1
|
Janssen L, van Linschoten RCA, West RL, Gilissen LPL, Romberg-Camps M, Brandts L, Mujagic Z, Römkens TE, Pierik M. Predicting mucosal inflammation in IBD patients using patient-reported symptom scores and a faecal calprotectin home test: protocol for a multicentre prospective validation study. BMJ Open 2024; 14:e076290. [PMID: 39375184 DOI: 10.1136/bmjopen-2023-076290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
INTRODUCTION Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD) with a relapsing-remitting nature. With adequate non-invasive prediction of mucosal inflammation, endoscopies can be prevented and treatment optimised earlier for better disease control. We aim to validate and recalibrate commonly used patient-reported symptom scores combined with a faecal calprotectin (FC) home test as non-invasive diagnostic tool for remote monitoring of IBD, both in daily practice and in a strict trial setting. Endoscopy will be used as the gold standard. METHODS AND ANALYSIS In this multicentre prospective validation study, adult IBD patients are asked to fill out questionnaires regarding disease activity (Monitor IBD At Home, mobile Health Index, Manitoba IBD Index, IBD control and patient-HBI/patient-Simple Clinical Colitis Activity Index), perform a FC home test and collect a stool sample for routine laboratory FC measurement, before the start of the bowel preparation for the ileocolonoscopy. Endoscopic disease activity will be scored according to the simplified endoscopic score for Crohn's disease (CD) for CD patients or Ulcerative Colitis Endoscopic Index for Severity and Mayo Endoscopic Subscore for ulcerative colitis patients. The main study outcome is the diagnostic test accuracy of the various patient-reported scores to assess mucosal inflammation in combination with a FC home test. ETHICS AND DISSEMINATION This study is approved by the Medical Research Ethics Committee of azM/UM in Maastricht dated 03 March 2021 (METC 20-085) and is monitored by the Clinical Trial Centre Maastricht according to Good Clinical Practice guidelines. Written informed consent will be obtained from all patients. Study results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT05886322.
Collapse
Affiliation(s)
- Laura Janssen
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Limburg, Netherlands
- Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Netherlands
| | - Reinier Cornelis Anthonius van Linschoten
- Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Netherlands
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Rachel Louise West
- Department of Gastroenterology & Hepatology, Franciscus Gasthuis, Rotterdam, Zuid-Holland, Netherlands
| | - Lennard P L Gilissen
- Department of Gastroenterology, Catharina Hospital, Eindhoven, North Brabant, Netherlands
| | - Mariëlle Romberg-Camps
- Gastroenterology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, Limburg, Netherlands
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, Limburg, Netherlands
| | - Zlatan Mujagic
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Limburg, Netherlands
- Division of Gastroenterology-Hepatology, Maastricht University Medical Centre+, Maastricht, Limburg, Netherlands
| | - Tessa Eh Römkens
- Department of Gastroenteroloy and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Noord-Brabant, Netherlands
| | - M Pierik
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Limburg, Netherlands
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, Limburg, Netherlands
| |
Collapse
|
2
|
Blüthner E, Dehe A, Büning C, Siegmund B, Prager M, Maul J, Krannich A, Preiß J, Wiedenmann B, Rieder F, Khedraki R, Tacke F, Sturm A, Schirbel A. Diagnostic delay in inflammatory bowel diseases in a German population. World J Gastroenterol 2024; 30:3465-3478. [PMID: 39156497 PMCID: PMC11326085 DOI: 10.3748/wjg.v30.i29.3465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/28/2024] [Accepted: 06/18/2024] [Indexed: 07/29/2024] Open
Abstract
BACKGROUND Early diagnosis is key to prevent bowel damage in inflammatory bowel disease (IBD). Risk factor analyses linked with delayed diagnosis in European IBD patients are scarce and no data in German IBD patients exists. AIM To identify risk factors leading to prolonged diagnostic time in a German IBD cohort. METHODS Between 2012 and 2022, 430 IBD patients from four Berlin hospitals were enrolled in a prospective study and asked to complete a 16-item questionnaire to determine features of the path leading to IBD diagnosis. Total diagnostic time was defined as the time from symptom onset to consulting a physician (patient waiting time) and from first consultation to IBD diagnosis (physician diagnostic time). Univariate and multivariate analyses were performed to identify risk factors for each time period. RESULTS The total diagnostic time was significantly longer in Crohn's disease (CD) compared to ulcerative colitis (UC) patients (12.0 vs 4.0 mo; P < 0.001), mainly due to increased physician diagnostic time (5.5 vs 1.0 mo; P < 0.001). In a multivariate analysis, the predominant symptoms diarrhea (P = 0.012) and skin lesions (P = 0.028) as well as performed gastroscopy (P = 0.042) were associated with longer physician diagnostic time in CD patients. In UC, fever was correlated (P = 0.020) with shorter physician diagnostic time, while fatigue (P = 0.011) and positive family history (P = 0.046) were correlated with longer physician diagnostic time. CONCLUSION We demonstrated that CD patients compared to UC are at risk of long diagnostic delay. Future efforts should focus on shortening the diagnostic delay for a better outcome in these patients.
Collapse
Affiliation(s)
- Elisabeth Blüthner
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Annalena Dehe
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Gastroenterology, Vivantes Klinikum im Friedrichshain, Berlin 10249, Germany
| | - Carsten Büning
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Internal Medicine, Krankenhaus Waldfriede, Berlin 14163, Germany
| | - Britta Siegmund
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Berlin 12203, Germany
| | - Matthias Prager
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Praxis für Gastroenterologie Berlin Zehlendorf, Berlin 14195, Germany
| | - Jochen Maul
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Gastroenterologie am Bayrischen Platz, Berlin 10825, Germany
| | - Alexander Krannich
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Clinical Trial Office, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Jan Preiß
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Gastroenterology, Diabetology and Hepatology, Vivantes Klinikum Neukölln, Berlin 10117, Germany
| | - Bertram Wiedenmann
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Florian Rieder
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Raneem Khedraki
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Andreas Sturm
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Department of Internal Medicine, DRK Kliniken Berlin Westend, Berlin 14050, Germany
| | - Anja Schirbel
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
- Gastroenterologie im Havelland, Straße der Einheit, Falkensee 14612, Germany
| |
Collapse
|
3
|
Yen HH, Wu JF, Wang HY, Chang TA, Chang CH, Chang CW, Chao TH, Chou JW, Chou YH, Chuang CH, Hsu WH, Hsu TC, Huang TY, Hung TI, Le PH, Lin CC, Lin CC, Lin CP, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsai TJ, Wang CY, Weng MT, Wong JM, Wu DC, Wei SC. Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023. Intest Res 2024; 22:213-249. [PMID: 39099217 PMCID: PMC11309818 DOI: 10.5217/ir.2023.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammation of the gastrointestinal tract and is characterized by alternating periods of inflammation and remission. Although UC incidence is lower in Taiwan than in Western countries, its impact remains considerable, demanding updated guidelines for addressing local healthcare challenges and patient needs. The revised guidelines employ international standards and recent research, emphasizing practical implementation within the Taiwanese healthcare system. Since the inception of the guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease has acknowledged the need for ongoing revisions to incorporate emerging therapeutic options and evolving disease management practices. This updated guideline aims to align UC management with local contexts, ensuring comprehensive and context-specific recommendations, thereby raising the standard of care for UC patients in Taiwan. By adapting and optimizing international protocols for local relevance, these efforts seek to enhance health outcomes for patients with UC.
Collapse
Affiliation(s)
- Hsu-Heng Yen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital, Renai-Branch, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colon and Rectal Surgery, Department of Surgery, Chiayi and Wangiao Branch, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Wei Chou
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, MacKay Memorial Hospital, MacKay Medical College, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-I Hung
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Pin Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University College of Medicine and Children’s Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Forensic Medicine and Pathology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pathology, Good Liver Clinic, Taipei, Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Gangshan Hospital, Kaohsiung, Taiwan
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
4
|
De Deo D, Dal Buono A, Gabbiadini R, Spaggiari P, Busacca A, Masoni B, Ferretti S, Bezzio C, Armuzzi A. Management of proctitis in ulcerative colitis and the place of biological therapies. Expert Opin Biol Ther 2024; 24:443-453. [PMID: 38874980 DOI: 10.1080/14712598.2024.2369189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/13/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Approximately 20-30% of the patients with ulcerative colitis (UC) may present with isolated proctitis. Ulcerative proctitis (UP) is a challenging condition to manage due to its significant burden in terms of disabling symptoms. AREAS COVERED PubMed was searched up to March 2024 to identify relevant studies on UP. A comprehensive summary and critical appraisal of the available data on UP are provided, highlighting emerging treatments and areas for future research. EXPERT OPINION Patients with UP are often undertreated, and the disease burden is often underestimated in clinical practice. Treat-to-target management algorithms can be applied to UP, aiming for clinical remission in the short term, and endoscopic remission and maintenance of remission in the long term. During their disease, approximately one-third of UP patients require advanced therapies. Escalation to biologic therapy is required for refractory or steroid dependent UP. For optimal patient care and management of UP, it is necessary to include these patients in future randomized clinical trials.
Collapse
Affiliation(s)
- Diletta De Deo
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Arianna Dal Buono
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | | | - Paola Spaggiari
- Department of Pathology, Humanitas Research Hospital, Rozzano Milan, Italy
| | - Anita Busacca
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Benedetta Masoni
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Silvia Ferretti
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Bezzio
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Armuzzi
- IBD Center, Humanitas Research Hospital - IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
5
|
Loveikyte R, Duijvestein M, Mujagic Z, Goetgebuer RL, Dijkstra G, van der Meulen-de Jong AE. Predicting response to iron supplementation in patients with active inflammatory bowel disease (PRIme): a randomised trial protocol. BMJ Open 2024; 14:e077511. [PMID: 38296290 PMCID: PMC10828887 DOI: 10.1136/bmjopen-2023-077511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Iron deficiency anaemia (IDA) is the most common systemic manifestation of inflammatory bowel disease (IBD) that has detrimental effects on quality of life (QoL) and disease outcomes. Iron deficiency (ID), with or without anaemia, poses a diagnostic and therapeutic challenge in patients with IBD due to the multifactorial nature of ID(A) and its frequent recurrence. Elevated hepcidin-a systemic iron regulator that modulates systemic iron availability and intestinal iron absorption-has been associated with oral iron malabsorption in IBD. Therefore, hepcidin could assist in therapeutic decision-making. In this study, we investigate whether hepcidin can predict response to oral and intravenous iron supplementation in patients with active IBD undergoing anti-inflammatory treatment. METHODS AND ANALYSIS PRIme is an exploratory, multicentre, open-label and randomised trial. All adult patients with active IBD and ID(A) will be assessed for eligibility. The participants (n=90) will be recruited at five academic hospitals within the Netherlands and randomised into three groups (1:1:1): oral ferrous fumarate, oral ferric maltol or intravenous iron. Clinical and biochemical data will be collected at the baseline and after 6, 14 and 24 weeks. Blood samples will be collected to measure hepcidin and other biomarkers related to iron status. In addition, patient-reported outcomes regarding QoL and disease burden will be evaluated. The primary outcome is the utility of hepcidin as a predictive biomarker for response to iron therapy, which will be assessed using receiver operating curve analysis. ETHICS AND DISSEMINATION The study has been approved by the Institutional Review Board at the Leiden University Medical Center (IRB No. P21.109) and other study sites. All participants will provide written informed consent to enrol in the study. The findings will be published in a peer-reviewed journal and disseminated at scientific conferences; the dataset will be available on reasonable request. TRIAL REGISTRATION Prospectively registered in the https://clinicaltrials.gov/ and the Eudra registries. First submitted on 10 May 2022 to the ClinicalTrials.gov (ID: NCT05456932) and on 3 March 2022 to the European Union Drug Regulating Authorities Clinical Trials Database (ID: 2022-000894-16).
Collapse
Affiliation(s)
- Roberta Loveikyte
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zlatan Mujagic
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rogier L Goetgebuer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | | |
Collapse
|
6
|
Maev IV, Bakulin IG, Skalinskaya MI, Skazyvaeva EV. [Inflammatory bowel diseases: Transformation of representations. A review]. TERAPEVT ARKH 2023; 95:1064-1074. [PMID: 38158940 DOI: 10.26442/00403660.2023.12.202507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Indexed: 01/03/2024]
Abstract
The global burden of inflammatory bowel disease (IBD) is currently significant and continues to grow due to the increasing prevalence of ulcerative colitis (UC) and Crohn's disease (CD), the increasing costs of diagnosis and treatment, and the high level of disability in patients with this disease. Categories, which leads to the search for risk factors and predictors of aggressive course and extraintestinal manifestations. According to the latest data, the prevalence of UC in Russia is 16.6 per 100 000 population, the annual registered increase is 11.3%; the prevalence of CD is 5.6 per 100 000 population, and the increase is 13.7%. In the Russian population of patients with IBD, the average age of disease onset is 35.3 years for UC and 31.2 years for CD. Moreover, in 89.3% of patients with UC, it took at least 2 years to verify the diagnosis, and in CD, within 2 years from the onset of clinical symptoms, the diagnosis was established in only 72.6% of patients. One of the dominant characteristics of IBD is its multisystem nature, which leads to the development of extraintestinal manifestations (ECM), which can be observed in 50-60% of patients, while up to 25% of patients with IBD have several EMC and the most common variants are joint lesions. A higher frequency of extraintestinal manifestations is observed in CD (up to 45% of patients), in female patients, in smokers and with a longer duration of the disease. To predict clinical remission, the level of fecal calprotectin and CRP, the need for glucocorticosteroids are important, to predict endoscopic remission - the level of fecal calprotectin, and to predict histological remission, an endoscopic Schroeder index value of ≤1 is important. The absolute risk of developing colorectal cancer in IBD remains relatively low, ranging from 1.1 to 5.4% after 20 years of disease. The main risk factors for IBD are total intestinal damage, high inflammatory activity, the stricturing phenotype of CD and the presence of primary sclerosing cholangitis.
Collapse
Affiliation(s)
- I V Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - I G Bakulin
- Mechnikov North-Western State Medical University
| | | | | |
Collapse
|
7
|
Loveikyte R, Bourgonje AR, van Goor H, Dijkstra G, van der Meulen-de Jong AE. The effect of iron therapy on oxidative stress and intestinal microbiota in inflammatory bowel diseases: A review on the conundrum. Redox Biol 2023; 68:102950. [PMID: 37918126 PMCID: PMC10643537 DOI: 10.1016/j.redox.2023.102950] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023] Open
Abstract
One in five patients with Inflammatory Bowel Disease (IBD) suffers from anemia, most frequently caused by iron deficiency. Anemia and iron deficiency are associated with worse disease outcomes, reduced quality of life, decreased economic participation, and increased healthcare costs. International guidelines and consensus-based recommendations have emphasized the importance of treating anemia and iron deficiency. In this review, we draw attention to the rarely discussed effects of iron deficiency and iron therapy on the redox status, the intestinal microbiota, and the potential interplay between them, focusing on the clinical implications for patients with IBD. Current data are scarce, inconsistent, and do not provide definitive answers. Nevertheless, it is imperative to rule out infections and discern iron deficiency anemia from other types of anemia to prevent untargeted oral or intravenous iron supplementation and potential side effects, including oxidative stress. Further research is necessary to establish the clinical significance of changes in the redox status and the intestinal microbiota following iron supplementation.
Collapse
Affiliation(s)
- R Loveikyte
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - A R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; The Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - H van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - A E van der Meulen-de Jong
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
8
|
Aruljothy A, Singh S, Narula N, Moran GW, Vuyyuru SK, Hogan M, Zayadi A, MacDonald JK, Caron B, Danese S, Biroulet LP, Ma C, Jairath V. Systematic review with meta-analysis: Medical therapies for treatment of ulcerative proctitis. Aliment Pharmacol Ther 2023; 58:740-762. [PMID: 37589498 PMCID: PMC11162959 DOI: 10.1111/apt.17666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/27/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ulcerative proctitis (UP) is a common highly symptomatic form of ulcerative colitis that can be difficult to treat. AIM To assess the efficacy of medical treatments for UP. METHODS We searched MEDLINE, EMBASE, and CENTRAL on 23 November 2022 for randomised controlled trials (RCTs) of medical therapy for adults with UP. Primary outcomes included induction and maintenance of clinical remission. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each outcome. RESULTS We included 53 RCTs (n = 4096) including 46 induction studies (n = 3731) and seven maintenance studies (n = 365). First-line therapies included topical 5-aminosalicylic acid (5-ASA), conventional corticosteroids, budesonide, and oral 5-ASA. Therapy for refractory UP included topical tacrolimus and small molecules. Topical 5-ASA was superior to placebo for induction (RR 2.72, 95% CI 1.94-3.82) and maintenance of remission (RR 2.09, 95% CI 1.26-3.46). Topical corticosteroids were superior to placebo for induction of remission (RR 2.83, 95% CI 1.62-4.92). Topical budesonide was superior to placebo for induction of remission (RR 2.34, 95% CI 1.44-3.81). Combination therapy with topical 5-ASA and topical corticosteroids was superior to topical monotherapy with either agent. Topical tacrolimus was superior to placebo. Etrasimod was superior to placebo for induction (RR 4.71, 95% CI 1.2-18.49) and maintenance of remission (RR 2.08, 95% CI 1.31-3.32). CONCLUSIONS Topical 5-ASA and corticosteroids are effective for active UP. Topical 5-ASA may be effective for maintenance of remission. Tacrolimus may be effective for induction of remission. Etrasimod may be effective for induction and for maintenance of remission. Trials should include UP to expand the evidence base for this under-represented population.
Collapse
Affiliation(s)
- Achuthan Aruljothy
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Gordon W. Moran
- National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals, Nottingham, UK
| | - Sudheer K. Vuyyuru
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
- Alimentiv, Inc., London, Ontario, Canada
| | | | | | | | - Benedicte Caron
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, Inserm, NGERE, Nancy, France
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Laurent Peyrin Biroulet
- Department of Gastroenterology, University of Lorraine, CHRU-Nancy, Nancy, France
- University of Lorraine, Inserm, NGERE, Nancy, France
| | - Christopher Ma
- Alimentiv, Inc., London, Ontario, Canada
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada
- Alimentiv, Inc., London, Ontario, Canada
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
9
|
Increased Proportion of Colorectal Cancer in Patients with Ulcerative Colitis undergoing Surgery in the Netherlands. Am J Gastroenterol 2022; 118:848-854. [PMID: 36623170 PMCID: PMC10144357 DOI: 10.14309/ajg.0000000000002099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The aim of the current study was to assess if there is an indication shift for surgery in patients with UC from refractory disease to malignant degeneration over the last 3 decades. METHODS All patients with histologically confirmed UC who underwent a colorectal resection between 1991 and 2020 were extracted from the nationwide Dutch Pathology Registry (PALGA). The primary outcome was the proportion of CRC in the colon specimens. Outcomes were compared between 3 periods (P1: 1991-2000, P2: 2001-2010, P3: 2011-2020). RESULTS Overall, 6,094 UC patients were included of which 4,854 underwent a (procto)colectomy and 1,240 a segmental resection. In 1,031 (16.9%) patients, CRC was demonstrated in the pathological resection specimen after a median disease duration of 11 years [IQR 3.0-19.0]. The proportion of CRC increased from 11.3% in P1, to 16.1% in P2, and 22.8% in P3 (p<0.001). Median disease duration at the time of resection increased from 4 years in P1, to 10 years in P2, and 17 years in P3 (p<0.001). The proportion of patients diagnosed with advanced malignancy (pT3/T4) (P1: 61.2% vs. P2: 65.2% vs. P3: 62.4%, respectively, p=0.633) and lymph node metastasis (N+) (P1: 33.0% vs. P2: 41.9% vs. P3: 38.2%, respectively, p=0.113) did not change over time. DISCUSSION This nationwide pathology study demonstrated an increased proportion of surgery for CRC over the last 3 decades. We hypothesize that the expanding therapeutic armamentarium for UC leads to exhausting medical options and hence postponed colectomy. This however, might be at the expense of an increased risk of CRC in the long term.
Collapse
|
10
|
Hu Y, Chen Z, Xu C, Kan S, Chen D. Disturbances of the Gut Microbiota and Microbiota-Derived Metabolites in Inflammatory Bowel Disease. Nutrients 2022; 14:5140. [PMID: 36501169 PMCID: PMC9735443 DOI: 10.3390/nu14235140] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/10/2022] Open
Abstract
Inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), is characterized as a chronic and recurrent inflammatory disease whose pathogenesis is still elusive. The gut microbiota exerts important and diverse effects on host physiology through maintaining immune balance and generating health-benefiting metabolites. Many studies have demonstrated that IBD is associated with disturbances in the composition and function of the gut microbiota. Both the abundance and diversity of gut microbiota are dramatically decreased in IBD patients. Furthermore, some particular classes of microbiota-derived metabolites, principally short-chain fatty acids, tryptophan, and its metabolites, and bile acids have also been implicated in the pathogenesis of IBD. In this review, we aim to define the disturbance of gut microbiota and the key classes of microbiota-derived metabolites in IBD pathogenesis. In addition, we also focus on scientific evidence on probiotics, not only on the molecular mechanisms underlying the beneficial effects of probiotics on IBD but also the challenges it faces in safe and appropriate application.
Collapse
Affiliation(s)
- Yongjia Hu
- School of Pharmacy, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
- State Key Laboratory of Microbial Metabolism, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
| | - Zhouzhou Chen
- School of Pharmacy, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
- State Key Laboratory of Microbial Metabolism, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
| | - Chengchen Xu
- School of Pharmacy, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
- State Key Laboratory of Microbial Metabolism, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
| | - Shidong Kan
- School of Pharmacy, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
- State Key Laboratory of Microbial Metabolism, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
| | - Daijie Chen
- School of Pharmacy, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
- State Key Laboratory of Microbial Metabolism, Shanghai Jiao Tong University, No. 800 Dongchuan Road, Minhang District, Shanghai 200240, China
| |
Collapse
|
11
|
Arkenbosch JHC, Mak JWY, Ho JCL, Beelen EMJ, Erler NS, Hoentjen F, Bodelier AGL, Dijkstra G, Romberg-Camps M, de Boer NKH, Stassen LPS, van der Meulen AE, West R, van Ruler O, van der Woude CJ, Ng SC, de Vries AC. Indications, Postoperative Management, and Long-term Prognosis of Crohn's Disease After Ileocecal Resection: A Multicenter Study Comparing the East and West. Inflamm Bowel Dis 2022; 28:S16-S24. [PMID: 34969091 DOI: 10.1093/ibd/izab316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The Crohn's disease (CD) phenotype differs between Asian and Western countries and may affect disease management, including decisions on surgery. This study aimed to compare the indications, postoperative management, and long-term prognosis after ileocecal resection (ICR) in Hong Kong (HK) and the Netherlands (NL). METHODS CD patients with primary ICR between 2000 and 2019 were included. The endpoints were endoscopic (Rutgeerts score ≥i2b and/or radiologic recurrence), clinical (start or switch of inflammatory bowel disease medication), and surgical recurrences. Cumulative incidences of recurrence were estimated with a Bayesian multivariable proportional hazards model. RESULTS Eighty HK and 822 NL patients were included. The most common indication for ICR was penetrating disease (HK: 32.5%, NL: 22.5%) in HK vs stricturing disease (HK: 32.5%, NL: 48.8%) in the NL (P < .001). Postoperative prophylaxis was prescribed to 65 (81.3%) HK patients (28 [35.0%] aminosalicylates [5-aminosalicylic acid]; 30 [37.5%] immunomodulators; 0 biologicals) vs 388 (47.1%) NL patients (67 [8.2%] 5-aminosalicylic acid; 187 [22.8%] immunomodulators; 69 [8.4%] biologicals; 50 [6.1%] combination therapy) (P < .001). Endoscopic or radiologic evaluation within 18 months was performed in 36.3% HK vs 64.1% NL (P < .001) patients. No differences between both populations were observed for endoscopic (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.24-1.21), clinical (HR, 0.91; 95% CI, 0.62-1.32), or surgical (HR, 0.61; 95% CI, 0.31-1.13) recurrence risks. CONCLUSION The main indication for ICR in CD patients is penetrating disease in HK patients and stricturing disease in NL patients. Although considerable pre- and postoperative management differences were observed between the two geographical areas, the long-term prognosis after ICR is similar.
Collapse
Affiliation(s)
- Jeanine H C Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Jacky C L Ho
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Evelien M J Beelen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.,Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology and Hepatology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, the Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Andrea E van der Meulen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rachel West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands.,Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Siew C Ng
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
12
|
Yanai H, Levine A, Hirsch A, Boneh RS, Kopylov U, Eran HB, Cohen NA, Ron Y, Goren I, Leibovitzh H, Wardi J, Zittan E, Ziv-Baran T, Abramas L, Fliss-Isakov N, Raykhel B, Gik TP, Dotan I, Maharshak N. The Crohn's disease exclusion diet for induction and maintenance of remission in adults with mild-to-moderate Crohn's disease (CDED-AD): an open-label, pilot, randomised trial. Lancet Gastroenterol Hepatol 2021; 7:49-59. [PMID: 34739863 DOI: 10.1016/s2468-1253(21)00299-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Crohn's disease exclusion diet (CDED) with partial enteral nutrition is effective for induction of remission in children with mild-to-moderate Crohn's disease. We aimed to assess the CDED in adults with Crohn's disease. METHODS We did an open-label, pilot randomised trial at three medical centres in Israel. Eligible patients were biologic naive adults aged 18-55 years with mild-to-moderate Crohn's disease (defined by a Harvey-Bradshaw Index score of 5-14 points), a maximal disease duration of 5 years, with active disease on colonoscopy, or imaging with elevated inflammatory markers (C-reactive protein >5 mg/L or faecal calprotectin concentration >200 μ/g). Patients were randomly assigned (1:1) to CDED plus partial enteral nutrition or CDED alone for 24 weeks. Randomisation was via block randomisation (block sizes of six) using sealed, numbered, and opaque envelopes. Patients and investigators were aware of which group patients were assigned to due to the nature of the different interventions. The primary endpoint was clinical remission, defined as a Harvey-Bradshaw Index score of less than 5 at week 6. The primary endpoint was assessed in the intention-to-treat (ITT) population, which included all patients who used the dietary therapy for at least 48 h. We report results of the final analysis. This trial is registered with ClinicalTrials.gov, NCT02231814. FINDINGS Between Jan 12, 2017, and May 11, 2020, 91 patients were screened, of whom 44 were randomly assigned to the CDED plus partial enteral nutrition group (n=20) or CDED alone group (n=24). 19 patients in the CDED plus partial enteral nutrition group and 21 patients in the CDED alone group received the allocated intervention for at least 48 h and thus were included in the ITT analysis. At week 6, 13 (68%) of 19 patients in the CDED plus partial enteral nutrition group and 12 (57%) of 21 patients in the CDED group had achieved clinical remission (p=0·4618). Among the 25 patients in remission at week 6, 20 (80%) were in sustained remission at week 24 (12 patients in the CDED plus partial enteral nutrition group and eight in the CDED alone group). 14 (35%) of 40 patients were in endoscopic remission at week 24 (eight patients in the CDED plus partial enteral nutrition group and six in the CDED alone group). No serious adverse events or treatment-related adverse events were reported in either group. INTERPRETATION CDED with or without partial enteral nutrition was effective for induction and maintenance of remission in adults with mild-to-moderate biologic naive Crohn's disease and might lead to endoscopic remission. These data suggest that CDED could be used for mild-to-moderate active Crohn's disease and should be assessed in a powered randomised controlled trial. FUNDING Azrieli Foundation and Nestle Health Science.
Collapse
Affiliation(s)
- Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Arie Levine
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Paediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Ayal Hirsch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rotem Sigall Boneh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Israel PIBD Research Center, Wolfson Medical Center, Holon, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology, Sheba Medical Center, Ramat-Gan, Israel
| | - Hagar Banai Eran
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nathaniel A Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yulia Ron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Idan Goren
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Leibovitzh
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joram Wardi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Gastroenterology Institute, Wolfson Medical Center, Holon, Israel
| | - Eran Zittan
- The Abraham and Sonia Rochlin IBD Unit, Department of Gastroenterology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel
| | - Tomer Ziv-Baran
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Abramas
- Israel PIBD Research Center, Wolfson Medical Center, Holon, Israel
| | - Naomi Fliss-Isakov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Barbara Raykhel
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Tamar Pfeffer Gik
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitsan Maharshak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| |
Collapse
|
13
|
Stulman MY, Asayag N, Focht G, Brufman I, Cahan A, Ledderman N, Matz E, Chowers Y, Eliakim R, Ben-Horin S, Odes S, Dotan I, Balicer RD, Benchimol EI, Turner D. Epidemiology of Inflammatory Bowel Diseases in Israel: A Nationwide Epi-Israeli IBD Research Nucleus Study. Inflamm Bowel Dis 2021; 27:1784-1794. [PMID: 33438721 DOI: 10.1093/ibd/izaa341] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are currently no nationwide data on the epidemiology of inflammatory bowel diseases (IBD) in Israel. We aimed to determine the population-based epidemiological trends of IBD in the diverse Israeli population. METHODS Health-administrative data were retrieved from all 4 Israeli health maintenance organizations, insuring 98% of the population, using validated identification algorithms. National trends were determined using Joinpoint regression analysis calculating annual percent change and average annual percent change (AAPC). RESULTS By 2019, there were 46,074 patients with IBD in Israel, corresponding to a national prevalence of 519/100,000 (0.52%), of whom 54.1% had Crohn disease (CD) and 45.9% had ulcerative colitis (UC). The number of Jewish patients doubled from 18,701 in 2005 (354/100,000) to 38,950 (589/100,000) in 2018 (AAPC, +4.0%; P < 0.05), and the number of Arab patients increased 3-fold from 1096 (102.1/100,000) to 3534 (240.7/100,000; AAPC, +6.8%; P < 0.05) during the same years. However, the increase rate has gradually decelerated over time (annual percent change during 2005-2008, 2009-2014, and 2005-2018 was +6.7%, +4.2%, and +2.3%, respectively; P < 0.05). Pediatric prevalence increased from 37.4 to 52.2/100,000, with CD predominating in both Jews and Arabs. The incidence of CD remained stable (from 15.9/100,000 to 14.9/100,000) and the incidence of UC decreased (15.4/100,000 to 10.5/100,000 (AAPC, -3.2%; P < 0.001)). In contrast, pediatric incidence of CD increased from 7.3/100,000 to 8.3/100,000 (AAPC, +1.9%; P < 0.05) and that of UC increased from 2.6 to 4.4/100,000 (AAPC, +5.8%; P < 0.05). CONCLUSIONS The IBD prevalence rate in Israel is still increasing but gradually decelerating, probably due to the decreasing overall IBD incidence. Nonetheless, incidence rate in children is still increasing. Ongoing narrowing in the rates between Jews and Arabs over time may indicate shared environmental factors.
Collapse
Affiliation(s)
- Mira Y Stulman
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Braun School of Public and Community Medicine, The Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Noa Asayag
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Brufman
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Amos Cahan
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Eran Matz
- Leumit Health Services, Tel Aviv, Israel
| | - Yehuda Chowers
- Department of Gastroenterology, Rambam Healthcare Campus, Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Rami Eliakim
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Odes
- Department of Gastroenterology and Hepatology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tivka, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ran D Balicer
- Clalit Research Institute, Chief's Office, Clalit Health Services, Tel Aviv, Israel
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,CHEO Inflammatory Bowel Disease Centre and CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Dan Turner
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
14
|
Song EM, Lee HS, Kim YJ, Oh EH, Ham NS, Kim J, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Myung SJ, Yang SK. Clinical outcomes and long-term prognosis of perianal Crohn's disease in an Asian population. J Gastroenterol Hepatol 2021; 36:1571-1579. [PMID: 33091187 DOI: 10.1111/jgh.15308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The clinical impact of perianal Crohn's disease (CD) (pCD), a well-known poor prognostic factor of CD, has not been fully evaluated in Asian patients. We investigated the outcomes of CD in Korean patients according to the presence of pCD at CD diagnosis. METHODS Using 2010-2014 data from the national health insurance claims database, we evaluated the disease course of CD according to the presence of pCD at CD diagnosis. The results were verified in a hospital-based cohort of 2923 patients. RESULTS The cumulative risk of intestinal resection was lower in patients with pCD at diagnosis than in those without, in the population-based cohort (9.1% vs 14.7% at 5 years after diagnosis, P < 0.001), but it was similar between the two groups in the hospital-based cohort (36.8% vs 36.8% at 10 years after diagnosis, P = 0.950). Moreover, the cumulative risk of behavioral progression was not significantly different between the two groups in the hospital-based cohort (43.4% vs 41.6% at 10 years after diagnosis, P = 0.366). On multivariable analysis, pCD at CD diagnosis was not a predictor of intestinal resection, behavioral progression, CD-related hospital admission, or diverting surgery; however, it was an independent predictor of proctectomy (hazard ratio [HR] 3.210, P < 0.001) and anorectal cancer (HR 3.104, P = 0.047). CONCLUSIONS Although the presence of pCD increased the risk of proctectomy and anorectal cancer in Asian patients, the clinical impact of pCD on the overall outcomes of patients with CD may be less significant in Asian patients compared with Western patients.
Collapse
Affiliation(s)
- Eun Mi Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ho-Su Lee
- Department of Biochemistry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Eun Hye Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Nam Seok Ham
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jeongseok Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| |
Collapse
|
15
|
Janssen L, Romberg-Camps M, van Bodegraven A, Haans J, Aquarius M, Boekema P, Munnecom T, Brandts L, Joore M, Masclee A, Jonkers D, Pierik M. Control Crohn Safe with episodic adalimumab monotherapy as first-line treatment study (CoCroS): study protocol for a randomised controlled trial. BMJ Open 2021; 11:e042885. [PMID: 33947729 PMCID: PMC8098960 DOI: 10.1136/bmjopen-2020-042885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease with a heterogeneous clinical presentation, relapse rate and treatment response. At present, no markers are available to adequately predict disease course at diagnosis. To prevent overtreatment of patients with a relative mild disease course, a step-up approach starting with corticosteroids is usually applied. Timely introduction of potentially disease modifying drugs and tight control of mucosal inflammation are crucial to prevent disease-related complications in patients with a complex disease course. We hypothesise that episodic treatment with adalimumab monotherapy in combination with close monitoring after drug discontinuation improves long-term outcome and reduces drug-related side effects, while preventing overtreatment. METHODS AND ANALYSIS In this pragmatic multicentre randomised controlled trial, newly diagnosed CD patients or CD patients with a flare, naïve to thiopurines and biologicals, will be included and randomised 1:1 to open-label episodic (ie, 24 weeks) adalimumab monotherapy or step-up care starting with corticosteroids. The primary outcome is the number of yearly quarters of corticosteroid free clinical (Monitor Inflammatory Bowel Disease At Home score ≤3) and biochemical (C reactive protein within normal range and faecal calprotectin ≤200 µg/g) remission at week 96. Secondary outcomes are total healthcare costs, cumulative corticosteroid dose, proportion of patients with endoscopic remission at week 24, corticosteroid-free clinical remission, time to remission and patient-reported outcome measures on quality of life, (work) disability and treatment adherence. Safety outcomes are drug-related and disease-related adverse events and disease progression on MRI-enterography at week 96. ETHICS AND DISSEMINATION This study is approved by the Medical Research Ethics Committee of azM/UM in Maastricht dated 21 August 2019 (METC18-076) and is monitored by the Clinical Trial Centre Maastricht according to Good Clinical Practice guidelines. Written informed consent will be obtained from all patients. Study results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT03917303.
Collapse
Affiliation(s)
- Laura Janssen
- NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, The Netherlands
| | - Mariëlle Romberg-Camps
- Gastroenterology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, Limburg, The Netherlands
| | - Ad van Bodegraven
- Gastroenterology, Zuyderland Medical Centre Sittard-Geleen, Sittard-Geleen, Limburg, The Netherlands
| | - Jeoffrey Haans
- Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, The Netherlands
| | - Michèl Aquarius
- Gastroenterology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Paul Boekema
- Gastroenterology, Maxima Medical Centre, Eindhoven, The Netherlands
| | - Tamara Munnecom
- Gastroenterology, Laurentius Hospital, Roermond, The Netherlands
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Manuela Joore
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
- CAPHRI - School for Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Adrian Masclee
- Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, The Netherlands
| | - D Jonkers
- NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - M Pierik
- Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, The Netherlands
| |
Collapse
|
16
|
Beelen EMJ, van der Woude CJ, Pierik MJ, Hoentjen F, de Boer NK, Oldenburg B, van der Meulen AE, Ponsioen CIJ, Dijkstra G, Bruggink AH, Erler NS, Schouten WR, de Vries AC. Decreasing Trends in Intestinal Resection and Re-Resection in Crohn's Disease: A Nationwide Cohort Study. Ann Surg 2021; 273:557-563. [PMID: 31188225 DOI: 10.1097/sla.0000000000003395] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess time trends in intestinal resection and re-resection in Crohn's disease (CD) patients. SUMMARY OF BACKGROUND DATA CD treatment has changed considerably over the past decades. The effect of these advances on the necessity of intestinal resections and the risk of re-resection is unclear. METHODS In this nationwide cohort study, adult CD patients with ileocolonic, small bowel, colon, or rectum resections between 1991 and 2015 were included. Data were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology (PALGA). Time trends were analyzed with a broken stick model and Cox proportional hazard model with smoothing splines. RESULTS The identified cohort comprised 8172 CD patients (3293/4879 male/female) in whom 10,315 intestinal resections were performed. The annual intestinal resection rate decreased nonlinearly from 1.9/100,000 (1991) to 0.2/100,000 (2015). A significantly steeper-decrease was observed before 1999 (slope –0.13) as compared to subsequent years (slope –0.03) (p<0.001). Analogous trends were observed for ileocolonic, small bowel, and colon resections. Overall cumulative risk of re-resection was 10.9% at 5 years, 18.6% at 10 years, and 28.3% at 20 years after intestinal resection. The hazard for intestinal re-resection showed a nonlinear decreasing trend, with hazard ratio 0.39 (95% confidence interval 0.36-0.44) in 2000 and hazard ratio 0.25 (95% confidence interval 0.18-0.34) in 2015 as compared to 1991. CONCLUSION Over the past 25 years, intestinal resection rate has decreased significantly for ileocolonic, small bowel, and colonic CD. In addition, current postoperative CD patients are at 75% lower risk of intestinal re-resection.
Collapse
Affiliation(s)
- Evelien M J Beelen
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | - C Janneke van der Woude
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | - Marie J Pierik
- Maastricht University Medical Center, Department of Gastroenterology and Hepatology, Maastricht, the Netherlands
| | - Frank Hoentjen
- Radboud University Medical Center, Department of Gastroenterology and Hepatology, Nijmegen, the Netherlands
| | - Nanne K de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam, The Netherlands
| | - Bas Oldenburg
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, the Netherlands
| | - Andrea E van der Meulen
- Leiden University Medical Center, Department of Gastroenterology and Hepatology, Leiden, the Netherlands
| | - Cyriel I J Ponsioen
- Amsterdam UMC, Academic Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - Gerard Dijkstra
- University of Groningen, Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Annette H Bruggink
- PALGA, Nationwide Network and Registry of Histopathology and Cytopathology in the Netherlands, Houten, the Netherlands
| | - Nicole S Erler
- Erasmus University Medical Center, Department of Biostatistics, Rotterdam, the Netherlands
| | - W Rudolph Schouten
- Erasmus University Medical Center, Department of Surgery, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| |
Collapse
|
17
|
Te Groen M, Derks MEW, Kuijpers CCHJ, Nagtegaal ID, Hoentjen F. Reduction in Inflammatory Bowel Disease Healthcare During the Coronavirus Disease 2019 Pandemic: A Nationwide Retrospective Cohort Study. Gastroenterology 2021; 160:935-937.e1. [PMID: 33127390 PMCID: PMC7581342 DOI: 10.1053/j.gastro.2020.10.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Maarten Te Groen
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Monica E W Derks
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
18
|
Walentynowicz M, Van de Pavert I, Coenen S, Fierens L, Vlaeyen J, von Leupoldt A, Van Oudenhove L, Vermeire S, Van Assche G, Ferrante M, Van Diest I. Worries and concerns of inflammatory bowel disease (IBD) patients in Belgium - a validation of the Dutch rating form. Scand J Gastroenterol 2020; 55:1427-1432. [PMID: 33135491 DOI: 10.1080/00365521.2020.1839962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Worry is the most common psychological complaint among patients with Inflammatory Bowel Disease (IBD). This study aimed to translate and test the psychometric properties the Rating Form of IBD Patient Concerns (RFIPC) among Dutch-speaking patients with IBD in Belgium. It also aimed to describe worries and concerns, and to examine possible differences in worry patterns between patients with different disease types and disease activities. METHODS The RFIPC was translated into Dutch following the guidelines of the Rome Foundation and was completed by patients with Crohn's disease (CD, n = 336) and ulcerative colitis (UC, n = 160). To test concurrent validity, the Depression Anxiety Stress Scales (DASS-21) were used. Factor structure was examined with confirmatory factor analysis. RESULTS The four-factor structure including subscales 'impact of the disease', 'sexual intimacy', 'complications of the disease' and 'body stigma' was confirmed in the Dutch sample. All factors had high internal consistency (>.70). Correlations with DASS-21 suggest good concurrent validity, all rs>.30, ps<.001. No differences in the RFIPC scores were observed between patients with CD and UC. Patients with active disease (53%) had higher scores than patients in remission (47%). Across all groups, the order of top concerns was consistent and included worries about energy level, side effects of medication, having an ostomy bag/surgery, and uncertain nature of the disease. CONCLUSIONS The Dutch version of the RFIPC is a valid and reliable measure of IBD-specific worries and concerns which can be used in both research and clinical settings.
Collapse
Affiliation(s)
- Marta Walentynowicz
- Centre for the Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium.,Psychological Science Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | | | - Sofie Coenen
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Liselotte Fierens
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Johan Vlaeyen
- Health Psychology Research Group, KU Leuven, Leuven, Belgium
| | | | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium.,Cognitive and Affective Neuroscience Lab, Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Gert Van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Van Diest
- Health Psychology Research Group, KU Leuven, Leuven, Belgium
| |
Collapse
|
19
|
Terlouw LG, Verbeten M, van Noord D, Brusse-Keizer M, Beumer RR, Geelkerken RH, Bruno MJ, Kolkman JJ. The Incidence of Chronic Mesenteric Ischemia in the Well-Defined Region of a Dutch Mesenteric Ischemia Expert Center. Clin Transl Gastroenterol 2020; 11:e00200. [PMID: 32955192 PMCID: PMC7431271 DOI: 10.14309/ctg.0000000000000200] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION This study aimed to determine the incidence of chronic mesenteric ischemia (CMI) and to examine the influence of the etiological cause, location, and severity of a mesenteric artery stenosis on the probability of having CMI. METHODS A prospective database, containing the details of all patients with suspected CMI referred to a renowned CMI expert center, was used. Patients residing within the expert centers' well-defined region, between January 2014 and October 2019, were included. CMI was diagnosed when patients experienced sustained symptom improvement after treatment. RESULTS This study included 358 patients, 75 had a ≥50% atherosclerotic stenosis of 1 vessel (CMI 16%), 96 of 2 or 3 vessels (CMI 81%), 81 celiac artery compression (CMI 25%), and 84 no stenosis (CMI 12%). In total, 138 patients were diagnosed with CMI, rendering a mean incidence of 9.2 (95% confidence interval [CI] 6.2-13.7) per 100,000 inhabitants. Atherosclerotic CMI was most common, with a mean incidence of 7.2 (95% CI 4.6-11.3), followed by median arcuate ligament syndrome 1.3 (95% CI 0.5-3.6) and chronic nonocclusive mesenteric ischemia 0.6 (95% CI 0.2-2.6). The incidence of CMI was highest in female patients (female patients 12.0 [95% CI 7.3-19.6] vs male patients 6.5 [95% CI 3.4-12.5]) and increased with age. CMI was more prevalent in the presence of a ≥70% atherosclerotic single-vessel stenosis of the superior mesenteric artery (40.6%) than the celiac artery (5.6%). DISCUSSION The incidence of CMI is higher than previously believed and increases with age. Probability of CMI seems highest in suspected CMI patients with multivessel disease or a ≥70% atherosclerotic single-vessel superior mesenteric artery stenosis.
Collapse
Affiliation(s)
- Luke G. Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Mandy Verbeten
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | | | - Ruth R. Beumer
- Department of General Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H. Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3I) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J. Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dutch Mesenteric Ischemia Study Group
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of General Medicine, University Medical Center Groningen, Groningen, the Netherlands
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3I) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
20
|
Lie MRKL, Kreijne JE, Dijkstra G, Löwenberg M, van Assche G, West RL, van Noord D, van der Meulen-de Jong AE, Oldenburg B, Zaal RJ, Hansen BE, de Vries AC, Janneke van der Woude C. No Superiority of Tacrolimus Suppositories vs Beclomethasone Suppositories in a Randomized Trial of Patients With Refractory Ulcerative Proctitis. Clin Gastroenterol Hepatol 2020; 18:1777-1784.e2. [PMID: 31610337 DOI: 10.1016/j.cgh.2019.09.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ulcerative proctitis (UP) refractory to 5-aminosalicylic acid (5-ASA) suppositories is a challenge to treat, often requiring step up to immunomodulator or biological therapy. Topical tacrolimus is effective and safe in patients with refractory UP. However, it is not clear how tacrolimus suppositories fit into in the treatment algorithm of UP. METHODS We performed a randomized controlled, double-blind study at 8 hospitals in the Netherlands and Belgium from 2014 through 2017. Eighty-five patients with refractory UP (65% women) were randomly assigned to groups given once daily tacrolimus suppositories (2 mg; n = 43) or beclomethasone (3 mg; n = 42) for 4 weeks. The primary outcome was clinical response (decrease in Mayo score of 3 or more). Secondary outcomes included clinical remission, endoscopic response and remission, adverse events and quality of life. Outcomes were compared using Fisher's exact test and Mann-Whitney U test. RESULTS Proportions of patients with clinical responses were 63% in the tacrolimus group and 59% in the beclomethasone group (P = .812); proportions of patients in clinical remission were 46% and 38%, respectively (P = .638). Proportions of patients with an endoscopic response were 68% and 60% in the tacrolimus group and in the beclomethasone group (P = .636); proportions in endoscopic remission rates were 30% and 13%, respectively (P = .092) Median increases in the inflammatory bowel disease questionnaire score were 18.0 in the tacrolimus group and 20.5 in the beclomethasone group (P = .395). Adverse event rates did not differ significantly between groups. CONCLUSIONS In a 4-week randomized controlled trial, tacrolimus and beclomethasone suppositories induce comparable clinical and endoscopic responses in patients with UP refractory to 5-ASA. There were no significant differences in adverse events rates. Tacrolimus and beclomethasone suppositories are therefore each safe and effective treatment options for 5-ASA refractory disease. EUDRACT 2013-001259-11; Netherlands Trial Register NL4205/NTR4416.
Collapse
Affiliation(s)
- Mitchell R K L Lie
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Joany E Kreijne
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gerard Dijkstra
- Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Mark Löwenberg
- Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Gert van Assche
- Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Rachel L West
- Gastroenterology and Hepatology, Franciscus Hospital and Vlietland Hospital, Rotterdam, the Netherlands
| | - Desiree van Noord
- Gastroenterology and Hepatology, Franciscus Hospital and Vlietland Hospital, Rotterdam, the Netherlands
| | | | - Bas Oldenburg
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rianne J Zaal
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bettina E Hansen
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands; Center for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Annemarie C de Vries
- Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | |
Collapse
|
21
|
de Jong MJ, Boonen A, van der Meulen-de Jong AE, Romberg-Camps MJ, van Bodegraven AA, Mahmmod N, Markus T, Dijkstra G, Winkens B, van Tubergen A, Masclee A, Jonkers DM, Pierik MJ. Cost-effectiveness of Telemedicine-directed Specialized vs Standard Care for Patients With Inflammatory Bowel Diseases in a Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:1744-1752. [PMID: 32335133 DOI: 10.1016/j.cgh.2020.04.038] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/15/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Telemedicine can be used to monitor determinants and outcomes of patients with chronic diseases, possibly increasing the quality and value of care. Telemedicine was found to reduce outpatient visits and hospital admissions for patients with inflammatory bowel diseases (IBD). We performed a full economic evaluation of telemedicine interventions in patients with IBD, comparing the cost-utility of telemedicine vs standard care. METHODS We performed a randomized trial of 909 patients with IBD at 2 academic and 2 non-academic hospitals in The Netherlands. Patients were randomly assigned to groups that received telemedicine (myIBDcoach; n = 465) or standard outpatient care (n = 444) and followed for 12 months. Costs were measured from a societal perspective. Direct healthcare costs were based on actual resource use. Indirect costs comprised self-reported hours sick leave from work, intervention costs (annual license fee of €40 per patient [$45]), and utility costs (assessed using EQ5D). Cost-utility and uncertainty were estimated using the non-parametric bootstrapping method. RESULTS Telemedicine resulted in lower mean annual costs of €547/patient [$612] (95% CI, €1029-2143 [$1150-2393]; mean costs of €9481 [$10,587] for standard care and €8924 [$9965] for telemedicine) without changing quality adjusted life years. At the Dutch threshold of €80,000 [$89,335] per quality adjusted life year, the intervention had increased incremental cost-effectiveness over standard care in 83% of replications and an incremental net monetary benefit of €707/patient [$790] (95% CI, €1241-2544 [$1386-2841]). CONCLUSIONS Telemedicine with myIBDcoach is cost saving and has a high probability of being cost effective for patients with IBD. This self-management tool enables continuous registration of quality indicators and (patient-reported) outcomes and might help reorganize IBD care toward value-based healthcare. ClinicalTrials.gov no: NCT02173002.
Collapse
Affiliation(s)
- Marin J de Jong
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht; Maastricht University Medical Centre+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht
| | - Annelies Boonen
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Rheumatology, Maastricht; Maastricht University Medical Centre+, CAPHRI - Care and Public Health Research Institute, Maastricht
| | | | - Mariëlle J Romberg-Camps
- Zuyderland Medical Centre, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Sittard-Geleen
| | - Ad A van Bodegraven
- Zuyderland Medical Centre, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Sittard-Geleen
| | - Nofel Mahmmod
- St Antonius Hospital, Department of Gastroenterology and Hepatology, Nieuwegein
| | - Tineke Markus
- Dutch Crohn's and Colitis Organisation, CCUVN, Woerden
| | - Gerard Dijkstra
- University Medical Centre Groningen, Department of Gastroenterology and Hepatology, Groningen
| | - Bjorn Winkens
- Maastricht University Medical Centre+, CAPHRI - Care and Public Health Research Institute, Maastricht; Maastricht University, Department of Methodology and Statistics, Maastricht, Netherlands
| | - Astrid van Tubergen
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Rheumatology, Maastricht; Maastricht University Medical Centre+, CAPHRI - Care and Public Health Research Institute, Maastricht
| | - Ad Masclee
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht; Zuyderland Medical Centre, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Sittard-Geleen
| | - Daisy M Jonkers
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht; Maastricht University Medical Centre+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht
| | - Marie J Pierik
- Maastricht University Medical Centre+, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht; Maastricht University Medical Centre+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht.
| |
Collapse
|
22
|
Kalman TD, Everhov ÅH, Nordenvall C, Sachs MC, Halfvarson J, Ekbom A, Ludvigsson JF, Myrelid P, Olén O. Decrease in primary but not in secondary abdominal surgery for Crohn's disease: nationwide cohort study, 1990–2014. Br J Surg 2020; 107:1529-1538. [PMID: 32452553 DOI: 10.1002/bjs.11659] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/25/2020] [Accepted: 04/04/2020] [Indexed: 12/15/2022]
Abstract
AbstractBackgroundTreatment of patients with Crohn's disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated.MethodsIn this nationwide cohort study, incident patients of all ages with Crohn's disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990–1995 and 1996–2000 with use of inpatient registries, 2001, and 2002–2008 and 2009–2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan–Meier method.ResultsAmong 21 273 patients with Crohn's disease, the cumulative incidence of first abdominal surgery within 5 years of Crohn's disease diagnosis decreased continuously from 54·8 per cent in 1990–1995 to 40·4 per cent in 1996–2000 (P < 0·001), and again from 19·8 per cent in 2002–2008 to 17·3 per cent in 2009–2014 (P < 0·001). Repeat 5-year surgery rates decreased from 18·9 per cent in 1990–1995 to 16·0 per cent in 1996–2000 (P = 0·009). After 2000, no further significant decreases were observed.ConclusionThe 5-year rate of surgical intervention for Crohn's disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy.
Collapse
Affiliation(s)
- T D Kalman
- Division of Surgery, Department of Clinical and Experimental Medicine, Faulty of Health Sciences, Linköping University, Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - Å H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Stockholm, Sweden
| | - C Nordenvall
- Department of Molecular Medicine and Surgery, Stockholm, Sweden
- Centre for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - M C Sachs
- Division of Clinical Epidemiology, Department of Medicine Solna, Stockholm, Sweden
| | - J Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - A Ekbom
- Division of Clinical Epidemiology, Department of Medicine Solna, Stockholm, Sweden
| | - J F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
| | - P Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faulty of Health Sciences, Linköping University, Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - O Olén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Stockholm, Sweden
- Department of Paediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden
| |
Collapse
|
23
|
Smits LJT, Pauwels RWM, Kievit W, de Jong DJ, de Vries AC, Hoentjen F, van der Woude CJ. Lengthening adalimumab dosing interval in quiescent Crohn's disease patients: protocol for the pragmatic randomised non-inferiority LADI study. BMJ Open 2020; 10:e035326. [PMID: 32461297 PMCID: PMC7259868 DOI: 10.1136/bmjopen-2019-035326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Adalimumab is effective for maintenance of remission in patients with Crohn's disease (CD) at a dose of 40 mg subcutaneously every 2 weeks. However, adalimumab is associated with (long-term) adverse events and is costly. The aim of this study is to demonstrate non-inferiority and cost-effectiveness of disease activity guided adalimumab interval lengthening compared to standard dosing of every other week (EOW). METHODS AND ANALYSIS The Lengthening Adalimumab Dosing Interval (LADI) study is a pragmatic, multicentre, open label, randomised controlled non-inferiority trial. Non-inferiority is reached if the difference in cumulative incidence of persistent (>8 weeks) flares does not exceed the non-inferiority margin of 15%. 174 CD patients on adalimumab maintenance therapy in long-term (>9 months) clinical and biochemical remission will be included (C-reactive protein (CRP) <10 mg/L, faecal calprotectin (FC) <150 µg/g, Harvey-Bradshaw Index (HBI) <5). Patients will be randomised 2:1 into the intervention (adalimumab interval lengthening) or control group (adalimumab EOW). The intervention group will lengthen the adalimumab administration interval to every 3 weeks, and after 24 weeks to every 4 weeks. Clinical and biochemical disease activity will be monitored every 12 weeks by physician global assessment, HBI, CRP and FC. In case of disease flare, dosing will be increased. A flare is defined as two of three of the following criteria; FC>250 µg/g, CRP≥10 mg/l, HBI≥5. Secondary outcomes include cumulative incidence of transient flares, adverse events, predictors for successful dose reduction and cost-effectiveness. ETHICS AND DISSEMINATION The study is approved by the Medical Ethics Committee Arnhem-Nijmegen, the Netherlands (registration number NL58948.091.16). Results will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBERS EudraCT registry (2016-003321-42); Clinicaltrials.gov registry (NCT03172377); Dutch trial registry (NTRID6417).
Collapse
Affiliation(s)
- L J T Smits
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - R W M Pauwels
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - W Kievit
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - D J de Jong
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - A C de Vries
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - F Hoentjen
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - C J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
24
|
Incidence and Outcomes of Perianal Disease in an Asian Population with Crohn's Disease: A Nationwide Population-Based Study. Dig Dis Sci 2020; 65:1189-1196. [PMID: 31485994 DOI: 10.1007/s10620-019-05819-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about the natural history of perianal fistulas in Asian populations with Crohn's disease (CD). AIMS We investigated the incidence and outcomes of perianal CD (pCD) in Korean CD patients. METHODS A nationwide population-based cohort of 6265 CD patients diagnosed in 2010-2014 was analyzed to investigate the incidence and outcomes of pCD. The results were validated in a hospital-based cohort of 2923 CD patients diagnosed in 1981-2015. Factors associated with pCD development were analyzed. The incidence and outcomes of pCD were compared between the prebiologic and biologic eras. RESULTS pCD occurred in 39.2% of the population-based cohort and 56.1% of the hospital-based cohort during the median follow-up of 4.2 and 8.5 years, respectively. The cumulative incidence of pCD was 40.0% at 5 years after CD diagnosis in the population-based cohort and 62.5% at 20 years in the hospital-based cohort. In multivariate analysis, pCD development was positively associated with male sex, younger age and colonic involvement at diagnosis, early diagnosis, and CD diagnosis in the prebiologic era. The cumulative probability of proctectomy at 10, 20, and 30 years after pCD diagnosis was 2.9%, 12.2%, and 16.2%, respectively. The cumulative incidence of pCD occurring after CD diagnosis and the cumulative probability of proctectomy were significantly lower in the biologic era than in the prebiologic era (p < 0.001 and p = 0.03, respectively). CONCLUSIONS Compared with Western patients with CD, Korean patients show a high incidence of pCD but have a low probability of proctectomy, suggesting the favorable course of pCD.
Collapse
|
25
|
van Bodegraven AA, Bravenboer N. Perspective on skeletal health in inflammatory bowel disease. Osteoporos Int 2020; 31:637-646. [PMID: 31822927 PMCID: PMC7075921 DOI: 10.1007/s00198-019-05234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/14/2019] [Indexed: 12/18/2022]
Abstract
Osteopenia and osteoporosis are common features in inflammatory bowel disease (IBD), comprising both Crohn's disease and ulcerative colitis. Moreover, Crohn's disease is associated with increased fracture risk. The etiology of bone loss in IBD is multifactorial. It includes insufficient intake or absorption of calcium, vitamin D, and potassium; smoking; a low peak bone mass; a low body mass index; and decreased physical activity. In several studies, it has been shown that elevated concentrations of systemic and local pro-inflammatory cytokines, including tumor necrosis factor alpha (TNF-α), interferon-γ (IFNγ), interleukin (IL)-1β, IL-4, IL-5, IL-6, IL-13, and IL-17, present in IBD patients are potentially detrimental for bone metabolism and may be responsible for bone loss and increased fracture risk. This perspective aims to review the current literature on the role of inflammatory factors in the pathophysiology of skeletal problems in IBD and to suggest potential treatment to improve bone health, based on a combination of evidence and clinical and pathophysiological reasoning.
Collapse
Affiliation(s)
- A. A. van Bodegraven
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine(Co-MIK), Zuyderland MC, Sittard-Geleen-Heerlen, Dr H van der Hoffplein 1, 6162 BG Geleen, Netherlands
- Department of Gastroenterology, Amsterdam UMC, Location Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, Netherlands
| | - N. Bravenboer
- Department of Clinical Chemistry, Research Institute Amsterdam Movement Sciences Amsterdam UMC, Location Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, Netherlands
- Department of Internal Medicine, Endocrinology Section, Centre for Bone Quality LUMC, Albinusdreef 2, Leiden, 2333 ZA Netherlands
| |
Collapse
|
26
|
Klepp P, Brackmann S, Cvancarova M, Hoivik ML, Hovde Ø, Henriksen M, Huppertz-Hauss G, Bernklev T, Hoie O, Kempski-Monstad I, Solberg IC, Stray N, Jahnsen J, Vatn MH, Moum B. Risk of colorectal cancer in a population-based study 20 years after diagnosis of ulcerative colitis: results from the IBSEN study. BMJ Open Gastroenterol 2020; 7:e000361. [PMID: 32337058 PMCID: PMC7170403 DOI: 10.1136/bmjgast-2019-000361] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023] Open
Abstract
Objective The association between ulcerative colitis (UC) and colorectal cancer (CRC) is widely accepted, although attenuated risk has been reported in recent years. Colonoscopic surveillance is recommended with intervals based on established clinical risk factors. Nevertheless, a significant number of patients develop interval cancers, indicating the need of improved individualised assessment. In the present study, we evaluated clinical risk factors associated with CRC during a prescheduled follow-up 20 years after diagnosis, the IBSEN study. Design A population-based inception cohort of patients diagnosed with inflammatory bowel disease from 1 January 1990 until 31 December 1993, prospectively followed at 1, 5, 10 and 20 years after diagnosis. A total of 517 patients with UC were included; 264 (51 %) men; median age at inclusion 37.4 years (4–88). Results The overall incidence of CRC was 1.6% (8/517) at a 20-year follow-up. The total lifetime risk of CRC prior to or after UC diagnosis was 2.3%. (12/517). Patients older than 70 years at diagnosis had a 15-fold higher risk of CRC compared with those diagnosed when younger than 40 years, with HR 15.68 (95% CI: 1.31 to 187.92). Neither sex, first-degree relative with CRC, extent of colitis nor primary sclerosing cholangitis affected the risk of CRC. Conclusion The risk of CRC in UC was low and comparable with the risk of CRC in the background population of Norway.
Collapse
Affiliation(s)
- Pasquale Klepp
- Unger-Vetlesen Institute, Lovisenberg Diakonale Hospital, Oslo, Norway.,Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Stephan Brackmann
- Department of Gastroenterology, Akershus University Hospital, Lorenskog, Norway.,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Milada Cvancarova
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marte Lie Hoivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øistein Hovde
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Innlandet Hospital Trust, Gjøvik, Oppland, Norway
| | - Magne Henriksen
- Department of Gastroenterology, Østfold Hospital Trust, Gralum, Kalnes, Norway
| | - Gert Huppertz-Hauss
- Department of Gastroenterology, Telemark Hospital, Ulefossveien, Skien, Norway
| | - Tomm Bernklev
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,R&D Department, Vestfold Hospital Trust, Tonsberg, Norway
| | - Ole Hoie
- Department of Internal Medicine, Sørlandet Hospital, Sykehusveien, Arendal, Norway
| | | | | | - Njaal Stray
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Jorgen Jahnsen
- Department of Gastroenterology, Akershus University Hospital, Lorenskog, Norway.,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Morten H Vatn
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjorn Moum
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
27
|
Mak WY, Zhao M, Ng SC, Burisch J. The epidemiology of inflammatory bowel disease: East meets west. J Gastroenterol Hepatol 2020; 35:380-389. [PMID: 31596960 DOI: 10.1111/jgh.14872] [Citation(s) in RCA: 331] [Impact Index Per Article: 82.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/13/2022]
Abstract
The incidence of inflammatory bowel diseases (IBD) in East has risen over the past decade to become a global disease. The increasing number of studies on the incidence and course of IBD in East has enabled us to explore East versus West differences in the epidemiology of IBD which could enhance our understanding of the heterogeneity of the disease and eventually assist in the discovery of novel therapeutic targets and design of preventive strategies. Comparison of population-based data in East and West reveals that the incidence of IBD has risen rapidly in East while plateauing in West. Furthermore, the clinical presentation and course of IBD differs between East and West with more patients in East presenting with complicated disease. Considering the scarcity of population-based data from East and the lack of studies with long durations of follow-up, it remains to be clarified whether these differences reflect true differences in disease presentation. The effects of genetic and environmental risk factors contributing to IBD also differ between Eastern and Western populations. Considering the differential effects of genetic and environmental risk factors in East and West, future studies should seek to discover novel genetic and environmental risk factors which might specifically apply to eastern populations. In this narrative review, we compare the epidemiology of IBD between eastern and western countries by summarizing evidence from population-based cohort studies in the last ten years. Furthermore, we look at differences in genetic susceptibility and environmental triggers of IBD between East and West.
Collapse
Affiliation(s)
- Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - Mirabella Zhao
- Gastrounit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| | - Siew Chien Ng
- Gastrounit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre University Hospital, Hvidovre, Denmark
| |
Collapse
|
28
|
Vulvar and vaginal neoplasia in women with inflammatory bowel disease. Dig Liver Dis 2020; 52:149-155. [PMID: 31718933 DOI: 10.1016/j.dld.2019.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 02/06/2023]
Abstract
Immunosuppressive drugs are the cornerstone in the treatment of inflammatory bowel disease (IBD), however they are associated with an increased risk of extra-intestinal cancer. Whether the risk for female genital tract malignancies, including vulvar and vaginal cancer, is increased is less clear. Our aim was to investigate the risk of these malignancies in IBD-patients. Histopathological data of all IBD patients with a vulvar or vaginal (pre-)cancerous lesion were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology from 1991 to 2015. Medical history was retrieved from patient records. Data from the Central Office for Statistics, the Dutch comprehensive cancer organization, and the IBDSL cohort were obtained to calculate the standardized, and age-adjusted incidence rates. Fifty-five patients met the inclusion criteria. A standardized incidence rate of 1.2(95% CI:0.8-1.7) for vulvar and vaginal carcinoma among adult female IBD was calculated, which did not significantly differ from the general population. The use of immunosuppressive therapy did not increase the occurrence of vulvovaginal malignancy, nor did it influence the recurrence rate. However, immunosuppressive drugs ever-users were on average 11 years younger at the time of their gynaecological diagnosis. Overall, our data do not support intensified screening for vulvar or vaginal malignancies in female IBD patients.
Collapse
|
29
|
Prevalence of Anal Fistulas in Europe: Systematic Literature Reviews and Population-Based Database Analysis. Adv Ther 2019; 36:3503-3518. [PMID: 31656013 PMCID: PMC6860471 DOI: 10.1007/s12325-019-01117-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Indexed: 12/12/2022]
Abstract
Introduction Despite the fact that perianal fistulas are associated with significant morbidity and impaired quality of life, their prevalence in Europe is unknown. The aim of this study was to estimate the prevalence of perianal fistulas in Europe, overall and according to etiology. Methods Two independent literature reviews were performed using different search strategies to maximize the identification of potentially relevant studies. Data from relevant articles were used to estimate the prevalence of perianal fistulas in Europe. The robustness of the estimate was evaluated using data from a large population-based database from the UK. Results A total of 26 studies provided epidemiological data on perianal fistulas, of which 16 provided suitable data to estimate the prevalence. Estimations using these data yielded a total prevalence of 1.69 per 10,000 population. Cryptoglandular infection and Crohn’s disease (CD) were the predominant etiologies, with prevalence rates at 0.86 and 0.76 per 10,000 population, respectively. Comparison of prevalence data from the UK population-based database with the European population resulted in a standardized prevalence estimate of all perianal fistulas of 1.83 per 10,000 population, confirming the robustness of the literature-based estimate. Conclusion Although in terms of incidence cryptoglandular fistulas were clearly predominant, the prevalence of fistulas in CD and cryptoglandular infection appeared more balanced. This is due to the longer duration and higher frequency of relapses of fistulas in CD. The estimated prevalence implies that perianal fistulas meet the criteria to be considered as a rare condition in Europe (prevalence less than 5 per 10,000 population). Funding This study was funded by Takeda Pharmaceutical U.S.A., Inc. and TiGenix SAU. Electronic Supplementary Material The online version of this article (10.1007/s12325-019-01117-y) contains supplementary material, which is available to authorized users.
Collapse
|
30
|
Efficiency and safety of one-year anti-TNF-α treatment in Crohn's disease: a Polish single-centre experience. GASTROENTEROLOGY REVIEW 2019; 15:156-160. [PMID: 32550949 PMCID: PMC7294981 DOI: 10.5114/pg.2019.90079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/08/2019] [Indexed: 12/11/2022]
Abstract
Introduction Anti-TNF-α therapy of Crohn’s disease (CD) represents considerable progress in inflammatory bowel disease (IBD) treatment; however, many patients still require surgical intervention. The Polish National Insurance Fund currently only covers up to 2 years of infliximab (IFX) therapy in CD patients and 1 year of adalimumab (ADA). Aim To estimate the effectiveness and side effects of the anti-TNF-α Polish therapeutic program in CD patients. Material and methods In this retrospective study, medical documentation of 80 CD patients treated with anti-TNF-α (IFX or ADA) was analysed. Fifty-two patients finished 1 year of therapy, and 28 individuals did not complete it due to lack of response to treatment or severe side effects. Results After treatment, 27 (67.50%) patients achieved a semi-annual remission and 14 (35%) achieved yearly remission. Twenty percent of patients experienced severe side effects such as anaphylactic shock, pneumonia, shingles, or upper respiratory tract infections. A strong negative correlation between the number of patients in remission and the period since therapy termination (r = –0.996, p < 0.001) was found. During the 1-year follow-up, 20 patients were re-enrolled in the biological therapy program (the median time to next therapy was 231 days IQR: 126.5–300.5) Conclusions Anti-TNF-α treatment in CD is relatively safe. The restricted time period of the therapy affects the clinical course of the disease and entails the need to resume biological therapy.
Collapse
|
31
|
Park SH, Kim YJ, Rhee KH, Kim YH, Hong SN, Kim KH, Seo SI, Cha JM, Park SY, Jeong SK, Lee JH, Park H, Kim JS, Im JP, Yoon H, Kim SH, Jang J, Kim JH, Suh SO, Kim YK, Ye BD, Yang SK. A 30-year Trend Analysis in the Epidemiology of Inflammatory Bowel Disease in the Songpa-Kangdong District of Seoul, Korea in 1986-2015. J Crohns Colitis 2019; 13:1410-1417. [PMID: 30989166 DOI: 10.1093/ecco-jcc/jjz081] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Although the incidence of inflammatory bowel disease [IBD] is increasing in Asia, data on long-term epidemiological trends are limited. We performed a 30-year longitudinal study to investigate temporal trends in the epidemiology of Crohn's disease [CD] and ulcerative colitis [UC] in Seoul, Korea. METHODS This population-based study included 1431 IBD patients [418 CD, 1013 UC] diagnosed between 1986 and 2015 in the Songpa-Kangdong district of Seoul, Korea. Temporal trends in incidence, prevalence, and disease phenotype at diagnosis were analysed. RESULTS The adjusted mean annual incidence rates of CD and UC per 100 000 inhabitants increased from 0.06 (95% confidence interval [CI], 0.05-0.07) and 0.29 [95% CI, 0.27-0.31], respectively, in 1986-1990 to 2.44 [95% CI, 2.38-2.50] and 5.82 [95% CI, 5.73-5.92], respectively, in 2011-2015. Average annual percentage change in IBD incidence was 12.3% in 1986-1995, 12.3% in 1996-2005, and 3.3% in 2006-2015. The male-to-female ratio of the adjusted incidence rate was 3.3:1 for CD and 1.2:1 for UC. Perianal fistula/abscess was present in 43.3% of patients before or at CD diagnosis. At diagnosis, 54.3% of UC patients presented only with proctitis. The adjusted prevalence rate in 2015 was 31.59/100 000 [95% CI, 31.10-32.07] for CD and 76.66/100 000 [95% CI, 75.91-77.42] for UC. CONCLUSIONS The incidence and prevalence of IBD in Korea have continued to increase over the past three decades. Korean patients have distinct demographic and phenotypic characteristics, including a male predominance and high frequency of perianal fistula/abscess in CD and high proportion of proctitis in UC.
Collapse
Affiliation(s)
- Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Ho Kim
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seung In Seo
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sun Yong Park
- Kangdong Seoul Colon and Rectal Surgery, Seoul, Korea
| | | | - Ji Hyun Lee
- Digestive Endoscopic Center, Seoul Song Do Colorectal Hospital, Seoul, Korea
| | - Hyunju Park
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sung Hoon Kim
- Department of Internal Medicine, VHS Medical Center, Seoul, Korea
| | - Jisun Jang
- Department of Internal Medicine, VHS Medical Center, Seoul, Korea
| | - Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University Medical Center, Seoul, Korea
| | - Seong O Suh
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | | | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | |
Collapse
|
32
|
Opstelten JL, Vaartjes I, Bots ML, Oldenburg B. Mortality After First Hospital Admission for Inflammatory Bowel Disease: A Nationwide Registry Linkage Study. Inflamm Bowel Dis 2019; 25:1692-1699. [PMID: 31189013 PMCID: PMC6749886 DOI: 10.1093/ibd/izz055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The goal of this study was to determine long-term mortality and causes of death in patients after hospitalization for inflammatory bowel disease (IBD). METHODS A cohort of patients admitted to the hospital because of IBD for the first time between 1998 and 2010 was identified by linkage of nationwide Dutch registries. Mortality risks and causes of death in Crohn's disease (CD) and ulcerative colitis (UC) patients were compared with a large random sample of individuals from the general population. Multivariable Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS In total, 23,003 patients (56.1% women; mean age, 44.8 years) were hospitalized for IBD. Patients admitted for IBD had a higher risk of death than those from the general population. Adjusted HRs for 5-year all-cause mortality were 2.42 (95% CI, 1.15-5.12) and 1.45 (95% CI, 1.26-1.66) in men and women hospitalized for CD, respectively. Corresponding HRs for UC were 1.59 (95% CI, 1.39-1.83) and 1.13 (95% CI, 0.98-1.31). Mortality among patients after hospitalization for IBD decreased between 1998-2004 and 2005-2010. Patients admitted for UC had a higher risk of all-cause mortality than those admitted for CD. Inflammatory bowel disease patients died more often from (colorectal) cancer and gastrointestinal disease and less often from cardiovascular disease relative to the general population. CONCLUSIONS Mortality of patients after hospitalization for IBD has decreased over time. Causes of death in CD and UC patients differ from those in the general population.
Collapse
Affiliation(s)
- Jorrit L Opstelten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands,Address correspondence to: B. Oldenburg, MD, PhD, Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands ()
| |
Collapse
|
33
|
de Jong MJ, Roosen D, Degens JHRJ, van den Heuvel TRA, Romberg-Camps M, Hameeteman W, Bodelier AGL, Romanko I, Lukas M, Winkens B, Markus T, Masclee AAM, van Tubergen A, Jonkers DMAE, Pierik MJ. Development and Validation of a Patient-reported Score to Screen for Mucosal Inflammation in Inflammatory Bowel Disease. J Crohns Colitis 2019; 13:555-563. [PMID: 30476099 DOI: 10.1093/ecco-jcc/jjy196] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Patient-reported outcome measures [PROMs] assessing inflammatory bowel disease [IBD] activity are of interest for monitoring in clinical practice, telemedicine systems, or trials. Different PROMs for follow-up of disease activity are available; however, none was developed with endoscopy as gold standard. The objective of this study was to develop and validate a PROM to predict endoscopic disease activity, following the recommendations of the Food and Drug Administration. METHODS During development, 178 IBD patients undergoing a colonoscopy were asked to fill out 13 clinical questions derived from the literature. During endoscopy, inflammation was assessed with the simplified endoscopic score for Crohn's disease [CD] and the Mayo endoscopic subscore for ulcerative colitis [UC]. Based on correlation with endoscopic inflammation, questions were reduced to a total of six for CD and five for UC. The newly developed Monitor IBD At Home questionnaire [MIAH] was validated in an independent cohort of 135 CD and 131 UC patients. Additionally, diagnostic accuracy of the MIAH combined with a calprotectin home test [CHT] was assessed. RESULTS The MIAH-CD includes questions on rectal bleeding, mucus, stool frequency, urgency, fatigue, and patient-reported disease activity. The MIAH-UC contains items on rectal bleeding, stool frequency, urgency, abdominal pain, and patient-reported disease activity. Both questionnaires showed to be valid, reliable, and responsive to changes. The MIAH and CHT combined had a sensitivity, specificity, negative predictive value [NPV], and positive predicitive value [PPV] of 96.7%, 66.7%, 94.7%, and 76.3% for CD and of 88.2%, 81.4%, 95.6%, and 60.0% for UC, respectively, compared with endoscopy. CONCLUSIONS The MIAH is the first PROM developed to predict endoscopic inflammation in IBD patients. A combination of this questionnaire and a CHT shows excellent diagnostic accuracy to screen for patients who need further assessment of disease activity, and can be used in daily practice, telemedicine systems, and trials.
Collapse
Affiliation(s)
- Marin J de Jong
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Danielle Roosen
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands
| | - Juliette H R J Degens
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands
| | - Tim R A van den Heuvel
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Marielle Romberg-Camps
- Zuyderland Medical Center, Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine [Co-MIK], Sittard-Geleen, The Netherlands
| | - W Hameeteman
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands
| | - Alexander G L Bodelier
- Amphia Hospital Breda, Department of Gastroenterology and Hepatology, Breda, The Netherlands
| | - Igor Romanko
- Clinical Research Center for Inflammatory Bowel Diseases IBD Center ISCARE, Prague, Czech Republic
| | - Milan Lukas
- Clinical Research Center for Inflammatory Bowel Diseases IBD Center ISCARE, Prague, Czech Republic
| | - Bjorn Winkens
- Maastricht University Medical Center, Department of Methodology and Statistics, Maastricht, The Netherlands.,Maastricht University Medical Center+, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | | | - Ad A M Masclee
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Astrid van Tubergen
- Maastricht University Medical Center+, Department of Rheumatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Daisy M A E Jonkers
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Marie J Pierik
- Maastricht University Medical Center+, Department Gastroenterology and Hepatology, Maastricht, The Netherlands.,Maastricht University Medical Center+, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| |
Collapse
|
34
|
Seinen ML, De Boer NK, van Bodegraven AA. Key insights from therapeutic drug monitoring in Crohn's disease patients. Expert Opin Drug Metab Toxicol 2019; 15:399-406. [PMID: 30892105 DOI: 10.1080/17425255.2019.1597054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The incidence and prevalence of Crohn's disease are increasing causing a significant disease burden. Therapeutic drug monitoring (TDM) is advocated as a promising tool for personalized or individual-tailored therapy strategies and has been welcomed as a new means to improve current therapy strategies. Nevertheless, pharmacokinetic-based TDM has limitations, and straightforward target concentrations for most therapies are lacking. Areas covered: In the following concise review of literature, key insights of TDM in thiopurine, methotrexate, anti-TNF, vedolizumab and ustekinumab therapy for Crohn's disease are being described. Expert opinion: Therapeutic drug monitoring may, up till now, be helpful to adjust thiopurine and infliximab therapy, primarily in a reactive setting, in case of inefficacy and of occurrence of adverse event. With this restricted application, the goal of individualized therapy based on TDM has not yet been achieved.
Collapse
Affiliation(s)
- Margien L Seinen
- a Department of Gastroenterology and Hepatology, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Nanne K De Boer
- b Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Adriaan A van Bodegraven
- a Department of Gastroenterology and Hepatology, Amsterdam UMC , Vrije Universiteit Amsterdam , Amsterdam , The Netherlands.,c Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK) , Zuyderland Medical Center , Heerlen-Sittard-Geleen , The Netherlands
| |
Collapse
|
35
|
Novacek G, Gröchenig HP, Haas T, Wenzl H, Steiner P, Koch R, Feichtenschlager T, Eckhardt G, Mayer A, Kirchgatterer A, Ludwiczek O, Platzer R, Papay P, Gartner J, Fuchssteiner H, Miehsler W, Peters PG, Reicht G, Vogelsang H, Dejaco C, Waldhör T. Diagnostic delay in patients with inflammatory bowel disease in Austria. Wien Klin Wochenschr 2019; 131:104-112. [PMID: 30715607 DOI: 10.1007/s00508-019-1451-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed diagnosis seems to be common in inflammatory bowel diseases (IBD). The study was carried out to investigate the diagnostic delay and associated risk factors in Austrian IBD patients. METHODS In a multicenter cross-sectional study adult patients with IBD attending 18 Austrian outpatient clinics completed a multi-item questionnaire that recorded medical and socioeconomic characteristics. The study outcome was diagnostic delay defined as the period from symptom onset to diagnosis of IBD. RESULTS A total of 1286 patients (Crohn's disease 830, ulcerative colitis 435, inflammatory bowel disease unclassified 21; females 651) with a median age of 40 years (interquartile range 31-52 years) and a median disease duration of 10 years (4-18 years) were analyzed. The median diagnostic delay was 6 months (2-23 months) in Crohn's disease and 3 months (1-10 months) in ulcerative colitis (p < 0.001). In the multivariable regression analysis Crohn's disease, greater age at diagnosis and a high educational level (compared to middle degree level) were independently associated with longer diagnostic delay. CONCLUSION The diagnostic delay was longer in Crohn's disease than in ulcerative colitis patients and was associated with greater age at diagnosis and a higher educational level.
Collapse
Affiliation(s)
- Gottfried Novacek
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Hans Peter Gröchenig
- Department of Internal Medicine, Brothers of St. John of God Hospital, St. Veit an der Glan, Spitalgasse 26, 9300, St. Veit an der Glan, Austria
| | - Thomas Haas
- Darmpraxis Salzburg, Bayernstraße 17, 5020, Salzburg, Austria
| | - Heimo Wenzl
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Auenbruggerplatz 2, 8036, Graz, Austria
| | - Pius Steiner
- Department of Internal Medicine I, Wels-Grieskirchen Hospital, Grieskirchnerstraße 42, 4600, Wels, Austria
| | - Robert Koch
- Department of Internal Medicine I, Medical University of Innsbruck, Christoph-Probst-Platz 1, Innrain 52, 6020, Innsbruck, Austria
| | - Thomas Feichtenschlager
- Department of Internal Medicine IV, Rudolfstiftung Hospital, Juchgasse 25, 1030, Vienna, Austria
| | - Gerald Eckhardt
- Department of Internal Medicine, Oberpullendorf Hospital, Spitalstraße 32, 7350, Oberpullendorf, Austria
| | - Andreas Mayer
- Department of Internal Medicine II, Universitätsklinikum St. Pölten, Dunant-Platz 1, 3100, St. Pölten, Austria
| | - Andreas Kirchgatterer
- Department of Internal Medicine V, Wels-Grieskirchen Hospital, Wagnleithnerstraße 27, 4710, Grieskirchen, Austria
| | - Othmar Ludwiczek
- Department of Internal Medicine, Hall in Tirol Hospital, Milserstraße 10, 6060, Hall in Tirol, Austria
| | - Reingard Platzer
- Department of Internal Medicine I, Wiener Neustadt Hospital, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
| | - Pavol Papay
- Department of Internal Medicine, Franziskus Hospital, Nikolsdorfergasse 32, 1050, Vienna, Austria
| | - Johanna Gartner
- Department of Internal Medicine, Hanusch Hospital, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
| | - Harry Fuchssteiner
- Department of Internal Medicine IV, Elisabethinen Hospital, Fadingerstraße 1, 4020, Linz, Austria
| | - Wolfgang Miehsler
- Department of Internal Medicine, Brothers of St. John of God Hospital, Kajetanerplatz 1, 5010, Salzburg, Austria
| | - Paul-Gerhard Peters
- Department of Internal Medicine, Feldkirch Hospital, Carinagasse 47, 6800, Feldkirch, Austria
| | - Gerhard Reicht
- Department of Internal Medicine II, Brothers of St. John of God Hospital, Marschallgasse 12, 8020, Graz, Austria
| | - Harald Vogelsang
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Clemens Dejaco
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Waldhör
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1090, Vienna, Austria
| | | |
Collapse
|
36
|
Goet JC, Beelen EMJ, Biermann KE, Gijsbers AH, Schouten WR, van der Woude CJ, de Vries AC. Cholecystectomy Risk in Crohn's Disease Patients After Ileal Resection: a Long-term Nationwide Cohort Study. J Gastrointest Surg 2019; 23:1840-1847. [PMID: 30411310 PMCID: PMC6702183 DOI: 10.1007/s11605-018-4028-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The risk of gallstone disease necessitating cholecystectomy after ileal resection (IR) in Crohn's disease (CD) patients is not well established. We studied the incidence, cumulative and relative risk of cholecystectomy after IR in CD patients, and associated risk factors. METHODS CD patients with a first IR between 1991 and 2015 were identified in PALGA, a nationwide pathology database in the Netherlands. Details on subsequent cholecystectomy and IR were recorded. Yearly cholecystectomy rates from the general Dutch population were used as a reference. RESULTS A cohort of 8302 (3466 (41.7%) males) CD patients after IR was identified. During the 11.9 (IQR 6.3-18.0) years median follow-up, the post-IR incidence rate of cholecystectomy was 5.2 (95% CI 3.5-6.4)/1000 persons/year. The cumulative incidence was 0.5% at 1 year, 2.4% at 5 years, 4.6% at 10 years, and 10.3% after 20 years. In multivariable analyses, female sex (HR 1.9, CI 1.5-2.3), a later calendar year of first IR (HR/5-year increase, HR 1.27, CI 1.18-1.35), and ileal re-resection (time-dependent HR 1.37, CI 1.06-1.77) were associated with cholecystectomy. In the last decade, cholecystectomy rates increased and were higher in our postoperative CD population than in the general population (relative incidence ratio 3.13 (CI 2.29-4.28; p < 0.0001) in 2015). CONCLUSIONS Although higher in females, increasing in recent years, and higher than in the general population, the overall risk of cholecystectomy in CD patients following IR is low and routine prophylactic measures seem unwarranted.
Collapse
Affiliation(s)
- Jorn C. Goet
- 000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Evelien M. J. Beelen
- 000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katharina E. Biermann
- 000000040459992Xgrid.5645.2Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annette H. Gijsbers
- The nationwide network and registry of histopathology and cytopathology in the Netherlands (PALGA), Houten, Netherlands
| | - W. Rudolph Schouten
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - C. Janneke van der Woude
- 000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annemarie C. de Vries
- 000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
37
|
Sochal M, Mosińska P, Fichna J. Diagnostic value of chemerin in lower gastrointestinal diseases-a review. Peptides 2018; 108:19-24. [PMID: 30165089 DOI: 10.1016/j.peptides.2018.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
Abstract
Chemerin is a protein secreted among others by adipose tissue and liver, with a dual pro- and anti-inflammatory role in the body. These molecules exert systemic effects by modulating tissue-specific immune response and metabolism. Chemerin isoforms correlate with the turnover of fatty acids and lipoproteins that could affect intestinal inflammation. Although chemerin may interact with three types of receptors, CMKLR1 is the best studied. In this paper we reviewed current knowledge about the relationship between chemerin and lower gastrointestinal (GI) diseases, such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) and colorectal cancer (CRC). A more detailed understanding of the role of the adipose tissue in the GI tract will not only unravel the pathophysiology of chronic intestinal diseases, but may also indicate a new therapeutic tool for their management.
Collapse
Affiliation(s)
- Marcin Sochal
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland
| | - Paula Mosińska
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 6/8, 92-215 Lodz, Poland.
| |
Collapse
|
38
|
Kato S, Ishibashi A, Kani K, Yakabi K. Optimized Management of Ulcerative Proctitis: When and How to Use Mesalazine Suppository. Digestion 2018; 97:59-63. [PMID: 29393142 DOI: 10.1159/000484224] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ulcerative proctitis, one of the disease types of ulcerative colitis, is considered one of the initial manifestations of ulcerative colitis. Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis. Here we reviewed the epidemiology, diagnosis, and management of ulcerative proctitis. SUMMARY The number of patients with ulcerative proctitis is increasing. Disease extension occurs in many patients with ulcerative proctitis. Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features. Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis because of its high effectiveness and safety. Topical treatment of ulcerative proctitis, particularly using mesalazine suppository has been underused in clinical practice. Key Messages: Mesalazine suppositories are more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine. However, low adherence to rectal mesalazine has hindered remission in patients with ulcerative proctitis.
Collapse
|
39
|
Eriksson C, Cao Y, Rundquist S, Zhulina Y, Henriksson I, Montgomery S, Halfvarson J. Changes in medical management and colectomy rates: a population-based cohort study on the epidemiology and natural history of ulcerative colitis in Örebro, Sweden, 1963-2010. Aliment Pharmacol Ther 2017; 46:748-757. [PMID: 28833287 DOI: 10.1111/apt.14268] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/03/2017] [Accepted: 07/24/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Whether the epidemiology of ulcerative colitis (UC) has changed during recent decades is partly unknown. AIM To depict temporal trends in the epidemiology and medical treatment of UC as well as the long-term risk of progression in disease extent and colectomy, during 1963-2010. METHODS Patients were identified by evaluation of all medical records in the archive of the Colitis Clinic, Örebro University Hospital. Comparisons were made between three time periods, 1963-1975, 1976-1990 and 1991-2005. RESULTS The annual age-standardised incidence increased from 3.5 to 18.5 per 100 000 during the study period (P < .01). Correspondingly, the prevalence increased from 44 to 474 per 100 000 between 1965 and 2010. A higher proportion of males than females had extensive colitis at diagnosis (odds ratio: 1.55; 95% CI 1.17-2.05; P < .01). The risk for progression in disease extent was 34.5% and 18.5% at 10 years, for patients with proctitis and left-sided colitis, respectively (P < .01). The use of 5-aminosalicylates, within 10 years, rise from 79% to 92% between 1963-1975 and 1976-1990 (P < .01). Thiopurine use increased from 7% in 1976-1990 to 34% during 1991-2005 (P < .01). The colectomy rate at 10 years was 13.5% (95% CI 11.1%-15.8%), and the risk was lower among patients diagnosed in 1991-2005 compared to 1963-1975 (adjusted hazard ratio: 0.61; 95% CI 0.39-0.94; P = .02). CONCLUSION The incidence and prevalence of UC increased over time, and the observed prevalence in 2010 is among the highest reported. In parallel, a decrease in colectomy rates was observed during the most recent decades, potentially reflecting improved medical treatment.
Collapse
Affiliation(s)
- C Eriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Y Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - S Rundquist
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Y Zhulina
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - I Henriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - S Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - J Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| |
Collapse
|