(s) in RCA: 401] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Multiple environmental factors have been associated with the development of inflammatory bowel diseases (IBDs). We performed an umbrella review of meta-analyses to summarize available epidemiologic evidence and assess its credibility. METHODS We systematically identified and appraised meta-analyses of observational studies examining environmental factors and risk of IBD (Crohn's disease [CD] or ulcerative colitis [UC]). For each meta-analysis, we considered the random effects estimate, its 95% confidence interval, the estimates of heterogeneity, and small-study effects, and we graded the evidence according to prespecified criteria. Methodologic quality was assessed with AMSTAR (ie, A Measurement Tool to Assess Systematic Reviews) 2. RESULTS We examined 183 estimates in 53 meta-analyses of 71 environmental factors related to lifestyles and hygiene, surgeries, drug exposures, diet, microorganisms, and vaccinations. We identified 9 factors that increase risk of IBD: smoking (CD), urban living (CD and IBD), appendectomy (CD), tonsillectomy (CD), antibiotic exposure (IBD), oral contraceptive use (IBD), consumption of soft drinks (UC), vitamin D deficiency (IBD), and non-Helicobacter pylori-like enterohepatic Helicobacter species (IBD). We identified 7 factors that reduce risk of IBD: physical activity (CD), breastfeeding (IBD), bed sharing (CD), tea consumption (UC), high levels of folate (IBD), high levels of vitamin D (CD), and H pylori infection (CD, UC, and IBD). Epidemiologic evidence for all of these associations was of high to moderate strength; we identified another 11 factors associated with increased risk and 16 factors associated with reduced risk with weak credibility. Methodologic quality varied considerably among meta-analyses. Several associations were based on findings from retrospective studies, so it is not possible to determine if these are effects of IBD or the results of recall bias. CONCLUSIONS In an umbrella review of meta-analyses, we found varying levels of evidence for associations of different environmental factors with risk of IBD. High-quality prospective studies with analyses of samples from patients with recent diagnoses of IBD are needed to determine whether these factors cause or are results of IBD and their pathogenic mechanisms.
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Affiliation(s)
- Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Inflammatory Bowel Disease Center, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Inflammatory Bowel Disease Center, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and INSERM U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | | | - Theodore Lytras
- Hellenic Center for Disease Control and Prevention, Athens, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Inflammatory Bowel Disease Center, Humanitas Clinical and Research Center-IRCCS, Milan, Italy.
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