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Jayasooriya N, Baillie S, Blackwell J, Bottle A, Petersen I, Creese H, Saxena S, Pollok RC. Systematic review with meta-analysis: Time to diagnosis and the impact of delayed diagnosis on clinical outcomes in inflammatory bowel disease. Aliment Pharmacol Ther 2023; 57:635-652. [PMID: 36627691 DOI: 10.1111/apt.17370] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/29/2022] [Accepted: 12/10/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The impact of diagnostic delay on the clinical course of inflammatory bowel disease (IBD) remains uncertain. AIM To perform a systematic review of time to diagnosis and the impact of delayed diagnosis on clinical outcomes in Crohn's disease (CD) and ulcerative colitis (UC). METHODS We searched EMBASE and Medline from inception to 30th November 2022 for studies reporting diagnostic interval, from symptom onset to IBD diagnosis. We calculated the median, interquartile range (IQR) and pooled weighted median, of median diagnostic intervals of eligible studies. We defined delayed diagnosis as individuals above the 75th centile of longest time to diagnosis in each study. Using random effects meta-analysis, we pooled odds ratios (ORs) with 95% confidence intervals (CI) for studies reporting clinical outcomes, according to delayed diagnosis. RESULTS One hundred and one studies representing 112,194 patients with IBD (CD = 59,359; UC = 52,835) met inclusion criteria. The median of median times to diagnosis was 8.0 (IQR: 5.0-15.2) and 3.7 months (IQR: 2.0-6.7) in CD and UC, respectively. In high-income countries, this was 6.2 (IQR: 5.0-12.3) and 3.2 months (IQR: 2.2-5.3), compared with 11.7 (IQR: 8.3-18.0) and 7.8 months (IQR: 5.2-21.8) in low-middle-income, countries, for CD and UC respectively. The pooled weighted median was 7.0 (95% CI: 3.0-26.4) and 4.6 (95% CI: 1.0-96.0) months, for CD and UC respectively. Eleven studies, representing 6164 patients (CD = 4858; UC = 1306), were included in the meta-analysis that examined the impact of diagnostic delay on clinical outcomes. In CD, delayed diagnosis was associated with higher odds of stricturing (OR = 1.88; CI: 1.35-2.62), penetrating disease (OR = 1.64; CI: 1.21-2.20) and intestinal surgery (OR = 2.24; CI: 1.57-3.19). In UC, delayed diagnosis was associated with higher odds of colectomy (OR = 4.13; CI: 1.04-16.40). CONCLUSION Delayed diagnosis is associated with disease progression in CD, and intestinal surgery in both CD and UC. Strategies are needed to achieve earlier diagnosis of IBD.
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Affiliation(s)
- Nishani Jayasooriya
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Samantha Baillie
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Jonathan Blackwell
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Alex Bottle
- School of Public Health, Imperial College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Hanna Creese
- School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's Healthcare NHS Trust, St George's University, London, UK
- Institute of Infection and Immunity, St George's University, London, UK
- School of Public Health, Imperial College London, London, UK
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Gao H, He Q, Xu C, Pang Z, Feng B, Chen T, Yang W, Zhou G, Wang Y, Li J, Su J, Miao Y, Zhao Y, Liao Z, Xu C, Liu Z. The Development and Validation of Anti-paratuberculosis-nocardia Polypeptide Antibody [Anti-pTNP] for the Diagnosis of Crohn's Disease. J Crohns Colitis 2022; 16:1110-1123. [PMID: 35029687 DOI: 10.1093/ecco-jcc/jjac008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/17/2021] [Accepted: 01/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Non-invasive biomarkers in sera of patients with inflammatory bowel disease [IBD] are not currently available for rapidly and accurately diagnosing the disease. We aimed to investigate and validate the potential roles of anti-paratuberculosis-nocardia polypeptide antibodies [anti-pTNP] in the diagnosis of IBD. METHODS Serum samples were collected from 502 patients with diagnosed Crohn's disease [CD], 141 patients with ulcerative colitis [UC], and 109 healthy donors. The levels of anti-pTNPs and anti-Saccharomyces cerevisiae antibodies [ASCAs] were determined by enzyme-linked immunosorbent assay. The effects of each variable on the diagnosis were analysed by receiver operating characteristic [ROC] analysis. We also performed an estimate study by first developing a clinical prediction model, with external validation in CD patients from nine IBD medical centres in China. RESULTS The levels of anti-pTNPs in sera of CD patients were higher than those in UC patients and healthy donors. The positive rates of anti-pTNPs were significantly higher in ileal CD patients than in ileocolonic and colonic CD patients, and the levels of anti-pTNP IgG in perianal patients were significantly higher than those in non-perianal CD patients. Of note, anti-pTNPs and perianal diseases were important predictors for active stage of CD patients. Discriminative ability to predict active CD patients was 0.918 (95% confidence interval [CI]:0.886-0.949). CONCLUSIONS Anti-pTNP functions as a novel biological marker for diagnosing CD and can be used to assess disease severity, particularly in those with lesion locations in the terminal ileum and stricturing and perianal diseases. A validated prediction model reveals that anti-pTNPs are useful for estimating the likelihood of active CD.
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Affiliation(s)
- Han Gao
- Center for Inflammatory Bowel Disease Research, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qiong He
- Center for Inflammatory Bowel Disease Research, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chunjin Xu
- Department of Gastroenterology, First People's Hospital of Shangqiu City Affiliated to Xinxiang Medical University, Shangqiu, China
| | - Zhi Pang
- Department of Gastroenterology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, Suzhou, China
| | - Baisui Feng
- Department of Gastroenterology, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tingting Chen
- Laboratory of Experimental Analysis, Shanxi Ruihao Biotechnology, Taiyuan, China
| | - Wu Yang
- Laboratory of Experimental Analysis, Shanxi Ruihao Biotechnology, Taiyuan, China
| | - Guangxi Zhou
- Department of Gastroenterology, Affiliated Hospital of Jining Medical College, Jining, China
| | - Yufang Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Junxiang Li
- Department of Gastroenterology, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing,China
| | - Jingling Su
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Yinglei Miao
- Department of Gastroenterology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ye Zhao
- Department of Gastroenterology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Can Xu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhanju Liu
- Center for Inflammatory Bowel Disease Research, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
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Dulai PS, Boland BS, Singh S, Chaudrey K, Koliani-Pace JL, Kochhar G, Parikh MP, Shmidt E, Hartke J, Chilukuri P, Meserve J, Whitehead D, Hirten R, Winters AC, Katta LG, Peerani F, Narula N, Sultan K, Swaminath A, Bohm M, Lukin D, Hudesman D, Chang JT, Rivera-Nieves J, Jairath V, Zou GY, Feagan BG, Shen B, Siegel CA, Loftus EV, Kane S, Sands BE, Colombel JF, Sandborn WJ, Lasch K, Cao C. Development and Validation of a Scoring System to Predict Outcomes of Vedolizumab Treatment in Patients With Crohn's Disease. Gastroenterology 2018; 155:687-695.e10. [PMID: 29857091 PMCID: PMC6419724 DOI: 10.1053/j.gastro.2018.05.039] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 04/30/2018] [Accepted: 01/02/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS As more treatment options for inflammatory bowel diseases become available, it is important to identify patients most likely to respond to different therapies. We created and validated a scoring system to identify patients with Crohn's disease (CD) who respond to vedolizumab. METHODS We collected data from the GEMINI 2 phase 3 trial of patients with active CD treated with vedolizumab for 26 weeks (n = 814) and performed logistic regression analysis to identify factors associated with clinical, steroid-free, and durable remission (derivation set). We used these data to develop a clinical decision support tool, which we validated using data from 366 participants in a separate clinical practice observational cohort of patients with active CD treated with vedolizumab for 26 weeks (the VICTORY cohort). We evaluated the ability of this tool to identify patients in clinical remission or corticosteroid-free remission, or those with mucosal healing (MH), clinical remission with MH, or corticosteroid-free remission with MH after vedolizumab therapy using receiver operating characteristic area under the curve (AUC) analyses. The primary outcome was to develop and validate a list of factors associated with achieving remission by vedolizumab in patients with active CD. RESULTS In the derivation analysis, we identified absence of previous treatment with a tumor necrosis factor antagonist (+3 points), absence of prior bowel surgery (+2 points), absence of prior fistulizing disease (+2 points), baseline level of albumin (+0.4 points per g/L), and baseline concentration of C-reactive protein (reduction of 0.5 points for values between 3.0 and 10.0 mg/L and 3.0 points for values >10.0 mg/L) as factors associated with remission. In the validation set, our model identified patients in clinical remission with an AUC of 0.67, patients in corticosteroid-free remission with an AUC of 0.66, patients with MH with an AUC of 0.72, patients in clinical remission with MH with an AUC of 0.73, and patients in corticosteroid-free clinical remission with MH with an AUC of 0.75. A cutoff value of 13 points identified patients in clinical remission after vedolizumab therapy with 92% sensitivity, patients in corticosteroid-free remission with 94% sensitivity, patients with MH with 98% sensitivity, patients with clinical remission and MH with 100% sensitivity, and patients with corticosteroid-free clinical remission with MH with 100% sensitivity. CONCLUSIONS We developed and validated a scoring system to identify patients with CD most likely to respond to 26 weeks of vedolizumab therapy. Further studies are needed to optimize its accuracy in select populations and determine its cost-effectiveness.
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Affiliation(s)
| | | | | | | | | | | | | | - Eugenia Shmidt
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | - Leah G. Katta
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Farhad Peerani
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,University of Alberta, Edmonton, AB, Canada
| | - Neeraj Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,McMaster University Medical Centre, Hamilton, ON, Canada
| | - Keith Sultan
- North Shore University Hospital, Manhasset, NY, USA
| | | | | | - Dana Lukin
- Montefiore Medical Center, New York, NY, USA
| | | | - John T. Chang
- University of California - San Diego, La Jolla, CA, USA
| | | | | | - GY Zou
- University of Western Ontario, London, ON, Canada
| | | | - Bo Shen
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | | | - Bruce E. Sands
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Karen Lasch
- Takeda Pharmaceuticals USA Inc., Deerfield, IL, USA
| | - Charlie Cao
- Takeda Pharmaceuticals USA Inc., Deerfield, IL, USA
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Dulai PS, Singh S, Ohno-Machado L, Sandborn WJ. Population Health Management for Inflammatory Bowel Disease. Gastroenterology 2018; 154:37-45. [PMID: 29122544 DOI: 10.1053/j.gastro.2017.09.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel diseases (IBDs) are chronic and impose significant, multidimensional burdens on patients and health care systems. The increasing prevalence of IBD will only worsen this problem globally-population health management (PHM) strategies are needed to increase quality of care and population health outcomes while reducing health care costs. We discuss the key components of PHM in IBD. Effective implementation of PHM strategies requires accurate identification of at-risk patients and key areas of variability in care. Improving outcomes of the at-risk population requires implementation of a multicomponent chronic care model designed to shift delivery of ambulatory care from acute, episodic, and reactive encounters, to proactive, planned, long-term care. This is achieved through team care of an activated patient with the help of remote monitoring, clinical information systems, and integrated decision support, with accompanying changes in delivery systems. Performance measurement is integral to any PHM strategy. This involves developing and implementing meaningful metrics of different phases of quality of IBD care and measuring them efficiently using modern clinical information systems. Such an integrated framework of PHM in IBD will facilitate the delivery of high-value care to patients.
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Affiliation(s)
- Parambir S Dulai
- Division of Gastroenterology, University of California at San Diego, San Diego, California.
| | - Siddharth Singh
- Division of Gastroenterology, University of California at San Diego, San Diego, California; Health System Department of Biomedical Informatics, University of California at San Diego, San Diego, California
| | - Lucilla Ohno-Machado
- Health System Department of Biomedical Informatics, University of California at San Diego, San Diego, California
| | - William J Sandborn
- Division of Gastroenterology, University of California at San Diego, San Diego, California
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Abstract
BACKGROUND AND OBJECTIVES Crohn disease (CD) is an increasingly recognized problem in Saudi Arabia. The aim of this study was to describe the clinical pattern in children and adolescents with CD seen at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. DESIGN AND SETTING Retrospective hospital-based study conducted on data collected for the period between January 2001 and March 2010. PATIENTS AND METHODS Data for all children and adolescents diagnosed at KAUH with CD in the period were retrieved and analyzed. RESULTS Ninety-six patients were identified. The median age at diagnosis was 11.3 years (range, 0.12-17.6 years). Fifty (52.1%) were males. Sixty-four (66.7%) were Saudis. Nine (9.4%) had a first degree relative with inflammatory bowel disease. The most common presenting symptoms were diarrhea (88.5%), weight loss (84.2%) and anorexia (80.2%). At least one extraintestinal manifestation occurred in 24% of patients. Forty-two percent were underweight and 19% had short stature. The most common distribution was ileocolonic (37.5%), followed by colonic in 31.2%. Twenty-five (26%) patients had perianal disease, 13 (13.5%) had strictures and 15 (15.6%) had penetrating disease. Laboratory investigations revealed anemia in 84.4%, thrombocytosis in 50%, hypoalbuminemia in 64.6%, elevated erythrocyte sedimentation rate (ESR) in 50% and elevated C-reactive protein in 58.3%. Induction of remission was achieved with enteral nutrition in 20% of patients and with corticosteroids in the remaining. CONCLUSIONS The clinical pattern of CD in children from the Western Province of Saudi Arabia was found to be similar to reports from the West. Pediatricians should be aware of the varying presentations of CD. Early referral to specialized centers is crucial.
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Affiliation(s)
- Omar I Saadah
- Department of Pediatrics, King Abdulaziz University, PO Box 80215 Jeddah 21589, Western Province, Saudi Arabia.
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Gupta N, Bostrom AG, Kirschner BS, Ferry GD, Gold BD, Cohen SA, Winter HS, Baldassano RN, Abramson O, Smith T, Heyman MB. Incidence of stricturing and penetrating complications of Crohn's disease diagnosed in pediatric patients. Inflamm Bowel Dis 2010; 16:638-44. [PMID: 19760783 PMCID: PMC3258512 DOI: 10.1002/ibd.21099] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The development of disease complications is poorly characterized in pediatric patients with Crohn's disease (CD). METHODS We retrospectively determined the cumulative incidence of stricturing and penetrating complications of CD prior to first surgery utilizing data from 989 consecutively enrolled CD patients (age 0-17 years at diagnosis) collected between January 2000 and November 2003 and stored in the Pediatric IBD Consortium Registry. RESULTS Mean age at diagnosis was 11.5 +/- 3.8 (standard deviation) years. Median follow-up time was 2.8 years. Prior to first surgery, the cumulative incidence of stricturing or penetrating complications was 27% at 5 years and 38% at 10 years from the diagnosis of inflammatory bowel disease. The cumulative incidence of complicated disease was lowest in isolated colonic disease (P = 0.009). Penetrating complications that followed stricturing complications prior to first surgery occurred within 2 years of stricturing complications (cumulative incidence was 13% at 2 years from diagnosis of stricturing disease). Stricturing complications that followed penetrating complications prior to first surgery occurred within 8 years of penetrating complications (cumulative incidence was 26% at 8 years from diagnosis of penetrating complications). CONCLUSIONS Strictures, abscesses, and fistulas are common in pediatric CD. Earlier aggressive management may be indicated. Prospective study is required to identify genetic and serologic markers that predict a patient's risk for the development of complicated disease and to determine optimal treatment regimens.
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Affiliation(s)
- Neera Gupta
- UCSF Children's Hospital, University of California, San Francisco, California, USA.
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Goldstein NS. Isolated Ileal Erosions in Patients With Mildly Altered Bowel Habits. Am J Clin Pathol 2006. [DOI: 10.1309/4pk0g68m2g1l6x47] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Nos P, Garrigues V, Bastida G, Maroto N, Ponce M, Ponce J. Outcome of patients with nonstenotic, nonfistulizing Crohn's disease. Dig Dis Sci 2004; 49:1771-6. [PMID: 15628701 DOI: 10.1007/s10620-004-9568-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The nonstenotic, nonfistulizing (or inflammatory) pattern of Crohn's disease appears to be unstable in time and may evolve toward either the stenotic or the fistulizing pattern. We aimed to assess the course of the inflammatory disease and its relation to certain clinical characteristics. After a mean follow-up of 93 months, we evaluated 73 patients with an inflammatory pattern. The behavior trend and its relation to disease location, initial treatment, and need for corticosteroids, immunosuppressors, and surgical resection were analyzed. In 64% of the patients the inflammatory pattern did not change, while in 14 and 22% it evolved toward a stenotic and a fistulizing pattern, respectively. This change was mainly determined by the appearance of perianal disease (75%). The mean time to behavior evolution was 67 months. Most patients required corticosteroids (92%). Need for immunosuppressors (48%) and surgical resection (30%) was significantly greater (P < 0.05) among patients with a change in pattern than in those with persistent inflammatory disease. The inflammatory pattern of CD remains stable in about half of patients. The course of this pattern is not indolent, however, since the needs for immunosuppression and surgical resection during follow-up are considerable.
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