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Magro F, Estevinho MM, Catalano G, Patita M, Arroja B, Lago P, Rosa I, Tavares de Sousa H, Ministro P, Mocanu I, Vieira A, Castela J, Moleiro J, Roseira J, Cancela E, Sousa P, Portela F, Correia L, Moreira P, Santiago M, Dias S, Afonso J, Danese S, Peyrin-Biroulet L, Dias CC. How many biomarker measurements are needed to predict prognosis in Crohn's disease patients under infliximab?-A prospective study. United European Gastroenterol J 2023. [PMID: 37318072 DOI: 10.1002/ueg2.12420] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/07/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Timely stratification of Crohn's disease (CD) is essential for patients' management. The use of noninvasive accurate biomarkers is key to monitor treatment and to pursue mucosal healing, the ultimate treatment endpoint in CD. OBJECTIVE We aimed to evaluate the performance of readily available biomarkers and develop risk matrices to predict CD progression. METHODS Data from 289 CD patients receiving infliximab (IFX) maintenance therapy for 2 years was collected; those patients were included in DIRECT, a prospective multicenter observational study. Disease progression was evaluated using two composite outcomes incorporating clinical and drug-related factors, the first including IFX dose and/or frequency adjustments. Univariate and multivariable logistic regressions were used to calculate the odds ratios (OR) and to develop risk matrices. RESULTS The isolated presence of anemia at least once during follow-up was a significant predictor of disease progression (OR 2.436 and 3.396 [p ≤ 0.001] for composite outcomes 1 and 2, respectively) regardless of confounding factors. Isolated highly elevated C-reactive protein (CRP; >10.0 mg/L) and fecal calprotectin (FC; >500.0 μg/g) in at least one visit were also significant predictors, while milder elevations (3.1-10.0 mg/L and 250.1-500.0 μg/g) were only relevant when detected in at least two visits (consecutive or not). The combination of biomarkers in risk matrices had good ability to predict progression; patients simultaneously presenting anemia, highly elevated CRP and FC at least once had 42%-63% probability of achieving the composite outcomes. CONCLUSION The combined evaluation of hemoglobin, CRP, and FC in at least one time point and their incorporation into risk matrices seems to be the optimal strategy for CD management, as data from additional visits did not meaningfully influence the predictions and may delay decision-making.
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Affiliation(s)
- Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Gastroenterology, São João Hospital University Centre, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Unidade de Farmacologia Clínica, São João Hospital University Centre, Porto, Portugal
| | - Maria Manuela Estevinho
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Gastroenterology, Vila Nova de Gaia Espinho Hospital Center, Vila Nova de Gaia, Portugal
| | - Gaia Catalano
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marta Patita
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Bruno Arroja
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
| | - Paula Lago
- Department of Gastroenterology, Porto Hospital University Centre, Porto, Portugal
| | - Isadora Rosa
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Helena Tavares de Sousa
- Department of Gastroenterology, Algarve Hospital University Centre - Portimão Unit, Portimão, Portugal
- ABC - Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Paula Ministro
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Irina Mocanu
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Ana Vieira
- Department of Gastroenterology, Garcia da Orta Hospital, Almada, Portugal
| | - Joana Castela
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Joana Moleiro
- Department of Gastroenterology, IPOLFG, EPE, Lisbon, Portugal
| | - Joana Roseira
- Department of Gastroenterology, Algarve Hospital University Centre - Portimão Unit, Portimão, Portugal
| | - Eugénia Cancela
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Paula Sousa
- Department of Gastroenterology, Viseu-Tondela Hospital Centre, Viseu, Portugal
| | - Francisco Portela
- Department of Gastroenterology, Coimbra Hospital University Centre, Coimbra, Portugal
| | - Luís Correia
- Department of Gastroenterology, Northern Lisbon University Hospital Centre, Lisbon, Portugal
| | - Paula Moreira
- Unidade de Farmacologia Clínica, São João Hospital University Centre, Porto, Portugal
| | - Mafalda Santiago
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Portuguese Group of Studies in Inflammatory Bowel Disease (Grupo de Estudos da Doença Inflamatória Intestinal - GEDII), Porto, Portugal
| | - Sandra Dias
- Portuguese Group of Studies in Inflammatory Bowel Disease (Grupo de Estudos da Doença Inflamatória Intestinal - GEDII), Porto, Portugal
| | - Joana Afonso
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, Nancy, France
| | - Cláudia Camila Dias
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
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Halligan S, Boone D, Archer L, Ahmad T, Bloom S, Rodriguez-Justo M, Taylor SA, Mallett S. Prognostic biomarkers to identify patients likely to develop severe Crohn's disease: a systematic review. Health Technol Assess 2021; 25:1-66. [PMID: 34225839 DOI: 10.3310/hta25450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Identification of biomarkers that predict severe Crohn's disease is an urgent unmet research need, but existing research is piecemeal and haphazard. OBJECTIVE To identify biomarkers that are potentially able to predict the development of subsequent severe Crohn's disease. DESIGN This was a prognostic systematic review with meta-analysis reserved for those potential predictors with sufficient existing research (defined as five or more primary studies). DATA SOURCES PubMed and EMBASE searched from inception to 1 January 2016, updated to 1 January 2018. REVIEW METHODS Eligible studies were studies that compared biomarkers in patients who did or did not subsequently develop severe Crohn's disease. We excluded biomarkers that had insufficient research evidence. A clinician and two statisticians independently extracted data relating to predictors, severe disease definitions, event numbers and outcomes, including odds/hazard ratios. We assessed risk of bias. We searched for associations with subsequent severe disease rather than precise estimates of strength. A random-effects meta-analysis was performed separately for odds ratios. RESULTS In total, 29,950 abstracts yielded just 71 individual studies, reporting 56 non-overlapping cohorts. Five clinical biomarkers (Montreal behaviour, age, disease duration, disease location and smoking), two serological biomarkers (anti-Saccharomyces cerevisiae antibodies and anti-flagellin antibodies) and one genetic biomarker (nucleotide-binding oligomerisation domain-containing protein 2) displayed statistically significant prognostic potential. Overall, the strongest association with subsequent severe disease was identified for Montreal B2 and B3 categories (odds ratio 4.09 and 6.25, respectively). LIMITATIONS Definitions of severe disease varied widely, and some studies confounded diagnosis and prognosis. Risk of bias was rated as 'high' in 92% of studies overall. Some biomarkers that are used regularly in daily practice, for example C-reactive protein, were studied too infrequently for meta-analysis. CONCLUSIONS Research for individual biomarkers to predict severe Crohn's disease is scant, heterogeneous and at a high risk of bias. Despite a large amount of potential research, we encountered relatively few biomarkers with data sufficient for meta-analysis, identifying only eight biomarkers with potential predictive capability. FUTURE WORK We will use existing data sets to develop and then validate a predictive model based on the potential predictors identified by this systematic review. Contingent on the outcome of that research, a prospective external validation may prove clinically desirable. STUDY REGISTRATION This study is registered as PROSPERO CRD42016029363. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 45. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London, London, UK
| | - Lucinda Archer
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College Hospital, London, UK
| | | | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
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Ministro P, Dias CC, Portela F, Fernandes S, Bernardo S, Pires F, Lago P, Rosa I, Trindade E, Alves C, Correia L, Magro F. Age at Diagnosis Is Determinant for the Outcome of Inflammatory Bowel Disease: Is It a Myth? Clin Transl Gastroenterol 2021; 12:e00309. [PMID: 33587489 PMCID: PMC7886471 DOI: 10.14309/ctg.0000000000000309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/18/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Patients with elderly-onset inflammatory bowel disease were previously associated with a less aggressive course of the disease. However, there are conflicting data that need further validation. We aimed to determine the association between age at diagnosis and the development of progressive disease in patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS This cohort study included patients with CD and UC followed in 6 secondary and tertiary care centers in mainland Portugal. Patients were divided into a derivation (80%) cohort and a validation (20%) cohort. The primary outcome was progressive disease. Logistic regression analysis, receiver operating characteristic curves, and the areas under the curve (AUC) were performed. Odds ratios with 95% confidence intervals (CIs) were estimated. RESULTS The derivation cohorts included 1245 patients with CD (68% with progressive disease) and 1210 patients with UC (37% with progressive disease), whereas the validation cohorts included 302 patients with CD and 271 patients with UC, respectively, with similar outcome proportions. In our final model, age at diagnosis older than 60 years was significantly associated with a lower risk of developing progressive disease (odds ratio 0.390, 95% CI 0.164-0.923, P = 0.032), with a high discriminative power (AUC 0.724, 95% CI 0.693-754) in patients with CD. However, according to this model, no significant associations were found between age at diagnosis and the risk of developing progressive disease in patients with UC. No differences were observed in the AUC values between the validation and the derivation cohorts. DISCUSSION Patients with elderly-onset CD, but not patients with UC, were associated with a less progressive course of the disease.
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Affiliation(s)
- Paula Ministro
- Department of Gastroenterology, Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Francisco Portela
- Department of Gastroenterology, University Hospital Centre of Coimbra, Coimbra, Portugal
| | - Samuel Fernandes
- Department of Gastroenterology, Lisbon North Hospital Centre, Santa Maria Hospital, Lisbon, Portugal
| | - Sónia Bernardo
- Department of Gastroenterology, Lisbon North Hospital Centre, Santa Maria Hospital, Lisbon, Portugal
| | - Francisco Pires
- Department of Gastroenterology, Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - Paula Lago
- Department of Gastroenterology, Porto Hospital Centre, Porto, Portugal
| | - Isadora Rosa
- Department of Gastroenterology, Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal
| | - Eunice Trindade
- Department of Paediatrics, São João Hospital, Porto, Portugal
| | | | - Luís Correia
- Department of Gastroenterology, Lisbon North Hospital Centre, Santa Maria Hospital, Lisbon, Portugal
| | - Fernando Magro
- Department of Gastroenterology, São João Hospital, Porto, Portugal
- Institute of Pharmacology and Therapeutics, Faculty of Medicine of the University of Porto, Porto, Portugal
- Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
- Clinical Pharmacology Unit, São João Hospital University Centre, Porto, Portugal
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Monstad IL, Solberg IC, Cvancarova M, Hovde O, Henriksen M, Huppertz-Hauss G, Gunther E, Moum BA, Stray N, Vatn M, Hoie O, Jahnsen J. Outcome of Ulcerative Colitis 20 Years after Diagnosis in a Prospective Population-based Inception Cohort from South-Eastern Norway, the IBSEN Study. J Crohns Colitis 2020; 15:969-979. [PMID: 33367569 PMCID: PMC8218709 DOI: 10.1093/ecco-jcc/jjaa232] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS The long-term course of ulcerative colitis [UC] is difficult to predict. Mortality, colectomy, cancer, and hospitalisation represent hard outcomes of disease. Moreover, knowledge on the risk of relapses and need for potent medication add important information about living with UC. We aimed to evaluate the course and prognosis of UC during the first 20 years after diagnosis, and to identify early prognostic risk factors. METHODS From 1990 to 1994, a population-based inception cohort of patients with inflammatory bowel disease was enrolled in South-Eastern Norway. A systematic follow-up [FU] was conducted at 1,5, 10, and 20 years after diagnosis. Clinical outcomes were recorded continuously, and possible relationships between early disease characteristics and outcomes were analysed using multiple regression analysis. RESULTS Among 519 UC patients, 119 died, 60 were lost to FU, and 340 were included in the FU cohort. The 20-year cumulative risk of colectomy was 13.0% (95% confidence interval [CI] [11.4-14.6]). Extensive colitis at diagnosis was independently associated with an increased risk of colectomy compared with proctitis (hazard ratio [HR] = 2].8, 95% CI [1.3-6.1]). In contrast, mucosal healing at 1-year FU was independently associated with reduced risk of colectomy [HR = 0.4, 95% CI [0.2-0.8]), and inversely associated with subsequent risk of relapse [adjusted HR = 0.5, 95% CI [0.3-0.7]). CONCLUSIONS The overall risk of colectomy in our cohort was lower than expected from previous studies, although considerable for patients with extensive colitis at diagnosis. Early mucosal healing was associated with better disease outcomes 20 years after diagnosis.
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Affiliation(s)
- Iril Lovise Monstad
- Department of Gastroenterolgy, Oslo University Hospital, Ulleval, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Corresponding author: Dr Iril L. Monstad, Lovisenberg Diaconal Hospital, Lovisenberg Street 17, 1456 Oslo, Norway. Tel.: + 47 984 48 423;
| | | | | | - Oistein Hovde
- Department of Gastroenterology, Innlandet Hospital Trust, Gjøvik, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magne Henriksen
- Department of Gastroenterology, Østfold Hospital, Fredrikstad, Norway
| | | | - Eva Gunther
- Department of Gastroenterology, Østfold Hospital, Fredrikstad, Norway
| | - Bjørn Allan Moum
- Department of Gastroenterolgy, Oslo University Hospital, Ulleval, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Njaal Stray
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Morten Vatn
- EpiGen Institute, Akershus University Hospital, Lørenskog, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ole Hoie
- Department of Internal Medicine, Hospital of Southern Norway, Arendal, Norway
| | - Jørgen Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Abstract
Mucosal healing (MH) is the goal of the “treat to target” strategy in Crohn's disease (CD), which seeks to prevent disability. However, evidence is limited regarding whether achieving MH can reduce disability in CD. We aimed to estimate the probability of disabling disease and to investigate the association between MH and disabling disease in CD.
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A clinical risk matrix for obstructive sleep apnea using Bayesian network approaches. INTERNATIONAL JOURNAL OF DATA SCIENCE AND ANALYTICS 2018. [DOI: 10.1007/s41060-018-0118-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Dias CC, Pereira Rodrigues P, Fernandes S, Portela F, Ministro P, Martins D, Sousa P, Lago P, Rosa I, Correia L, Moura Santos P, Magro F. The risk of disabling, surgery and reoperation in Crohn's disease - A decision tree-based approach to prognosis. PLoS One 2017; 12:e0172165. [PMID: 28225800 PMCID: PMC5321294 DOI: 10.1371/journal.pone.0172165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/17/2017] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease known to carry a high risk of disabling and many times requiring surgical interventions. This article describes a decision-tree based approach that defines the CD patients' risk or undergoing disabling events, surgical interventions and reoperations, based on clinical and demographic variables. MATERIALS AND METHODS This multicentric study involved 1547 CD patients retrospectively enrolled and divided into two cohorts: a derivation one (80%) and a validation one (20%). Decision trees were built upon applying the CHAIRT algorithm for the selection of variables. RESULTS Three-level decision trees were built for the risk of disabling and reoperation, whereas the risk of surgery was described in a two-level one. A receiver operating characteristic (ROC) analysis was performed, and the area under the curves (AUC) Was higher than 70% for all outcomes. The defined risk cut-off values show usefulness for the assessed outcomes: risk levels above 75% for disabling had an odds test positivity of 4.06 [3.50-4.71], whereas risk levels below 34% and 19% excluded surgery and reoperation with an odds test negativity of 0.15 [0.09-0.25] and 0.50 [0.24-1.01], respectively. Overall, patients with B2 or B3 phenotype had a higher proportion of disabling disease and surgery, while patients with later introduction of pharmacological therapeutic (1 months after initial surgery) had a higher proportion of reoperation. CONCLUSIONS The decision-tree based approach used in this study, with demographic and clinical variables, has shown to be a valid and useful approach to depict such risks of disabling, surgery and reoperation.
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Affiliation(s)
- Cláudia Camila Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine of the University of Porto, Porto, Portugal
- CINTESIS – Center for Health Tecnology and Services Research, Porto, Portugal
| | - Pedro Pereira Rodrigues
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine of the University of Porto, Porto, Portugal
- CINTESIS – Center for Health Tecnology and Services Research, Porto, Portugal
| | - Samuel Fernandes
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, Lisboa, Portugal
| | - Francisco Portela
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Paula Ministro
- Gastroenterology Department, Centro Hospitalar Tondela e Viseu, Viseu, Portugal
| | - Diana Martins
- Gastroenterology Department, Centro Hospitalar Tondela e Viseu, Viseu, Portugal
| | - Paula Sousa
- Gastroenterology Department, Centro Hospitalar Tondela e Viseu, Viseu, Portugal
| | - Paula Lago
- Gastroenterology Department, Centro Hospitalar do Porto, Porto, Portugal
| | | | - Luis Correia
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, Lisboa, Portugal
| | - Paula Moura Santos
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, Lisboa, Portugal
| | - Fernando Magro
- Gastroenterology Department, Hospital São João, Porto, Portugal
- Institute of Pharmacology and Therapeutics Faculty of Medicine of the University of Porto, Porto, Portugal
- MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
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