VAlidation of an 8-item-questionnaire predictive for a positive caLprotectin tEst and Real-life implemenTation in primary care to reduce diagnostic delay in inflammatory bowel disease (ALERT): protocol for a prospective diagnostic study

Spondyloarthritis with inflammatory bowel disease: the latest on biologic and targeted therapies

Spondyloarthritis (SpA) encompasses a heterogeneous group of chronic inflammatory diseases that can affect both axial and peripheral joints, tendons and entheses. Among the extra-articular manifestations, inflammatory bowel disease (IBD) is associated with considerable morbidity and effects on quality of life. In everyday clinical practice, treatment of these conditions requires a close collaboration between gastroenterologists and rheumatologists to enable early detection of joint and intestinal manifestations during follow-up and to choose the most effective therapeutic regimen, implementing precision medicine for each patient's subtype of SpA and IBD. The biggest issue in this field is the dearth of drugs that are approved for both diseases, as only TNF inhibitors are currently approved for the treatment of full-spectrum SpA-IBD. Janus tyrosine kinase inhibitors are among the most promising drugs for the treatment of peripheral and axial SpA, as well as for intestinal manifestations. Other therapies such as inhibitors of IL-23 and IL-17, phosphodiesterase 4 inhibitor, α4β7 integrin blockers and faecal microbiota transplantation seem to only be able to control some disease domains, or require further studies. Given the growing interest in the development of novel drugs to treat both conditions, it is important to understand the current state of the art and the unmet needs in the management of SpA-IBD.

Can the simplified magnetic resonance index of activity be used to evaluate the degree of activity in Crohn's disease?

Background and aims

A simplified magnetic resonance index of activity (MaRIAs) was recently proposed. Our aim was to verify whether MaRIAs can accurately assess the activity degree of CD.

Methods

We retrospectively analyzed the MRI, ileocolonoscopy, fecal calprotectin (FC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) data of 93 CD patients. With the SES-CD as the gold standard, MaRIAs’ accuracy, the correlation of MaRIAs and SES-CD, FC, ESR, CRP, and interevaluator reliability were assessed.

Results

MaRIAs ≥ 1 detected segments with active CD with 90.80% specificity and 81.37% sensitivity (area under the curve was 0.91, 95% confidence interval 0.87–0.94). MaRIAs score of 2 or more detected severe lesions with 88.89% specificity and 95.12% sensitivity (AUC was 0.96, 95% confidence interval was 0.94–0.98). The MaRIAs score showed a high correlation with the SES-CD in the terminal ileum, transverse colon, right colon, and left colon (r = 0.85, 0.91, 0.88, 0.86, P < 0.001) and a moderate correlation with the SES-CD in the rectum (r = 0.74, P < 0.001). The global MaRIAs score was highly correlated with the global SES-CD (r = 0.90, P < 0.001). The global MaRIAs score was positively correlated with the fecal calprotectin (FC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) (r = 0.77, r = 0.64, and r = 0.68). The intragroup correlation coefficient (ICC) of the two physicians was nice in the terminal ileum, the right colon, the transverse colon, the left colon and was moderately good in the rectum.

Conclusion

MaRIAs can accurately evaluate the disease activity level of CD and are highly correlated with SES-CD and biomarkers. The interrater reliability of the two physicians was moderately good to nice.

Prevalence and patient awareness of inflammatory bowel disease in Kazakhstan: a cross-sectional study

BACKGROUND/AIMS

There has been a paucity of published data on the epidemiology of inflammatory bowel disease (IBD) in Central Asia and Kazakhstan. Therefore, we aimed to study IBD prevalence and patient awareness among adults in Kazakhstan.

METHODS

The cross-sectional study was carried out among subjects of both sexes aged 18 years and older using IBD Alert Questionnaire (CalproQuest), single fecal calprotectin test, and endoscopy with biopsy to verify IBD from January to December 2017, across regions of Kazakhstan. All participants were included in the study after providing informed consent.

RESULTS

Out of 115,556 subjects, there were 128 confirmed IBD cases, in which 36 Crohn's disease (CD) and 92 ulcerative colitis (UC) cases identified. The age and sex-adjusted IBD prevalence were 113.9 (95% confidence interval [CI], 69.0-158.9) per 100,000 population. The age- and sex-adjusted prevalence for UC were 84.4 (95% CI, 44.8-123.9) and for CD were 29.5 (95% CI, 8.2-50.9) per 100,000 population.

CONCLUSIONS

This is the first report on the prevalence of IBD with a verified diagnosis in the Central Asia and could be used to better plan and allocate healthcare resources for IBD management program.

Can the CalproQuest predict a positive Calprotectin test? A prospective diagnostic study

Background

Diagnosis of inflammatory bowel disease (IBD) in primary care (PC) is challenging and associated with a considerable diagnostic delay. Using a calprotectin test for any PC patient with abdominal complaints would cause significant costs. The 8-item-questionnaire CalproQuest was developed to increase the pre-test probability for a positive Calprotectin. It is a feasible instrument to assess IBD in PC, but has not yet been evaluated in clinical routine. This study, therefore, aimed to validate whether the CalproQuest increases pretest-probability for a positive fecal Calprotectin.

Methods

Prospective diagnostic trial. The CalproQuest consists of 4 major and 4 minor questions suggestive for IBD. It is considered positive if ≥ 2 major or 1 major and 2 minor criteria are positive. Primary outcome: Sensitivity and specificity of the CalproQuest for Calprotectin levels ≥ 50 μg/g and for positive IBD diagnosis among patients referred to endoscopic evaluation at secondary care level. Secondary finding: Patient-reported diagnostic delay.

Results

156 patients from 7 study centers had a complete CalproQuest and fecal Calprotectin test. The sensitivity and specificity of CalproQuest for Calprotectin ≥ 50 μg/g was 36% and 57%. The sensitivity and specificity of the CalproQuest for positive IBD diagnosis was 37% and 67%. The diagnostic delay was 61 months (SD 125.2).

Conclusion

In this prospective diagnostic study, the sensitivity and specificity of CalproQuest for Calprotectin levels ≥ 50 μg/g and positive IBD diagnosis were poor. Additional prospective studies concerning the ideal cut-off values, validity and cost-effectiveness of a combined use with the Calprotectin test in the PC setting are necessary.

Feasibility of an 8-item questionnaire for early diagnosis of inflammatory bowel disease in primary care

AIMS

Diagnosis of inflammatory bowel disease (IBD) is often associated with a diagnostic delay. Although faecal calprotectin is a helpful screening tool, the widespread use in primary care (PC) may not be appropriate due to the low prevalence of IBD in this setting. To increase pretest probability for a positive calprotectin test, an 8-item questionnaire (CalproQuest) was tested for its feasibility and acceptability in PC.

METHODS

Population: PC patients with unspecific gastrointestinal complaints for at least 2 weeks. The CalproQuest consists of four major and four minor questions specific for IBD. It is considered positive if greater than or equal to two major or one major and two minor criteria are positive.

PRIMARY OUTCOME

feasibility of CalproQuest, secondary outcome: patient's acceptance of stool sampling.

RESULTS

Of 95 patients with a complete CalproQuest 52 (54.7%) were positive, 39 (41.1%) fulfilled two major and 13 (13.7%) one major and greater than or equal to two minor criteria. Twenty-seven general practitioners completed 83 (87.4%) questionnaires on feasibility which was assessed positive. Eighty-two patients (86.3%) completed questionnaires on acceptance which was high.

CONCLUSION

The CalproQuest is a feasible instrument for assessing IBD in PC. Further prospective studies concerning validity and cost effectiveness of a combined use with the calprotectin test in this setting are necessary.

The Time Course of Diagnostic Delay in Inflammatory Bowel Disease Over the Last Sixty Years: An Italian Multicentre Study

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] patients are still under-diagnosed or diagnosed with serious delay. We examined whether diagnostic delay [DD] in IBD has changed over the last 60 years, and explored the risk factors of longer DD.

METHODS

In total, 3392 IBD patients recorded in the registry of four IBD Italian centres were divided according to the year of diagnosis into a historical cohort [HC: 1955-84] and modern cohort [MC: 1985-2014]. DD, i.e. time lapse between onset of symptoms indicative of IBD and definitive diagnosis, was divided into four sub-periods [0-6, 7-12, 13-24, >24 months], which were correlated with age and disease location/behaviour at diagnosis.

RESULTS

Median DD in IBD was 3.0 months, it was significantly [P < 0.0001] higher in Crohn's disease [CD] [7.1 months] than in ulcerative colitis [UC] [2.0 months], and did not differ either between the HC and the MC or over the last three decades. However, the proportion of patients with a DD>24 months was significantly [P < 0.0001] higher in the HC [26.0%] than in the MC [18.2%], and the same trend was evident over the last three decades [1985-94: 19.9%; 1995-2004: 16.4%; 2005-14: 13.9%; P = 0.04]. At logistic regression analysis, age at diagnosis >40 years (CD: odds ratio 1.73, 95% confidence interval [CI] 1.31-2.28, P < 0.0001; UC: 1.41, 95% CI 1.02-1.96, P = 0.04) and complicated disease at CD diagnosis [1.39, 95% CI 1.06-1.82, P = 0.02] were independently associated with a DD>24 months.

CONCLUSIONS

DD duration has not changed over the last 60 years in Italy, but the number of IBD patients with a longer DD significantly decreased. Older age at diagnosis and a complicated disease at CD diagnosis are risk factors for longer DD.

Fecal calprotectin for diagnosis of digestive system diseases

Calprotectin is a 36 kDa calcium- and zinc-binding protein that belongs to the S100 family. Calprotectin shows an excellent stability in feces and appears to be superior to conventional fecal markers. Fecal calprotectin concentrations closely correlate with the fecal excretion of in-labelled leukocytes. In addition, fecal calprotectin has an overall high specificity. Therefore, it could be a useful marker for diagnosis of intestinal diseases. In this review we summarize the structure, physical and chemical characteristics of fecal calprotectin and analyze the relationship between calprotectin and intestinal diseases.