The incidence of inflammatory bowel disease in a rural region of Southern Germany: a prospective population-based study

Fecal short chain fatty acids and urinary 3-indoxyl sulfate do not discriminate between patients with Crohn´s disease and ulcerative colitis and are not of diagnostic utility for predicting disease severity

BACKGROUND

Urinary 3-indoxyl sulfate levels as well as fecal short chain fatty acid (SCFA) concentrations are surrogate markers for gut microbiota diversity. Patients with inflammatory bowel diseases (IBDs) and patients with primary sclerosing cholangitis (PSC), a disease closely associated with IBD, have decreased microbiome diversity. In this paper, the fecal SCFAs propionate, acetate, butyrate and isobutyrate of patients with IBD and patients with PSC-IBD and urinary 3-indoxyl sulfate of IBD patients were determined to study associations with disease etiology and severity.

METHODS

SCFA levels in feces of 64 IBD patients and 20 PSC-IBD patients were quantified by liquid chromatography with tandem mass spectrometry (LC-MS/MS). Urinary 3-indoxyl sulfate levels of 45 of these IBD patients were analysed by means of reversed-phase liquid chromatography-electrospray ionization-tandem mass spectrometry. Feces of 17 healthy controls and urine of 13 of these controls were analyzed in parallel. These cohorts had comparable sex distribution and age.

RESULTS

Urinary 3-indoxyl sulfate concentrations (normalized to urinary creatinine levels) was increased (P = 0.030) and fecal isobutyrate levels (normalized to dry weight of the stool sample) of IBD patients were decreased (P = 0.035) in comparison to healthy controls. None of the analyzed metabolites differed between patients with Crohn´s disease (CD) and patients with ulcerative colitis (UC). Fecal acetate and butyrate positively correlated with fecal calprotectin (P = 0.040 and P = 0.005, respectively) and serum C-reactive protein (P = 0.024 and P = 0.025, respectively) in UC but not CD patients. UC patients with fecal calprotectin levels above 150 µg/g, indicating intestinal inflammatory activity, had higher fecal acetate (P = 0.016), butyrate (P = 0.007) and propionate (P = 0.046) in comparison to patients with fecal calprotectin levels < 50 µg/g. Fecal SCFA levels of PSC-IBD and IBD patients were comparable.

CONCLUSIONS

Current findings suggest that analysis of urinary 3-indoxyl-sulfate as well as fecal SCFAs has no diagnostic value for IBD and PSC-IBD diagnosis or monitoring of disease severity.

Urinary chemerin as a potential biomarker for inflammatory bowel disease

Purpose

Systemic levels of the adipokine chemerin are elevated in different inflammatory conditions such as inflammatory bowel disease (IBD). In IBD, chemerin protein expression in colon mucosa is induced and serum chemerin levels are increased. Aim of this study was to identify chemerin protein in human feces and/or urine and to evaluate a possible association with IBD activity.

Materials and methods

Feces and urine of 40 patients with IBD and the respective sera of 34 patients were collected. Chemerin levels were analyzed by immunoblot in feces and urine samples. In addition, enzyme-linked immunosorbent assay (ELISA) was used to measure chemerin in all urine, feces and serum samples of the patients and in urine of 17 healthy controls.

Results

Chemerin was not detectable in 80% of the human feces samples by ELISA. Chemerin in human urine was detected by immunoblot and ELISA. Compared to serum levels, urinary concentration was about 6,000-fold lower. Urinary chemerin did not differ between patients with ulcerative colitis (n = 15) and Crohn's disease (n = 25). Urinary chemerin was not related to its serum levels, did not correlate with serum C-reactive protein level and negatively correlated with serum creatinine. Of note, urinary chemerin of patients with a fecal calprotectin > 500 μg/g was significantly higher compared to patients with lower calprotectin levels and compared to healthy controls. Serum creatinine did not differ between the patient groups.

Conclusion

Urinary chemerin might present a novel non-invasive biomarker for monitoring IBD severity and clinical course.

Application of the capture–recapture method to ascertain the completeness of the Saxon pediatric IBD registry in Germany

Aim

The incidence of inflammatory bowel disease (IBD) is increasing worldwide. The Saxon Pediatric IBD Registry was founded in 2000 to describe the epidemiology of pediatric IBD in Germany. The aim of this study was to determinate the completeness of this registry for children and adolescents younger than 15 years and to make this approach transparent. Results of this completeness update have broad implications for further scientific publications from the registry dataset.

Method

The capture–recapture method with two data sources was used to ascertain completeness. A second data source was collected in 2019 for the observation period 2008–2014 from all pediatricians, gastroenterologists, and internists working in practices in a predefined region in Saxony, Germany.

Results

A total of 23 patients with IBD were reported who fulfilled the inclusion criteria. One of them was not recorded in the registry. Therefore, the completeness of the registry was estimated at 95.7% (95% CI 90.2–100). Initial analysis of the Saxon Pediatric IBD Registry over the 15-year period 2000–2014 includes 532 patients, 312 (58.6%) male and 220 (41.4%) female. The distribution of single IBD diseases in the registry was as follows: Crohn’s disease 338 patients (63.5%), ulcerative colitis 176 patients (33.1%), and unclassified IBD 18 patients (3.4%). Evaluations by sex and by disease in age groups and by age at onset were tabulated.

Conclusion

This study demonstrates that the completeness level of the Saxon Pediatric IBD Registry is high (95.7%), and thus the epidemiological data of the registry are reliable.

Current and projected incidence trends of pediatric-onset inflammatory bowel disease in Germany based on the Saxon Pediatric IBD Registry 2000–2014 –a 15-year evaluation of trends

Aims

An increasing number of children and adolescents worldwide suffer from inflammatory bowel disease (IBD) such as Crohn’s disease (CD) and ulcerative colitis (UC). The present work aims to investigate the incidence, prevalence and future trends of IBD in children and adolescents in Saxony, Germany.

Methods

The Saxon Pediatric IBD Registry collected data on patients up to 15 years of age from all 31 pediatric hospitals and pediatric gastroenterologists in Saxony over a 15-year period (2000–2014). In 2019, an independent survey estimated a registry completeness of 95.7%. Age-standardized incidence rates (ASR) per 100,000 person-years (PY) and prevalence per 100,000 children and adolescents were calculated. Evaluation was also been performed in sex and age subgroups. Joinpoint and Poisson regression were used for trend analyses and projections.

Results

532 patients with confirmed IBD during 2000–2014 were included in the epidemiological evaluation. 63.5% (n = 338) patients had CD, 33.1% (n = 176) had UC and 3.4% (n = 18) had unclassified IBD (IBD-U). The 15-year IBD prevalence was 111.8 [95%-CI: 102.3–121.3] per 100,000. The incidence ASR of IBD per 100,000 PY over the whole observation period was 7.5 [6.9–8.1]. ASR for the subtypes were 4.8 [4.3–5.3] for CD, 2.5 [2.1–2.9] for UC and 0.3 [0.1–0.4] for IBD-U. The trend analysis of ASR using the joinpoint regression confirmed a significant increase for incidence of IBD as well as CD. For IBD, the ASR per 100,000 PY increased from 4.6 [2.8–6.3] in 2000 to 8.2 [7.5–13.6] in 2014; projected incidence rates for IBD in Germany are 12.9 [6.5–25.5] in the year 2025 and 14.9 [6.7–32.8] in 2030, respectively. Thus, the number of new IBD diagnoses in Germany would more than triple (325%) in 2030 compared to 2000. The increase is expected to be faster in CD than UC, and be more in males than in females. The expected number of newly diagnosed children with IBD in Germany is projected to rise to about 1,584 [1,512–1,655] in 2025, and to about 1,918 [1,807–2,29] in 2030.

Conclusion

The incidence of IBD in children and adolescents in Saxony increased at a similar rate as in other developed countries during the observation period. Given this trend, the health care system must provide adequate resources for the care of these young patients in the future.

Effect of smoking on the development and outcomes of inflammatory bowel disease in Taiwan: a hospital-based cohort study

Smoking influences the risks of inflammatory bowel disease (IBD). A hospital-based cohort was conducted to evaluate the effect of smoking on the development and outcomes of IBD, with age, sex and comorbidities matched non-IBD controls from the National Health Interview Survey database of Taiwan. 700 IBD patients (360 ulcerative colitis (UC), 340 Crohn’s disease (CD)) were analyzed for outcomes; and 575 patients (297 UC, 278 CD) were analyzed for prevalence. Smoking prevalence was significantly lower in UC patients than controls (20.9% vs. 30.4%, p < 0.01), but no difference between CD patients and controls (19.8% vs. 22.1%, p = 0.60). UC smokers had fewer admissions (1.6 vs. 2.5, p < 0.05) but higher rates of new cancer development (16% vs. 6.7%, p < 0.05) and mortality (16% vs. 4.9%, p < 0.01) than nonsmokers. CD smokers tended to have higher rates of stricturing and penetrating diseases (p < 0.05), and higher surgery risk (60.3% vs. 38.3%, p < 0.01) than nonsmokers. Smoking prevents UC occurrence and is associated with fewer hospitalization but increases risks of cancer and mortality. By contrast, smoking does not affect CD occurrence but is related to more aggressive behavior which results in a higher surgical rate.

Transfer of FRozen Encapsulated multi-donor Stool filtrate for active ulcerative Colitis (FRESCO): study protocol for a prospective, multicenter, double-blind, randomized, controlled trial

Background

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with significant morbidity and mortality. Although the precise cause remains unknown, disturbances in the intestinal microbial community have been linked to its pathogenesis. Randomized controlled trials in UC and relapsing Clostridioides difficile infection (CDI) have established fecal microbiota (FM) transfer (FMT) as an effective therapy. In this context, preliminary results indicated that the transfer of sterile fecal microbiota filtrates (<0.2 μm; FMF, FMFT) of donor stool also drives gastrointestinal microbiota changes and eliminates symptoms in CDI patients. However, along with the success of FMT, regulatory agencies issued safety alerts following reports of serious adverse events due to transmission of enteric pathogens through FMT. To reduce this risk, we established an extensive test protocol for our donors and quarantine regulations for the produced capsules, but alternative concepts are desirable.

Methods

Our project is a randomized, controlled, longitudinal, prospective, three-arm, multicenter, double-blind study to determine the safety and efficacy of repeated long-term, multi-donor FM or FMF transfers compared to placebo using oral, frozen capsules in 174 randomized patients with mild to moderate active UC. The primary outcome will be clinical remission at week 12.

Discussion

This proposal aims to examine (a) the efficacy of encapsulated transfer of FM and FMF as a therapy for mild to moderate UC, (b) the short- and long-term safety of FMT and FMFT in patients with UC, and (c) the microbial and immunologic changes that occur after FMT and FMFT to help understand how and why it affects inflammatory bowel disease.

Trial registration

ClinicalTrials.govNCT03843385. DRKS (Deutsches Register für Klinische Studien) DRKS00020471

Prevalence of inflammatory bowel disease in young Greek Army male recruits from 2006 to 2018: a 13-year retrospective study from a tertiary center

BACKGROUND

The prevalence and incidence of inflammatory bowel diseases (IBDs) vary among countries. Data regarding prevalence of IBD in Greece are limited or outdated.

METHODS

We reviewed the medical records of IBD patients from a population of 551,808 Greek Army recruits in a 13-year period (2006-2018). Study population consisted of males 18-37 of age from Northwest, Central Greece (including Attica), Peloponnese, and Aegean Sea Islands. Age, disease distribution, pharmaceutical treatment and IBD-related surgery at the time of patients' admission were recorded.

RESULTS

The prevalence of IBD among male recruits during the studied period was 0.15% (839/551 808, 95% confidence interval 0.14-0.16%). Of these, 448 (53.4%) had Crohn's disease (CD) and 391 (46.6%) ulcerative colitis (UC). Although 32.1% of CD patients had been treated with biologics, most often infliximab (60% of them), azathioprine was the most common as monotherapy (27% of patients). Among UC patients, mesalamine was the most often prescribed treatment (64.2%), whereas treatment with biologics as monotherapy or in combination with azathioprine was used in a ratio 1:2 compared to CD patients. A gradual reduction in steroid use was noted from 2006 to 2018, coinciding with the advent and increasing use of biologics. IBD-related surgery had been performed in 8% and 2.8% of CD and UC patients, respectively.

CONCLUSION

The prevalence of IBD in Greek male recruits was 0.15% with a slight CD predominance. Remarkable changes in therapeutic trends were noted with an increasing use of biologics and reduced prescription of steroids, especially for CD.

Epidemiologic trend of pediatric inflammatory bowel disease in Latin America: The Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) Working Group

INTRODUCTION AND AIMS

The primary aim was to explore the epidemiologic trend of pediatric inflammatory bowel disease in Latin America, and the secondary aims were to obtain an overview of the diagnostic/therapeutic focus of the members of the LASPGHAN and examine the relation of case frequency to year, during the study period.

MATERIALS AND METHODS

Latin American pediatric gastroenterologists participated in an online survey, conducted through the SurveyMonkey platform, that investigated the yearly frequency of new inflammatory bowel disease patients within the time frame of 2005-2016, their disease variety, the gastrointestinal segments affected, and the diagnostic and treatment methods utilized. The correlation of new case frequency with each study year was evaluated.

RESULTS

A total of 607 patients were studied. The diagnoses were ulcerative colitis in 475 (78.3%) cases, Crohn's disease in 104 (17.1%), and inflammatory bowel disease D unclassified in 28 (4.6%). The trend in ulcerative colitis was a lineal increase in the frequency of new cases related to each study year, with a significant correlation coefficient. Pancolitis was found in 67.6% of the patients. The diagnostic methods included clinical data, endoscopy, and biopsies in more than 99% of the cases, and imaging studies were indicated selectively. Drug regimens were limited to 5-aminosalicylic acid derivatives, azathioprine, 6-mercaptopurine, infliximab, and adalimumab.

CONCLUSIONS

Pediatric inflammatory bowel disease in Latin America appears to have increased during the years included in the study period, with a predominance of moderate or severe ulcerative colitis. That lineal trend suggests the predictive likelihood of a gradual increase in the coming years, with possible epidemiologic and clinical implications.

The Burden of Inflammatory Bowel Disease in Europe in 2020

New data suggest that incidence and prevalence of inflammatory bowel diseases [IBD] are still increasing worldwide, and approximately 0.2% of the European population suffer from IBD at the present time. Medical therapy and disease management have evolved significantly in recent decades, with an emphasis on tight objective monitoring of disease progression and a treat-to-target approach in Europe and also worldwide, aiming to prevent early bowel damage and disability. Surgery rate declined over time in Europe, with 10-30% of CD and 5-10% of UC patients requiring a surgery within 5 years. The health economic burden associated with IBD is high in Europe. Direct health care costs [approximately €3500 in CD and €2000 in UC per patient per year] have shifted from hospitalisation and surgery towards drug-related expenditures with the increasing use of biologic therapy and other novel agents, and substantial indirect costs arise from work productivity loss [approximately €1900 per patient yearly]. The aim of this paper is to provide an updated review of the burden of IBD in Europe by discussing current data on epidemiology, disease course, risk for surgery, hospitalisation, and mortality and cancer risks, as well as the economic aspects, patient disability, and work impairment, by discussing the latest population-based studies from the region.

Following Pediatric and Adult IBD Patients through the COVID-19 Pandemic: Changes in Psychosocial Burden and Perception of Infection Risk and Harm over Time

Background: COVID-19-associated restrictions impact societies. We investigated the impact in a large cohort of inflammatory bowel disease (IBD) patients. Methods: Pediatric (pIBD) and adult patients and pIBD parents completed validated questionnaires for self-perceived stress (Perceived Stress Questionnaire, PSQ) and quality of life from July to October 2020 (1st survey) and March to April 2021 (2nd survey). Analyses were stratified by age groups (6–20, >20–40, >40–60, >60 years). Perceived risk of infection and harm from COVID-19 were rated on a 1–7 scale. An index for severe outcome (SIRSCO) was calculated. Multivariable logistic regression analysis was performed. Results: Of 820 invited patients, 504 (62%, 6–85 years) patients and 86 pIBD parents completed the 1st, thereof 403 (80.4%) the 2nd survey. COVID-19 restrictions resulted in cancelled doctoral appointments (26.7%), decreased physical activity, increased food intake, unintended weight gain and sleep disturbance. PSQ increased with disease activity. Elderly males rated lower compared to females or younger adults. PSQ in pIBD mothers were comparable to moderate/severe IBD adults. Infection risk and harm were perceived high in 36% and 75.4%. Multivariable logistic models revealed associations of higher perceived risk with >3 household members, job conditions and female gender, and of perceived harm with higher SIRSCO, unintended weight change, but not with gender or age. Cancelled clinic-visits were associated with both. SARS-CoV-2 antibodies prior 2nd infection wave were positive in 2/472 (0.4%). Conclusions: IBD patients report a high degree of stress and self-perceived risk of complications from COVID-19 with major differences related to gender and age. Low seroprevalence may indicate altered immune response.

Impact of Cigarette Smoking on the Risk of Osteoporosis in Inflammatory Bowel Diseases

Cigarette smoking constitutes one of the most important modifiable factors of osteoporosis, as well as contributes to an early death, tumors, and numerous chronic diseases. The group with an increased risk of a lower bone mineral density are patients suffering from inflammatory bowel diseases. In fact, tobacco smoke, which contains more than 7000 chemical compounds, affects bone mineral density (BMD) both directly and indirectly, as it has an impact on the RANK-RANKL-OPG pathway, intestinal microbiota composition, and calcium-phosphate balance. Constant cigarette use interferes with the production of protective mucus and inhibits the repair processes in the intestinal mucus. Nicotine as well as the other compounds of the cigarette smoke are important risk factors of the inflammatory bowel disease and osteoporosis. Additionally, cigarette smoking may decrease BMD in the IBD patients. Interestingly, it affects patients with Crohn's disease and ulcerative colitis in different ways-on the one hand it protects against ulcerative colitis, whereas on the other it increases the risk of Crohn's disease development. Nevertheless, all patients should be encouraged to cease smoking in order to decrease the risk of developing other disorders.

Incidence trends of pediatric onset inflammatory bowel disease in the years 2000-2009 in Saxony, Germany-first results of the Saxon Pediatric IBD Registry

Aims

In developed countries, the incidence of inflammatory bowel disease (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Therefore, we aimed to investigate the incidence rates and trends over time in the population of children and adolescents in one of the federal states of Germany, in Saxony.

Methods

Over the 10-year period 2000–2009 all 31 children’s hospitals and pediatric gastroenterologists, respectively in Saxony reported all IBD patients up to 15 years of age to the Saxon Pediatric IBD Registry. The completeness of the registry was estimated as 96.7% by independent surveys in the years 2005–2009. Incidence rates were presented as age-standardized incidence rates (ASR) regarding New European Standard Population 1990 per 100,000 person-years (PY) with 95% confidence intervals [CI]. Joinpoint and linear regression was used for trend analyses.

Results

344 patients with confirmed IBD between 2000–2009 were included in the epidemiological evaluation: 212 (61.6%) patients with CD, 122 (35.6%) with UC and 10 (2.9%) with unclassified IBD (IBD-U). The ASR per 100,000 PY over the whole observation period was 7.2 [6.4–7.9] for IBD, 4.4 [3.8–5.0] for CD, 2.6 [2.1–3.0] for UC and 0.2 [0.1–0.3] for IBD-U. For IBD, the ASR per 100,000 PY increased from 4.6 [2.8–6.3] in 2000 to 10.5 [7.5–13.6] in 2009. The incidence trend analysis of ASRs using the joinpoint regression confirmed a significant increase of IBD as well as UC. The mean age at first diagnosis decreased significantly during the observation period from 11.5 (11.0–13.4) in 2000 to 9.6 (5.1–13.5) years in 2009. The median of the diagnostic latency among IBD patients was 3 months.

Conclusion

The incidence of IBD in children and adolescents in Saxony was slightly higher than the average of other countries in the same time period and followed the trend towards a general increase of IBD. The age at diagnosis was subject to a very unfavorable downward trend.

Sex matters: impact on pathogenesis, presentation and treatment of inflammatory bowel disease

Inflammatory bowel disease (IBD), as do most chronic inflammatory disorders, displays unique features and confers different risk factors in male and female patients. Importantly, sex-based differences in IBD exist for epidemiological incidence and prevalence among different age groups, with men and women developing distinct clinical symptoms and disparity in severity of disease. In addition, the presentation of comorbidities in IBD displays strong sex differences. Notably, particular issues exclusive to women's health, including pregnancy and childbirth, require specific considerations in female patients with IBD of childbearing age that can have a substantial influence on clinical outcomes. This Review summarizes the latest findings regarding sex-based differences in the epidemiology, clinical course, comorbidities and response to current therapies in patients with IBD. Importantly, the latest basic science discoveries in this area of investigation are evaluated to provide insight into potential mechanisms underlying the influence of sex on disease pathogenesis, as well as to design more personalized and efficacious care, in patients with IBD.

Epidemiologic trend of pediatric inflammatory bowel disease in Latin America: The Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) Working Group

INTRODUCTION AND OBJECTIVES

The primary aim was to explore the epidemiologic trend of pediatric inflammatory bowel disease in Latin America, and the secondary aims were to obtain an overview of the diagnostic/therapeutic focus of the members of the LASPGHAN and examine the relation of case frequency to year, during the study period.

MATERIALS AND METHODS

Latin American pediatric gastroenterologists participated in an online survey, conducted through the SurveyMonkey platform, that investigated the yearly frequency of new inflammatory bowel disease patients within the time frame of 2005 to 2016, their disease variety, the gastrointestinal segments affected, and the diagnostic and treatment methods utilized. The correlation of new case frequency with each study year was evaluated.

RESULTS

A total of 607 patients were studied. The diagnoses were ulcerative colitis in 475 (78.3%) cases, Crohn's disease in 104 (17.1%), and inflammatory bowel disease D unclassified in 28 (4.6%). The trend in ulcerative colitis was a lineal increase in the frequency of new cases related to each study year, with a significant correlation coefficient. Pancolitis was found in 67.6% of the patients. The diagnostic methods included clinical data, endoscopy, and biopsies in more than 99% of the cases, and imaging studies were indicated selectively. Drug regimens were limited to 5-aminosalicylic acid derivatives, azathioprine, 6-mercaptopurine, infliximab, and adalimumab.

CONCLUSIONS

Pediatric inflammatory bowel disease in Latin America appears to have increased during the years included in the study period, with a predominance of moderate or severe ulcerative colitis. That lineal trend suggests the predictive likelihood of a gradual increase in the coming years, with possible epidemiologic and clinical implications.

A Systematic Review and Meta-analysis of Paediatric Inflammatory Bowel Disease Incidence and Prevalence Across Europe

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] is often one of the most devastating and debilitating chronic gastrointestinal disorders in children and adolescents. The main objectives here were to systematically review the incidence and prevalence of paediatric IBD across all 51 European states.

METHODS

We undertook a systematic review and meta-analysis based on PubMed, CINAHL, the Cochrane Library, searches of reference lists, grey literature and websites, covering the period from 1970 to 2018.

RESULTS

Incidence rates for both paediatric Crohn's disease [CD] and ulcerative colitis [UC] were higher in northern Europe than in other European regions. There have been large increases in the incidence of both paediatric CD and UC over the last 50 years, which appear widespread across Europe. The largest increases for CD have been reported from Sweden, Wales, England, the Czech Republic, Denmark and Hungary, and for UC from the Czech Republic, Ireland, Sweden and Hungary. Incidence rates for paediatric CD have increased up to 9 or 10 per 100 000 population in parts of Europe, including Scandinavia, while rates for paediatric UC are often slightly lower than for CD. Prevalence reported for CD ranged from 8.2 per 100 000 to approximately 60 and, for UC, from 8.3 to approximately 30.

CONCLUSIONS

The incidence of paediatric IBD continues to increase throughout Europe. There is stronger evidence of a north-south than an east-west gradient in incidence across Europe. Further prospective studies are needed, preferably multinational and based on IBD registries, using standardized definitions, methodology and timescales.

Regional Incidence of Inflammatory Bowel Disease in a Czech Pediatric Population: 16 Years of Experience (2002-2017)

OBJECTIVES

Inflammatory bowel disease (IBD) is today a global disease, the incidence of which is growing in the pediatric population. This prospective study aims to decipher IBD incidence and its trend in a pediatric population through 16 years in the South Moravian Region of the Czech Republic.

METHODS

We evaluated data concerning 358 pediatric patients with newly diagnosed IBD at University Hospital Brno, which is a gastroenterology center for the entire pediatric population (0-18 years) and cares for all pediatric IBD patients in the South Moravian Region (1,187,667 inhabitants).

RESULTS

The study encompassed 3,488,907 children during 16 years. We diagnosed 192 children (53.6%) with Crohn disease (CD), 123 (34.4%) with ulcerative colitis (UC), and 43 (12.0%) with IBD-unclassified (IBD-U). The incidence of IBD increased from 3.8 (CD 2.9, UC 0.9, and IBD-U 0.0) per 100 000/year in 2002 to 14.7 (CD 9.8, UC 4.0, and IBD-U 0.9) per 100,000/year in 2017 (P < 0.001). The overall IBD incidence per 100,000/year was 9.8 (95% confidence interval [CI]: 8.8--10.9). Constituent incidences per 100,000/year were CD 5.2 (95% CI: 4.5--6.0), UC 3.4 (95% CI: 2.8--4.0), and IBD-U 1.2 (95% CI: 0.9--1.6). IBD incidence was projected to reach 18.9 per 100,000/year in 2022.

CONCLUSIONS

The overall incidence of pediatric IBD in the Czech Republic is increasing, and especially that of CD, whereas trends in UC and IBD-U appear to be constant. These data highlight the need to identify risk factors involved in the rising incidence of IBD.

Global smoking trends in inflammatory bowel disease: A systematic review of inception cohorts

Background and aims

The effect of smoking on the risk of developing inflammatory bowel diseases (IBD) may be heterogeneous across ethnicity and geography. Although trends in smoking for the general population are well described, it is unknown whether these can be extrapolated to the IBD cohort. Smoking prevalence trends specific to the global IBD cohort over time have not been previously reported. This is a systematic review of smoking prevalence specific to the IBD cohort across geography.

Methods

A systematic literature search was conducted on Medline and Embase from January 1^st 1946 to April 5^th 2018 to identify population-based studies assessing the prevalence of smoking at diagnosis in inception cohorts of Crohn’s disease(CD) or ulcerative colitis(UC). Studies that did not report smoking data from time of diagnosis or the year of IBD diagnosis were excluded. Prevalence of smoking in IBD was stratified by geography and across time.

Results

We identified 56 studies that were eligible for inclusion. Smoking prevalence data at diagnosis of CD and UC was collected from twenty and twenty-five countries respectively. Never-smokers in the newly diagnosed CD population in the West has increased over the last two decades, especially in the United Kingdom and Sweden; +26.6% and +11.2% respectively. Never-smokers at CD diagnosis in newly industrialised nations have decreased over the 1990s and 2000s; China (-19.36%). Never-smokers at UC diagnosis also decreased in China; -15.4%. The former-smoker population at UC diagnosis in China is expanding; 11%(1990–2006) to 34%(2011–2013).

Conclusion

There has been a reduction in the prevalence of smoking in the IBD cohort in the West. This is not consistent globally. Although, smoking prevalence has decreased in the general population of newly industrialised nations, this remains an important risk factor with longer term outcomes awaiting translation in both UC and CD.

Timing of surgery in ulcerative colitis in the biologic therapy era-the patient's perspective

BACKGROUND

There is no general consensus regarding the ideal timing of surgery in patients with refractory ulcerative colitis (UC). Decision-making and timing of restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is influenced by treating physicians and patients themselves. The aim of this study was to determine whether or not patients would have preferred the operation to be performed earlier, at the same time, or at a later point of time and to determine the reasons for their preference.

METHODS

Clinical data of 193 patients with UC who have undergone IPAA were documented in a prospective database at our institution between 2004 and 2015. From this database, 190 patients were identified and a standardized custom-made questionnaire was mailed for follow-up survey. Patients who did not respond were called by telephone and encouraged to complete the questionnaire.

RESULTS

One hundred nine questionnaires were eligible for analysis (57.4%). Average time between diagnosis and surgery was 11.2 ± 10.8 years (mean ± SD). Indications for surgery were refractory disease (70.6%), colitis-associated colorectal cancer (11.0%), high-grade dysplasia or stenosis (11.9%), and septic complications of UC (6.4%); 39 of 77 patients (50.6%) with refractory UC reported to have preferred their operation to be carried out earlier as it was actually performed (16.8 ± 11.9 months). Refractory course of the disease was identified as a predictor for a retrospectively desired earlier surgical approach (p = 0.014).

CONCLUSION

A substantial proportion of patients felt that they should have undergone surgery earlier than actually performed. It appears that timing of the decision to undergo surgery is suboptimal. This situation may be improved by earlier surgical consultation in the course of the disease.

Sex-Based Differences in Incidence of Inflammatory Bowel Diseases-Pooled Analysis of Population-Based Studies From Western Countries

BACKGROUND & AIMS

Although the incidence of inflammatory bowel diseases (IBDs) varies with age, few studies have examined variations between the sexes. We therefore used population data from established cohorts to analyze sex differences in IBD incidence according to age at diagnosis.

METHODS

We identified population-based cohorts of patients with IBD for which incidence and age data were available (17 distinct cohorts from 16 regions of Europe, North America, Australia, and New Zealand). We collected data through December 2016 on 95,605 incident cases of Crohn's disease (CD) (42,831 male and 52,774 female) and 112,004 incident cases of ulcerative colitis (UC) (61,672 male and 50,332 female). We pooled incidence rate ratios of CD and UC for the combined cohort and compared differences according to sex using random effects meta-analysis.

RESULTS

Female patients had a lower risk of CD during childhood, until the age range of 10-14 years (incidence rate ratio, 0.70; 95% CI, 0.53-0.93), but they had a higher risk of CD thereafter, which was statistically significant for the age groups of 25-29 years and older than 35 years. The incidence of UC did not differ significantly for female vs male patients (except for the age group of 5-9 years) until age 45 years; thereafter, men had a significantly higher incidence of ulcerative colitis than women.

CONCLUSIONS

In a pooled analysis of population-based studies, we found age at IBD onset to vary with sex. Further studies are needed to investigate mechanisms of sex differences in IBD incidence.

Current global trends in the incidence of pediatric-onset inflammatory bowel disease

AIM

To perform a comprehensive review and provide an up-to-date synopsis of the incidence and trends of inflammatory bowel disease (IBD).

METHODS

We systematically searched the MEDLINE (source PubMed), EMBASE and Cochrane Library databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (period: 1985-2018) to identify studies reporting population-based data on the incidence of pediatric-onset (< 19 years at diagnosis) IBD in full manuscripts. Two authors carried out screening and data extraction. Choropleth interactive maps and temporal trends were used to illustrate the international differences and incidences of and changes in IBD and subtypes.

RESULTS

In total, one hundred forty studies reporting data from 38 countries were considered in this review. The highest annual pediatric incidences of IBD were 23/100000 person-years in Europe, 15.2/100000 in North America, and 11.4/100000 in Asia/the Middle East and Oceania. The highest annual incidences of Crohn's disease (CD) were 13.9/100000 in North America and 12.3/100000 in Europe. The highest annual incidences of ulcerative colitis (UC) were 15.0/100000 in Europe and 10.6/100000 in North America. The highest annual incidences of IBD-unclassified (IBD-U) were 3.6/100000 in Europe and 2.1/100000 in North America. In the time-trend analyses, 67% of CD, 46% of UC and 11% of IBD-U studies reported an increasing incidence (P < 0.05). The risk of IBD is increasing among first-generation of migrant populations.

CONCLUSION

Globally, the incidence of IBD varies greatly by geographical areas. The steadily increasing incidence of pediatric IBD over time indicates its emergence as a global disease, suggesting that studies should investigate the environmental risk factors among pediatric cohorts.

Epidemiology of inflammatory bowel disease in Málaga: incidence rate and follow-up of a cohort diagnosed between 2007-2008

BACKGROUND AND OBJECTIVES

The incidence of inflammatory bowel disease (IBD) in Spain has been traditionally lower than in Northern European countries. Recent epidemiological studies have found that these differences are diminishing. This study estimates the incidence of IBD in Málaga (Spain), a city in Southern Spain and relates its results to those found in our neighboring countries.

MATERIAL AND METHODS

This was a prospective study designed to collect new cases diagnosed during the period from 2007-2008 and follow up these patients. Incidence is expressed as number of patients per 100,000 population per year. The population distribution found in the European Collaborative Study was used to standardize incidence rates.

RESULTS

The gross incidence rate of IBD in Málaga is 9/105, the standardized incidence rate is 12.3/105 (9.7-15.6).

CONCLUSIONS

These data are similar to those found in our surroundings, although a higher incidence rate for Crohn's disease (CD) as compared to ulcerative colitis (UC) was found. The clinical characteristics and outcomes of our patients do not differ significantly from those described for other populations.

Incidence and Treatment of Patients Diagnosed With Inflammatory Bowel Diseases at 60 Years or Older in Sweden

BACKGROUND & AIMS

Diagnosis of inflammatory bowel diseases (IBD) is increasing among elderly persons (60 years or older). We performed a nationwide population-based study to estimate incidence and treatment of IBD.

METHODS

We identified all incident IBD cases in Sweden from 2006 through 2013 using national registers and up to 10 matched population comparator subjects. We collected data on the patients' health care contacts and estimated incidence rates, health service burden, pharmacologic treatments, extra-intestinal manifestations, and surgeries in relation to age of IBD onset (pediatric, <18 years; adults, 18-59 years; elderly, ≥60 years).

RESULTS

Of 27,834 persons diagnosed with incident IBD, 6443 (23%) had a first diagnosis of IBD at 60 years or older, corresponding to an incidence rate of 35/100,000 person-years (10/100,000 person-years for Crohn's disease, 19/100,000 person-years for ulcerative colitis, and 5/100,000 person-years for IBD unclassified). During a median follow-up period of 4.2 years (range, 0-9 years), elderly patients had less IBD-specific outpatient health care but more IBD-related hospitalizations and overall health care use than adult patients with IBD. Compared with patients with pediatric or adult-onset IBD, elderly patients used fewer biologics and immunomodulators but more systemic corticosteroids. Occurrence of extra-intestinal manifestations was similar in elderly and adult patients, but bowel surgery was more common in the elderly (13% after 5 years vs 10% in adults) (P < .001). The absolute risk of bowel surgery was higher in the elderly than in the general population, but in relative terms, the risk increase was larger in younger age groups.

CONCLUSIONS

In a nationwide cohort study in Sweden, we associated diagnosis of IBD at age 60 years or older with a lower use of biologics and immunomodulators but higher absolute risk of bowel surgery, compared with diagnosis at a younger age. The large differences in pharmacologic treatment of adults and elderly patients are not necessarily because of a milder course of disease and warrant further investigation.

Quality of care in inflammatory bowel disease: results of a prospective controlled cohort study in Germany (NETIBD)

Background/aims

Patients with inflammatory bowel disease (IBD) need comprehensive, interdisciplinary and cross-sectoral health care. In Germany, evidence-based care pathways have been developed to improve the quality of care of IBD patients. We aimed to evaluate the effects of the implementation of some of these recommendations on patient-related outcomes.

Methods

In a region of North Germany, outpatients with IBD were recruited by gastroenterologists (intervention group). Three activities based on the recommendations of the IBD pathways were implemented, namely, 1) patient participation in a questionnaire-based assessment of 22 somatic and psychosocial problems combined with individualized care recommendations (patient activation procedure); 2) patient invitation to participate in a 2-day patient education program and 3) invitation to their gastroenterologists to participate in periodic interdisciplinary case conferences. For the control group, IBD patients receiving standard care at gastroenterology practices outside the specified region were recruited by their doctors. At baseline, 6- and 12-month follow-up, study patients were invited to complete questionnaires. Generic health-related quality of life, social participation and self-management skills were the main outcomes.

Results

At baseline, 349 patients were included in the study (intervention group: 189; control group: 160); 142 patients from the former and 140 from the latter group returned completed questionnaires at the 12-month follow-up. Over time, improvement in health-related quality of life and social participation was similar in both groups. Participants of the intervention group demonstrated improved self-management skills and more often followed steroid-free medication regimens.

Conclusion

In a real-world clinical context, patient activation procedure combined with patient education and case conferences was less effective than expected. The observed beneficial effects, however, encourage the evaluation of more intensive and addressee-centered activities.

Is There a Link Between H. Pylori and the Epidemiology of Crohn's Disease?

INTRODUCTION

Case control studies suggest an inverse association between Helicobacter pylori (H. pylori) and Crohn's disease (CD). It is possible this could be accounted for by confounders such as antibiotic therapy. Analyzing the geographic distribution of H. pylori and the links with the incidence and prevalence of CD would be an alternative approach to circumvent these confounders.

METHODS

The literature was searched for studies published between 1990 and 2016 that reported incidence or prevalence data for CD in random population samples in developed countries (GDP per capita >20,000 USD/year). Corresponding prevalence studies for H. pylori in these same regions were then sought matched to the same time period (±6 years). The association between the incidence and prevalence of CD and H. pylori prevalence rates were assessed before and after adjusting for GDP and life expectancy.

RESULTS

A total of 19 CD prevalence and 22 CD incidence studies from 10 European countries, Japan, USA, and Australia with date-matched H. pylori prevalence data were identified. The mean H. pylori prevalence rate was 43.4% (range 15.5-85%), and the mean rates for incidence and prevalence for CD were 6.9 and 91.0/100,000 respectively. The incidence (r = -0.469, p < 0.03) and prevalence (r = -0.527, p = 0.02) of CD was inversely and significantly associated with prevalence of H. pylori infection.

CONCLUSIONS

Our data demonstrate a significant inverse association between geographic distribution of H. pylori and CD. Thus, it is highly unlikely that the findings of previous case control studies were simply due to confounding factors such as concomitant antibiotic use in CD patients.

Recent advances in clinical practice: a systematic review of isolated colonic Crohn's disease: the third IBD?

The genetics of isolated colonic Crohn's disease place it approximately midway between Crohn's disease with small intestinal involvement and UC, making a case for considering it as a separate condition. We have therefore systematically reviewed its epidemiology, pathophysiology and treatment. Key findings include a higher incidence in females (65%) and older average age at presentation than Crohn's disease at other sites, a mucosa-associated microbiota between that found in ileal Crohn's disease and UC, no response to mesalazine, but possibly better response to antitumour necrosis factor than Crohn's disease at other sites. Diagnostic distinction from UC is often difficult and also needs to exclude other conditions including ischaemic colitis, segmental colitis associated with diverticular disease and tuberculosis. Future studies, particularly clinical trials, but also historical cohorts, should assess isolated colonic Crohn's disease separately.

Rising Incidence of Inflammatory Bowel Disease in Canterbury, New Zealand

BACKGROUND

A population-based study of inflammatory bowel disease (IBD) in the Canterbury province of New Zealand demonstrated an incidence of Crohn's disease (CD) of 16.5 per 100,000 population in 2004, along with a high rate of IBD overall. At the time, this was one of the highest rates of CD in the world. The current study aimed to ascertain the incidence of IBD in the same area 10 years later.

METHODS

All patients diagnosed with IBD in 2014 within the Canterbury region were identified and characterized. Diagnosis and disease classification were ascertained using standard accepted criteria. Projected population data for age and gender were used to calculate incidence rates for IBD overall and for CD, ulcerative colitis (UC), and inflammatory bowel disease-unclassified (IBDU).

RESULTS

During the 2014 years, 205 patients were diagnosed with IBD in Canterbury. This group comprised 134 patients with CD, 69 with UC, and 2 with IBDU. The age-standardized incidence of IBD, CD, UC, and IBDU was 39.5, 26.4, 12.6, and 0.17 per 100,000, respectively. Disease location of CD patients was evenly distributed (ileal 29%, colonic 35%, and ileocolonic 32%). Similarly, patients with UC had even distribution of proctitis, left-sided, and extensive disease.

CONCLUSIONS

This study demonstrates a substantial increase in the incidence of IBD in this geographically well-defined area. Overall, incidence rates were 1.6-fold greater than when assessed 10 years earlier. The reasons contributing to these continued increases remain unclear. However, further increases in rates of IBD indicate growing health system demands in the future.

The Expenditures for Academic Inpatient Care of Inflammatory Bowel Disease Patients Are Almost Double Compared with Average Academic Gastroenterology and Hepatology Cases and Not Fully Recovered by Diagnosis-Related Group (DRG) Proceeds

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) challenge economies worldwide. Detailed health economic data of DRG based academic inpatient care for inflammatory bowel disease (IBD) patients in Europe is unavailable.

METHODS

IBD was identified through ICD-10 K50 and K51 code groups. We took an actual costing approach, compared expenditures to G-DRG and non-DRG proceeds and performed detailed cost center and type accounting to identify coverage determinants.

RESULTS

Of all 3093 hospitalized cases at our department, 164 were CD and 157 UC inpatients in 2012. On average, they were 44.1 (CD 44.9 UC 43.3 all 58) years old, stayed 10.1 (CD 11.8 UC 8.4 vs. all 8) days, carried 5.8 (CD 6.4 UC 5.2 vs. all 6.8) secondary diagnoses, received 7.4 (CD 7.7 UC 7 vs. all 6.2) procedures, had a higher cost weight (CD 2.8 UC 2.4 vs. all 1.6) and required more intense nursing. Their care was more costly (means: total cost IBD 8477€ CD 9051€ UC 7903€ vs. all 5078€). However, expenditures were not fully recovered by DRG proceeds (means: IBD 7413€, CD 8441€, UC 6384€ vs all 4758€). We discovered substantial disease specific mismatches in cost centers and types and identified the medical ward personnel and materials budgets to be most imbalanced. Non-DRG proceeds were almost double (IBD 16.1% vs. all 8.2%), but did not balance deficits at total coverage analysis, that found medications (antimicrobials, biologics and blood products), medical materials (mostly endoscopy items) to contribute most to the deficit.

CONCLUSIONS

DRGs challenge sophisticated IBD care.

Never underestimate inflammatory bowel disease: High prevalence rates and confirmation of high incidence rates in Australia

BACKGROUND AND AIMS

Regional variations in inflammatory bowel disease (IBD) rates have been observed. Limited epidemiological data are available from Australasia. IBD prevalence rates have never been assessed in an Australian population-based setting. In addition, there are few historical IBD incidence data to allow assessment of rate changes. The aims were to calculate Australia's first population-based IBD prevalence rates, to reassess local IBD incidence rates, and to establish a population-based inception cohort.

METHODS

An observational, prospective population-based epidemiological study was performed to assess IBD prevalence and incidence rates from July 2010 to June 2011 in a geographically defined Australian population (Barwon, Victoria).

RESULTS

There were 1011 prevalent IBD cases identified, representing a crude point prevalence rate of 344.6 per 100,000 on June 30, 2011. Crohn's disease was the most common prevalent subtype. Seventy-one incident cases of IBD were identified, with a crude incidence rate of 24.2 per 100,000. Crohn's disease was again more common. Local incidence rates have not changed between 2007 and the present study. All incident cases were successfully incorporated into an inception cohort.

CONCLUSION

The burden of IBD in our local region is high. Demographic similarities allow these results to be applied to the broader Australian community. We propose that the number of existing and new cases each year in Australia has been previously underestimated. These revised figures will be important when planning the provision of health resources for these patients in the future and when assessing need for research funding priorities.

Benefit of Earlier Anti-TNF Treatment on IBD Disease Complications?

BACKGROUND

Anti-tumour necrosis factor [anti-TNF] treatment was demonstrated to have disease-modifying abilities in inflammatory bowel disease [IBD]. In this study, we aimed to determine the effect of anti-TNF treatment timing on IBD disease complications and mucosal healing [MH].

METHODS

The following IBD-related complications were tested in relation to timing of anti-TNF therapy start in newly diagnosed IBD patients [n = 413]: fistula formation, abscess formation, extra-intestinal manifestations [EIM], surgery, referral to academic centre, and MH.

RESULTS

A total of 85 patients [21%] received anti-TNF (66 Crohn's disease [CD], 16 ulcerative colitis [UC], 3 inflammatory bowel disease unclassified [IBDU]) of whom 57% [48 patients] were treated < 16 months after diagnosis. Patients receiving anti-TNF early [< 16 months] did not differ from patients receiving anti-TNF late [> 16 months] regarding gender, age, smoking status, and familial IBD. More importantly, patients receiving anti-TNF early did not suffer less IBD-related complications during follow-up as compared with patients started on anti-TNF late, nor was more MH observed. Similar results were obtained when anti-TNF treated patient were stratified more stringently, ie < 12 months [40 patients] vs >2 4 months [24 patients]. Cox regression analysis showed no beneficial correlations between anti-TNF timing and IBD-related complications. Anti-TNF treated patients achieving MH were 11 times less likely to develop EIMs compared with patients who did not achieved MH while on anti-TNF.

CONCLUSIONS

This study was unable to confirm a benefit of earlier anti-TNF treatment on IBD disease complications. This could be explained by more aggressive treatment earlier in disease, resulting in fewer IBD complications. However, it seems more likely that inappropriate selection of patients for therapy leads to suboptimal treatment and subsequently suboptimal outcome.

Patient-relevant endpoints in inflammatory bowel diseases--have changes occurred in Germany over the past twelve years?

BACKGROUND AND AIMS

Inflammatory bowel diseases (IBDs) are gaining increasing medical as well as economic significance. Improving medical treatment options can have a positive effect on number of hospitalized patients, necessary operations and the inability to work.

METHODS

To understand patient-relevant endpoints in IBDs, the data for 2000-12 published by the Federal Statistical Office and the data for 2012 according to Article 21 of the Hospital Reimbursement Act in Germany were assessed. In addition, data records held by a public health insurance company on the medication of IBD patients were evaluated.

RESULTS

During 2000-12, the number of hospitalized IBD patients (ICD 10 K50, K51) rose from 38533 to 43452 (+12.7%). The necessity of surgical intervention increased during the period under review. The number of people unable to work increased differently for Crohn's disease (CD) and ulcerative colitis (UC), by 2.1 and 9.5%, respectively. Entry of persons into the statutory pension insurance system did not decline from 2000 to 2012. The number of potential years of life lost (PYLL) in patients with IBD also remained constant during the period under review (2017 in 2000-02 versus 2011 in 2010-012). From 2009 to 2013 the percentage of patients treated with an anti-TNF-antibodies rose (2009, 4.3% for CD and 1.4% for UC; 2013, 8.4% for CD and 3.2% for UC).

CONCLUSIONS

An improvement in patient-relevant endpoints was not observed between 2000 and 2012 in IBD patients in Germany. Improvements can only be achieved through structured and interdisciplinary treatment concepts involving all healthcare providers.

Variation in incidence of pediatric Crohn's disease in relation to latitude and ambient ultraviolet radiation: a systematic review and analysis

BACKGROUND

Pediatric Crohn's disease (CD) is a lifelong, debilitating, and costly disease. In previous studies, CD incidence increased with higher geographic latitude in the Northern Hemisphere. This may indicate a role for lower vitamin D status as a risk factor for CD. Analysis of worldwide incidence of pediatric CD has not been previously reported.

METHODS

We undertook a systematic review of population-based studies reporting incidence of pediatric CD and published between 2003 and 2013. Included studies had well-defined diagnostic criteria for CD, evidence of high case ascertainment, reported incidence according to age group, and provided a specific location. Average daily ambient ultraviolet radiation (UVR) for each location was derived from satellite data. Negative binomial regression was used to assess the association between pediatric CD incidence and latitude and ambient UVR, adjusting for the study year.

RESULTS

Twenty-eight articles provided 39 incidence data points. Incidence of pediatric CD increased with higher latitude, and in association with a greater number of months where the average daily UVR was lower than a previously published threshold of 1.488 kJ/m. Incidence of pediatric CD increased over calendar time.

CONCLUSIONS

After applying rigorous quality assessment criteria, and including only population-based studies, there was a modest increase in incidence of pediatric CD with higher latitude and greater number of months with low ambient UVR. Reporting using nonconsistent diagnostic criteria and age groups, with poorly defined geographic locations, makes it difficult to compare data across different studies.

Evaluation of cardiac function by two-dimensional speckle tracking echocardiography in ulcerative colitis patients

PURPOSE

Although ulcerative colitis (UC) shows obvious similarities with other autoimmune diseases, cardiac consequences have not adequately introduced. The aim of our study was to evaluate left ventricular (LV) function in UC patients by using novel echocardiographic parameters.

RESULTS

Forty-five UC patients (mean age 37, 18 female) and 90 age- and sex-matched healthy volunteers (mean age 40, 38 female) included in the study. The mean disease activity score according to partial Mayo score was 2.16 ± 2.13. Mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) measurements were significantly lower (-21.16 ± 2.71 vs. -23.36 ± 3.34; p < 0.001 and -1.33 ± 0.24 vs. -1.43 ± 0.24; p = 0.037, respectively), whereas global circumferential (-22.67 ± 3.66 vs. -23.37 ± 3.99; p = 0.140) and global radial strain (43.07 ± 8.58 vs. 44.12 ± 9.32; p = 0.545) measurements of the LV were similar in patients with UC compared with controls. The correlation coefficient (r) between GLS and partial Mayo score was -0.578 (p < 0.001).

CONCLUSION

Our study suggests that systolic cardiac deformation values are impaired in UC patients. Reduced GLS and GLSR might be an early indicator of cardiac involvement in this population.

Age-related differences in presentation and course of inflammatory bowel disease: an update on the population-based literature

Current data indicate a change in the epidemiology of inflammatory bowel diseases. The disease has become more widespread and the rise in the incidence has been reported in all age groups including early childhood and according to recent data also the elderly population. Some earlier studies have suggested that the phenotype and natural history of the disease may be different according to age of onset. Recently the importance of age at onset was reported in two population-based studies from France and Hungary including both paediatric and adult onset inception cohorts. Early onset disease was associated with more frequent disease extension in both Crohn's disease and ulcerative colitis and in most but not all studies with higher frequency of complicated disease behaviour. This is also accompanied by striking differences in the medical management with earlier and more prevalent (2-3-fold) use of immunosuppressives and to some extent biologicals in patients with early compared to elderly-onset disease, especially in Crohn's disease. However, the results of population-based studies on impact of age on surgery rates in Crohn´s disease as well as ulcerative colitis are conflicting. Furthermore, published data indicate that relative but not absolute risk of developing cancer and mortality is higher in patients with an early onset disease. Critical reviews that focus on the importance of age at onset in inflammatory bowel disease are rare. Therefore, the aim of this review is to describe the differences in epidemiology, clinical characteristics, and natural history of paediatric and elderly-onset inflammatory bowel disease based on studies performed in general population.

How fast up the ladder? Factors associated with immunosuppressive or anti-TNF therapies in IBD patients at early stages: results from a population-based cohort

BACKGROUND

With the introduction of anti-TNF therapies in the treatment of IBD, the therapeutic strategies have changed to an accelerated step-up care to avoid long-term complications. Little is known about the implementation of these strategies into daily care. We aimed to evaluate this question and to identify factors associated with the early use of immunosuppressants or anti-TNF therapies in a population-based IBD cohort.

METHODS

Patients with an IBD diagnosed between January 2004 and December 2008 were included. Medical therapies were evaluated at first diagnosis and during a 5-year follow-up. Risk factors associated with the initiation of an immunosuppressive therapy were assessed.

RESULTS

Two hundred and forty-one patients were evaluated (145 Crohn's disease (CD), 96 ulcerative colitis (UC)). An immunosuppressive or anti-TNF therapy was started in 83 CD (57.2 %) and 40 UC (43 %) patients (p = 0.033, relative risks (RR) 1.77; 95 % confidence interval (CI) 1.05-3.0). After 5 years, 38.8 % CD patients on immunosuppressive therapy were treated with anti-TNF therapies. The use of corticosteroids at first diagnosis, disease localization and surgery were independent predictors for an immunosuppressive or anti-TNF therapy in CD. In UC, the extension of disease was associated with immunosuppressive therapies. The use of steroids and localization in CD patients and an extended disease in UC patients affected the time until an immunosuppressive therapy was started.

CONCLUSION

We found a high proportion of patients using an immunosuppressive therapy during the early course. Therefore, the accelerated step-up strategy seems to be successfully implemented in the daily care of IBD patients. We were able to identify several factors associated with an immunosuppressive or anti-TNF therapy in CD and UC.

Family history of inflammatory bowel disease among patients with ulcerative colitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Despite numerous shared susceptibility loci between Crohn's disease and ulcerative colitis, the prevalence of family history among ulcerative colitis patients is not well-established and considered to be less prevalent. A systemic review and meta-analysis were conducted to estimate the prevalence of family history of inflammatory bowel disease in ulcerative colitis patients, and its effect on disease outcomes.

METHODS

PubMED was searched to identify studies reporting the prevalence of family history of inflammatory bowel disease among ulcerative colitis patients. Definitions of family history, study type, and subtypes of family history prevalence were abstracted, as were disease outcomes including age at ulcerative colitis diagnosis, disease location, surgery and extraintestinal manifestations. Pooled prevalence estimates were calculated using random effects models.

RESULTS

Seventy-one studies (86,824 patients) were included. The prevalence of a family history of inflammatory bowel disease in ulcerative colitis patients was 12% (95% confidence interval [CI] 11 to 13%; range 0-39%). Family history of ulcerative colitis (9%; 22 studies) was more prevalent than Crohn's disease (2%; 18 studies). Patients younger than 18years of age at time of diagnosis had a greater family history of inflammatory bowel disease (prevalence 15%, 95% CI: 11-20%; 13 studies). There were no differences in disease location, need for surgery, or extraintestinal manifestations among those with a family history, although very few studies reported on these outcomes.

CONCLUSIONS

Overall, 12% of ulcerative colitis patients have a family history of inflammatory bowel disease, and were more likely to have a family history of ulcerative colitis than Crohn's disease. Pediatric-onset ulcerative colitis patients were more likely to have a family history of inflammatory bowel disease.

Epidemiology of inflammatory bowel disease in Québec: recent trends

BACKGROUND

Among 10 provinces in Canada, Québec has the second highest incidence of Crohn's disease (CD), based on data collected more than a decade ago. To date, there are no reports on the occurrence of ulcerative colitis (UC) and no updates on the occurrence of CD in Québec. We sought to describe trends in the annual incidence and prevalence of inflammatory bowel disease in Québec during 2001 to 2008.

METHODS

A population-based retrospective cohort study was conducted using the administrative health databases of Québec. IBD cases were identified using a validated case definition requiring at least 1 hospitalization or 4 physician claims within a 2-year period. Incident cases were defined as individuals who had been free of inflammatory bowel disease for at least 2 years before the 2-year time span of the case definition.

RESULTS

We identified 24,377 CD and 15,346 UC cases. The mean age at diagnosis was 39 and 46 years for CD and UC, respectively. There was a significant decline in the annual incidence from 2001 to 2008 for both CD (P < 0.003) and UC (P < 0.001). No significant change with time was found in pediatric cases. The point prevalence in 2008 was 277 CD and 164 UC cases per 100,000 population. The average incidence was 17.4 CD cases per 100,000 person-years and 10.1 UC cases per 100,000 person-years. There was no predominance of urban or rural cases for either CD or UC.

CONCLUSIONS

During 2001 to 2008, annual incidence for both CD and UC declined in Québec. There was no significant change with time in incidence for pediatric cases.

Smoking increases the risk of extraintestinal manifestations in Crohn's disease

AIM: To demonstrate a high prevalence of extraintestinal manifestations (EIMs) in a prospective population-based cohort of inflammatory bowel disease (IBD) patients at first diagnosis as well as during the early course of the disease.

METHODS: EIMs are common in patients with IBD. Data on the frequency of EIMs have mostly been assessed in patients from tertiary centers; however, data about the prevalence of EIMs at first diagnosis as well as factors influencing their incidence during the early course of disease from prospective population-based cohorts are scarce. We present data of patients of our population-based “Oberpfalz cohort” (Bavaria, Germany) from first diagnosis (up to 3 mo after first diagnosis) as well as during the early course of the disease. Possible risk factors were assessed by calculating the relative risk (RR) as well as using logistic regression analysis.

RESULTS: In total, data of 257 newly diagnosed patients with IBD were evaluated [161 Crohn’s disease (CD), 96 ulcerative colitis (UC)]. Median duration of follow-up was 50 mo after first diagnosis. In 63.4% of all patients (n = 163), an EIM was diagnosed at any point during the observation period. At first diagnosis, patients with CD had a significantly increased risk of an EIM [n = 69 (42.9%)] compared with UC patients [n = 21 (21.9%); P < 0.001; RR = 1.96; 95%CI: 1.30-2.98]. Active smoking increased the risk of CD patients developing an EIM during the early course of the disease, but notably not of UC patients (P = 0.046; RR = 1.96; 95%CI: 1.01-3.79). In addition, using logistic regression analysis, the need for IBD-related surgery and a young age at first diagnosis were identified as risk factors for the development of an EIM in CD patients. No association with EIMs was found for the factors sex, localization of the disease and positive family history of IBD. In contrast, no key factors which increased the risk of development of an EIM could be identified in UC patients.

CONCLUSION: We found a high prevalence of EIM in this cohort at first diagnosis and during the early course of the disease. In patients with CD, smoking, need for surgery and younger age at first diagnosis were risk factors for the development of an EIM.

Epidemiology of inflammatory bowel disease: focus on Asia

The epidemiology of inflammatory bowel disease (IBD) is changing globally. Incidence and prevalence may have stabilized in high-incidence areas such as North America and Europe but they continue to rise in previously low-incidence areas such as Eastern Europe, Asia, and much of the developing world. This epidemiological shift likely relates to westernization of lifestyle, changes in diet, and improved hygiene as part of socioeconomic development in developing countries. In Asia, UC is more prevalent than CD, although the UC:CD ratio is narrowing in certain areas. Clinical manifestations of IBD in Asia resemble the Western population, but with some differences, including higher prevalence of males and ileo-colonic CD, less familial clustering, lower surgical rates and extra-intestinal manifestations. These differences may relate to time, genetics and environmental factors. Studying the epidemiology of IBD in an area of rapidly increasing incidence may lead to discovery of important etiologic factors associated with disease development.

Incidence and clinical course of Crohn's disease during the first year - results from the IBD Cohort of the Uppsala Region (ICURE) of Sweden 2005-2009

BACKGROUND AND AIMS

As a part of the Swedish ICURE study where the epidemiological results of ulcerative colitis and microscopic colitis recently have been published, we hereby present the corresponding figures for Crohn's disease.

METHODS

All patients diagnosed with Crohn's disease in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new patients with Crohn's disease in Uppsala Region (642,117 inhabitants) during 2007-2009.

RESULTS

264 patients with Crohn's disease were included. The mean annual incidence was 9.9/100,000/year (95% CI: 7.1-12.6). Incidence among children <17 years was 10.0/100,000/year (95% CI: 3.8-16.3). 51% of the patients had ileal involvement (L1: n=73, 28%. L2: n=129, 49%. L3: n=62, 23%, L4: n=47, 18%) and 23% had a stricturing or penetrating disease (B1: n=204, 77%. B2: n=34, 13%. B3: n=26, 10%. p: n=27, 10%). Intestinal resection rate during the first year was 12.5%. Patients with complicated disease had longer symptom duration before diagnosis compared to patients with non-complicated disease (median months 12.0, IQR: 3.0-24.0 vs 4.0, IQR: 2.0-12.0, p=0.0032). Patients 40 years or older had an increased risk for surgery (HR: 2.03, 95% CI: 1.01-4.08, p=0.0457).

CONCLUSIONS

The incidence of Crohn's disease in a region of Sweden is one of the highest reported in Europe. Long symptom duration precedes stricturing or penetrating behaviour. Old age is an independent risk factor for surgery.

Incidence, Paris classification, and follow-up in a nationwide incident cohort of pediatric patients with inflammatory bowel disease

OBJECTIVES

The aim of the study was to evaluate the incidence, baseline disease characteristics, and disease location based on the Paris classification in pediatric inflammatory bowel disease (IBD) in the Hungarian nationwide inception cohort. In addition, 1-year follow-up with therapy was analyzed.

METHODS

From January 1, 2007 to December 31, 2009, newly diagnosed pediatric patients with IBD were prospectively registered. Twenty-seven pediatric gastroenterology centers participated in the data collection ensuring the data from the whole country. Newly diagnosed patients with IBD younger than 18 years were reported. Disease location was classified according to the Paris classification.

RESULTS

A total of 420 patients were identified. The incidence rate of pediatric IBD was 7.48/10⁵ (95% confidence interval [CI] 6.34/10⁵-8.83/10⁵). The incidence for Crohn disease (CD) was 4.72/10⁵ (95% CI 3.82-5.79), for ulcerative colitis (UC) 2.32/10⁵ (95% CI 1.71-3.09), and for IBD-unclassified 0.45/10⁵ (95% CI 0.22-0.84). Most common location in CD was L3 (58.7%); typical upper gastrointestinal abnormalities (ulcer, erosion and aphthous lesion) were observed in 29.9%. Extensive colitis in patients with UC (E4, proximal to hepatic flexure) was the most common disease phenotype (57%), whereas only 5% of children had proctitis. A total of 18.6% of patients had ever severe disease (S1). Frequency of azathioprine administration at diagnosis was 29.5% in patients with CD, and this rate increased to 54.6% (130/238) at 1-year follow-up. In UC, only 3.3% received azathioprine initially, and this rate elevated to 22.5% (25/111). Use of corticosteroid decreased from 50% to 15.3% in patients with UC. Rate of bowel resection in patients with CD during the first year of follow-up was 5%.

CONCLUSIONS

The incidence of pediatric IBD in Hungary was among the higher range reported. This is the first large, nationwide incident cohort analyzed according to the Paris classification, which is a useful tool to determine the characteristic pediatric CD phenotype.

Incidence and natural history of ulcerative colitis in the Uppsala Region of Sweden 2005-2009 - results from the IBD cohort of the Uppsala Region (ICURE)

BACKGROUND AND AIMS

The incidence of ulcerative colitis (UC) increased during the 20th century in Western Europe and the North America, but there are conflicting reports whether the incidence has declined, stabilized or continued to increase. The aim of this study was to evaluate the incidence of UC in the Uppsala Region, Sweden.

METHODS

All new UC patients in Uppsala County (305,381 inhabitants) were prospectively registered during 2005-2006 and the same for all new UC patients in the Uppsala Region (642,117 inhabitants) during 2007-2009. The extent and severity of disease according to the Montreal classification, relapse rates and surgery were assessed.

RESULTS

526 UC patients were included. The mean overall incidence for the time period was 20.0 (95% CI: 16.1-23.9) cases per 100,000 inhabitants. The incidence among children <17 years of age was 8.9 per 100,000. The extent at diagnosis was evenly distributed (E1: n=167, 32%, E2: n=161, 31%, E3: n=163, 31%). Half of the cases had moderate to severe symptoms (S1: n=269, 51%, S2: n=209, 40%, S3: n=45, 8.6%). 228 (43%) relapsed and 13 (2.5%) required colectomy during the first year. Children had a higher proportion of extensive disease vs adults (27/42 vs 136/484), but no increased risk for severe symptoms or colectomy.

CONCLUSION

In this prospective population-based study we found one of the highest incidences of UC in the world. The proportion of severe cases is comparable with historical data. The conclusion is that the nature of UC has not changed, only the incidence.

Phenotype of inflammatory bowel disease at diagnosis in the Netherlands: a population-based inception cohort study (the Delta Cohort)

BACKGROUND

To describe the clinical characteristics of inflammatory bowel disease (IBD) at diagnosis in The Netherlands at the population level in the era of biologics.

METHODS

All patients with newly diagnosed IBD (diagnosis made between January 1, 2006 and January 1, 2007) followed in 9 general hospitals in the southwest of the Netherlands were included in this population-based inception cohort study.

RESULTS

A total of 413 patients were enrolled, of which 201 Crohn's disease (CD) (48.7%), 188 ulcerative colitis (UC) (45.5%), and 24 IBD unclassified (5.8%), with a median age of 38 years (range, 14-95). Seventy-eight patients with CD (38.8%) had ileocolonic disease and 73 patients (36.3%) had pure colonic disease. In 8 patients (4.0%), the upper gastrointestinal tract was involved. Nineteen patients with CD (9.5%) had perianal disease. Thirty-nine patients with CD (19.4%) had stricturing phenotype. Of the patients with UC and IBDU, 39 (18.4%) suffered from pancolitis and 61 (29%) from proctitis. Severe endoscopic lesions at diagnosis were seen in 119 patients (28.8%, 68 CD, 49 UC, and 2 IBDU), whereas 98 patients (23.7%) had severe histological disease activity. Thirteen patients (3.1%, 10 CD and 3 UC) had extraintestinal manifestations at diagnosis. Twenty-three patients (5.6%, 20 CD and 3 UC) had fistula at diagnosis.

CONCLUSIONS

In this cohort, 31% of the patients with CD had complicated disease at diagnosis, 39% had ileocolonic disease, 9.5% had perianal disease, and in 4% the upper gastrointestinal tract was involved. Most patients with UC suffered from left-sided colitis (51%). Severe endoscopic lesions were reported in 34% of the patients with CD and 26% of the patients with UC. Three percent of the patients with IBD had extraintestinal manifestations.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

The impact of JNK inhibitor D-JNKI-1 in a murine model of chronic colitis induced by dextran sulfate sodium

Purpose:

The c-Jun N-terminal kinases (JNK) are involved in the activation of T cells and the synthesis of proinflammatory cytokines. Several studies have established the relevance of the JNK pathway in inflammatory bowel diseases. The present study analyzed the therapeutic effect of D-JNKI-1, a specific JNK-inhibiting peptide, in a low-dose dextran sulfate sodium (DSS) model of chronic colitis.

Methods:

DSS colitis was induced in female C57/BL6 mice by cyclic administration using different concentrations of DSS (1.0% and 1.5%). Mice in the intervention groups received subcutaneous administration of 1 μg/kg D-JNKI-1 on days 2, 12, and 22. They were monitored daily to assess the severity of colitis, body weight, stool consistency, and the occurrence of occult blood or gross rectal bleeding using evaluation of the disease activity index. The animals were sacrificed after 30 days, and the inflamed intestine was histologically evaluated using a crypt damage score. Immunohistochemical quantification of CD4⁺ and CD8⁺ cells was also carried out.

Results:

Administration of 1 μg/kg D-JNKI-1 resulted in a significant decrease in the disease activity index (P = 0.013 for 1.0% DSS; P = 0.007 for 1.5% DSS). As a mild form of colitis was induced, histological examination did not show any distinct damage to the mucosa and crypts. However, expression of CD4⁺ and CD8⁺ cells was reduced in mice treated with D-JNKI-1 (not significant).

Conclusion:

Administration of D-JNKI-1 resulted in a clinical attenuation of chronic DSS colitis, and a therapeutic effect of D-JNKI-1 must therefore be assumed. The decrease in CD4⁺ and CD8⁺ cells may reflect the influence of D-JNKI-1 on T-cell activation, differentiation, and migration.

The burden of inflammatory bowel disease in Europe

Inflammatory bowel diseases (IBD) are chronic disabling gastrointestinal disorders impacting every aspect of the affected individual's life and account for substantial costs to the health care system and society. New epidemiological data suggest that the incidence and prevalence of the diseases are increasing and medical therapy and disease management have changed significantly in the last decade. An estimated 2.5-3 million people in Europe are affected by IBD, with a direct healthcare cost of 4.6-5.6 bn Euros/year. Therefore, the aim of this review is to describe the burden of IBD in Europe by discussing the latest epidemiological data, the disease course and risk for surgery and hospitalization, mortality and cancer risks, as well as the economic aspects, patients' disability and work impairment.

Incidence of inflammatory bowel disease in the province of Styria, Austria, from 1997 to 2007: a population-based study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) varies widely between different countries. This large variation is also observed for the incidence of its main two forms, ulcerative colitis (UC) and Crohn's disease (CD). Controversy exists whether IBD incidence is increasing, especially in western countries. Currently no data are available for Austria. This study therefore aimed to evaluate for the first time the incidence of IBD over an eleven-year period in Styria, a province of Austria with a population of 1.2 million.

METHODS

All patients with an initial diagnosis of IBD between 1997 and 2007, who were Styrian residents, were eligible for this retrospective study. Data were acquired from electronically stored hospital discharge reports and individual reports by patients and physicians. According to population density Styria was divided into two rural and one urban area.

RESULTS

Throughout the study period 1527 patients with an initial diagnosis of IBD were identified. The average annual incidence was 6.7 (95% CI 6.2-7.1) per 100,000 persons per year for CD and 4.8 (95% CI 4.5-5.2) for UC. The average annual incidence increased significantly (p<0.01) for both diseases during the 11 year study period. Median age at initial diagnosis was 29 years (range 3-87) for CD and 39 years (range 3-94) for UC. At diagnosis, 8.5% of all IBD patients were <18 years of age. The incidence of both CD and UC was significantly higher in the urban area than in rural areas (CD: 8.8, 95% CI 7.8-9.8 versus 5.5, 95% CI 4.7-6.4 and 5.9, 95% CI 5.3-6.7; [p<0.001]; UC: 5.8, 95% CI 5.1-6.6 versus 4.0, 95% CI 3.4-4.7 and 4.7, 95% CI 4.1-5.4; [p=0.04]).

CONCLUSION

We observed an overall increase in the incidence of ulcerative colitis and Crohn's disease in a part of Austria during an eleven year period. IBD was more predominant in the largest urban area than in rural areas.

Rapidly increasing incidence of eosinophilic esophagitis in a large cohort

BACKGROUND

Recent literature has shown increasing incidence and prevalence rates of eosinophilic esophagitis (EoE). However, data are mainly based on small studies and come from centers dedicated to EoE. Aim of this study was to estimate the incidence rates of EoE by using a large database.

METHODS

We performed a cross-sectional study of the pathology reports describing esophageal eosinophilia from 1996 through 2010, using the nationwide network and registry of histo- and cytopathology in The Netherlands (PALGA). All histopathology reports nationwide enter this database. We classified cases according to the diagnosis made by the pathologist. Annual incidence rates of EoE were estimated.

KEY RESULTS

Our search criteria yielded 8838 positive pathology reports. Eosinophilic esophagitis was diagnosed in 674 patients, of which 74% were men. In another 174 patients, no distinction was made between eosinophilia caused by gastro-esophageal reflux disease or EoE. The incidence of EoE increased considerably over the years, being 0.01 in 1996, 0.01 in 2000, 0.14 in 2005, and 1.31 per 100,000 persons in 2010. Eosinophilic esophagitis was diagnosed in all age groups, but in 2010 the highest incidence was seen in 20-29 years old males, in whom it was estimated to be 3.23 per 100,000 persons. The incidence in children was 0.73 per 100,000 in 2010. No seasonal variation in diagnosis of EoE was observed.

CONCLUSIONS & INFERENCES

In this large study, we found robust data on increasing incidence rates of pediatric and adult EoE in the past 15 years. This rapidly increasing incidence has not reached a plateau yet.