1
|
Magrì S, Demurtas M, Onidi MF, Picchio M, Elisei W, Marzo M, Miculan F, Manca R, Dore MP, Quarta Colosso BM, Cicu A, Cugia L, Carta M, Binaghi L, Usai P, Lai M, Chicco F, Fantini MC, Armuzzi A, Mocci G. Clinical and epidemiological features of ulcerative colitis patients in Sardinia, Italy: Results from a multicenter study. World J Clin Cases 2022; 10:10921-10930. [PMID: 36338227 PMCID: PMC9631144 DOI: 10.12998/wjcc.v10.i30.10921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/06/2021] [Accepted: 08/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There are little data on the epidemiological and clinical features of adult patients with ulcerative colitis (UC) in the different Italian regions, mainly derived from the absence of a national registry. This prevents correct interpretation of the disease burden.
AIM To assess the main clinical and epidemiological features of adult patients diagnosed with UC in Sardinia, Italy.
METHODS We performed a multicenter, observational, cross-sectional study that included adult patients with UC enrolled in seven gastroenterology unit centers in Sardinia. Data were obtained from the patients’ medical records and from a questionnaire administered at the inclusion visit.
RESULTS Four hundred and forty-two patients with UC were included. The median age at diagnosis was 39 years (interquartile range 28-48). After a median disease duration of 10 years, 53 patients experienced proximal extension of proctitis or left-sided colitis. Seventy-five patients developed extraintestinal manifestations. Nineteen patients (4.3%) developed cancer: two with colorectal cancer and seventeen with extracolonic cancers. Mesalazine (5-ASA) remains the mainstay of treatment for UC. Overall, 95 patients (21.5%) were treated with one or more biologic agents, whereas 15 patients (3.4%) underwent surgery, mostly colectomy.
CONCLUSION Our results provide important insights into the clinical and epidemiological features of patients with UC, and while waiting for a national Italian registry, present eligible data on the UC population in Sardinia.
Collapse
Affiliation(s)
- Salvatore Magrì
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato 09042, Italy
- Endoscopy Unit, Humanitas Istituto Clinico Catanese, Catania 95045, Italy
| | - Mauro Demurtas
- Endoscopy Unit, San Martino Hospital, Oristano 09170, Italy
| | | | - Marcello Picchio
- Division of General Surgery, Ospedale Civile P Colombo, Velletri 00049, Italy
| | - Walter Elisei
- Gastroenterology Unit, San Camillo Forlanini Hospital, Rome 00152, Italy
| | - Manuela Marzo
- Internal Medicine and Gastroenterology Department, Cardinale Panico Hospital, Tricase 73039, Italy
| | - Federica Miculan
- Department of Surgery, San Martino Hospital, Oristano 09170, Italy
| | - Roberto Manca
- Division of Gastroenterology, Santissima Trinità Hospital, Cagliari 09121, Italy
| | - Maria Pina Dore
- Dipartimento di Medicina Clinica e Sperimentale, University of Sassari, Sassari 07100, Italy
| | | | - Antonio Cicu
- Unit of Gastroenterology, ASL Sassari, Sassari 07100, Italy
| | - Luigi Cugia
- Gastroenterology Unit, Santissima Annunziata Hospital, Sassari 07100, Italy
| | - Monica Carta
- Gastroenterology Unit, Santissima Annunziata Hospital, Sassari 07100, Italy
| | - Laura Binaghi
- Gastroenterology Unit, Brotzu Hospital, Cagliari 09121, Italy
| | - Paolo Usai
- Medical Science and Public Health, University of Cagliari, Cagliari 09042, Italy
| | - Mariantonia Lai
- Medical Sciences and Public health, Presidio Policlinico of Monserrato, Cagliari, Monserrato 09042, Cagliari, Italy
| | - Fabio Chicco
- Medical Science and Public Health, University of Cagliari, Cagliari 09042, Italy
| | | | | | - Giammarco Mocci
- Gastroenterology Unit, Brotzu Hospital, Cagliari 09121, Italy
| |
Collapse
|
2
|
Macaluso FS, Liguori G, Galli M. Vaccinations in patients with inflammatory bowel disease. Dig Liver Dis 2021; 53:1539-1545. [PMID: 34116972 DOI: 10.1016/j.dld.2021.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 02/07/2023]
Abstract
Treatment of inflammatory bowel disease (IBD) frequently requires administration of immunosuppressive therapies, which increases susceptibility to a number of infectious pathogens. However, many infections can be prevented by correct and appropriate utilization of vaccinations. While several guidelines have been published on vaccination schedules in patients with IBD, vaccination rates remain suboptimal and even lower than those in the general population. This is due to many factors including poor awareness of the importance of vaccines by gastroenterologists and general practitioners as well as potential prejudices of patients regarding the safety and benefits of vaccines. With the aim of increasing awareness about the key role of immunization in the management of patients with IBD, the present review examines the existing literature relating to the main vaccinations and their application in these patients. We also summarize current evidence in order to provide clinicians with an easy source of reference for the principal recommendations for prevention of infectious diseases in patients with IBD. In addition, the recommendations about traveling for IBD patients are briefly explored. Lastly, since it is important for gastroenterologists to be aware of recommendations on vaccination, we recommend implementing educational programs to ensure compliance with current guidelines.
Collapse
Affiliation(s)
- Fabio Salvatore Macaluso
- Department of Medicine, ''Villa Sofia-Cervello'' Hospital, Sicilian Network for Inflammatory Bowel Disease (SN-IBD), Palermo, Italy.
| | | | - Massimo Galli
- Department of Biomedical and Clinical Sciences, L Sacco" University of Milan, Via Giovan Battista Grassi 74, Milan 20157, Italy
| |
Collapse
|
3
|
Hashash JG, Picco MF, Farraye FA. Health Maintenance for Adult Patients with Inflammatory Bowel Disease. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2021; 19:583-596. [PMID: 34840495 PMCID: PMC8608358 DOI: 10.1007/s11938-021-00364-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW This review serves as a summary of healthcare maintenance items that should be addressed when managing patients with inflammatory bowel disease (IBD). This manuscript discusses vaccine-preventable illnesses, cancer prevention recommendations, and other screenings that are important to gastroenterologists and primary care physicians caring for patients with IBD. RECENT FINDINGS Patients with IBD often require immunomodulator agents and/or biologics to induce and maintain disease remission which can increase the risk of developing several infections. Also, subsets of patients with IBD are at an increased risk for a number of malignancies including colon, cervical, and skin cancers. SUMMARY Staying up-to-date with health care maintenance of patients with IBD is critical, especially given their increased risk for vaccine-preventable infections as well as comorbidities such as cancers, bone health, and mood disorders. Gastroenterologists and primary care physicians should familiarize themselves with the required screenings and vaccines that are recommended for adult patients with IBD, particularly those who are immunosuppressed.
Collapse
Affiliation(s)
- Jana G. Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Mayo Clinic, Jacksonville, FL USA
| | - Michael F. Picco
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Mayo Clinic, Jacksonville, FL USA
| | - Francis A. Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology, Mayo Clinic, Jacksonville, FL USA
| |
Collapse
|
4
|
Doherty J, Fennessy S, Stack R, O’ Morain N, Cullen G, Ryan EJ, De Gascun C, Doherty GA. Review Article: vaccination for patients with inflammatory bowel disease during the COVID-19 pandemic. Aliment Pharmacol Ther 2021; 54:1110-1123. [PMID: 34472643 PMCID: PMC8653045 DOI: 10.1111/apt.16590] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/10/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Poor immune responses are frequently observed in patients with inflammatory bowel disease (IBD) receiving established vaccines; risk factors include immunosuppressants and active disease. AIMS To summarise available information regarding immune responses achieved in patients with IBD receiving established vaccines. Using this information, to identify risk factors in the IBD population related to poor vaccine-induced immunity that may be applicable to vaccines against COVID-19. METHODS We undertook a literature review on immunity to currently recommended vaccines for patients with IBD and to COVID-19 vaccines and summarised the relevant literature. RESULTS Patients with IBD have reduced immune responses following vaccination compared to the general population. Factors including the use of immunomodulators and anti-TNF agents reduce response rates. Patients with IBD should be vaccinated against COVID-19 at the earliest opportunity as recommended by International Advisory Committees, and vaccination should not be deferred because a patient is receiving immune-modifying therapies. Antibody titres to COVID-19 vaccines appear to be reduced in patients receiving anti-TNF therapy, especially in combination with immunomodulators after one vaccination. Therefore, we should optimise any established risk factors that could impact response to vaccination in patients with IBD before vaccination. CONCLUSIONS Ideally, patients with IBD should be vaccinated at the earliest opportunity against COVID-19. Patients should be in remission and, if possible, have their corticosteroid dose minimised before vaccination. Further research is required to determine the impact of different biologics on vaccine response to COVID-19 and the potential for booster vaccines or heterologous prime-boost vaccinations in the IBD population.
Collapse
Affiliation(s)
- Jayne Doherty
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| | - Sean Fennessy
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| | - Roisin Stack
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| | - Neil O’ Morain
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| | - Garret Cullen
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| | - Elizabeth J. Ryan
- Department of Biological SciencesHealth Research InstituteUniversity of LimerickLimerickIreland
| | - Cillian De Gascun
- National Virus Reference LaboratoryUniversity College DublinDublinIreland
| | - Glen A. Doherty
- Centre for Colorectal DiseaseSt. Vincent’s University Hospital & School of MedicineUniversity College DublinDublinIreland
| |
Collapse
|
5
|
Sagami S, Kobayashi T, Hibi T. Prevention of Infectious Diseases due to Immunosuppression and Vaccinations in Asian Patients with Inflammatory Bowel Disease. Inflamm Intest Dis 2018; 3:1-10. [PMID: 30505836 DOI: 10.1159/000489643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/17/2018] [Indexed: 12/20/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) patients with immunocompromise have a high risk of developing complications related to viral infections. Western countries were the first to formulate vaccine guideline. Asian countries developed their national and international vaccine guidelines a little later in order to reduce the risk of mortality from viral infections. However, no studies to date have examined the differences in vaccinations that prevail among Asian countries. Summary This review summarizes the vaccination status and schedules in various Asian countries for immunocompromised IBD patients. Vaccination rates, regardless of the specific vaccine, were high in Japan, South Korea, and China and low in India and the Philippines. Vaccine schedules differed by country, and outbreaks of measles and rubella were seen due to low vaccination rates in Southeast Asia and South Asia. Live vaccines cannot be administered during immunosuppressive treatment. Infection with measles, mumps, and varicella during immunosuppressive therapy carries a high risk of mortality, and thus confirmation of immunization status is recommended as soon as IBD is diagnosed and, when possible, live vaccines should be administered before the initiation of immunosuppressive treatment. In patients seronegative for hepatitis B, administration of the hepatitis B vaccine is also recommended. Key Messages Physicians, while considering severity of outbreaks, should understand the differences in vaccination status that exist among the various Asian countries and regions.
Collapse
Affiliation(s)
- Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW Patients with inflammatory bowel disease (IBD) are not receiving preventative care services at the same rate as the general population. IBD patients are at increased risk for infections, osteoporosis, and certain malignancies secondary to their disease and as they are on immunosuppressive therapy. They are a younger population and often times consider their gastroenterologist as their primary care physician. In this review, we discuss up-to-date evidence pertaining to vaccine-preventable illnesses in the immunosuppressed IBD patient, screening for bone health, cervical cancer, skin malignancies, psychological wellbeing, and smoking cessation. RECENT FINDINGS Vaccinations are recommended in the IBD population as they are immunosuppressed and at increased risk for acquiring influenza and pneumonia. Not only are they at greater risk to acquire it but they also have a much severe complicated course. Ideally, IBD patients should be vaccinated prior to initiating immunosuppression and most inactive vaccines can be administered to them while they are on therapy. All IBD patients should be encouraged to stop smoking and have adequate vitamin D intake along with appropriate applicable cancer screenings. Gastroenterologists must work in collaboration with primary care providers along with other specialists to help provide our patients well-rounded care for their IBD.
Collapse
Affiliation(s)
- Fazia A Mir
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.
| |
Collapse
|
7
|
Bye WA, Jairath V, Travis SPL. Systematic review: the safety of vedolizumab for the treatment of inflammatory bowel disease. Aliment Pharmacol Ther 2017; 46:3-15. [PMID: 28449273 DOI: 10.1111/apt.14075] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 02/15/2017] [Accepted: 03/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vedolizumab specifically recognises the α4β7 integrin and selectively blocks gut lymphocyte trafficking: potentially, it offers gut-specific immunosuppression. AIM To review the safety of vedolizumab and summarise post-marketing data to assess if any safety concerns that differ from registration trials have emerged. METHOD A systematic bibliographic search identified six registration trials and nine cohort studies. RESULTS Integrated data from registration trials included 2830 vedolizumab-exposed patients (4811 person-years exposure [PYs]) and 513 placebo patients. This reported lower exposure-adjusted incidence rates of infection (63.5/100 PYs; 95% CI: 59.6-67.3) and serious adverse events (20.0/100 PYs; 95% CI: 18.5-21.5) compared to placebo (82.9/100 PYs; 95% CI: 68.3-97.5) and (28.3/100 PYs 95% CI: 20.6-35.9) respectively. Higher, but statistically insignificant rates of enteric infections occurred in vedolizumab-exposed patients (7.4/100 PYs; 95% CI: 6.6-8.3) compared to placebo (6.7 PYs; 95% CI: 3.2-10.1). Six post-marketing cohort studies (1049 patients, 403 PYs) demonstrated rates of infection of 8% (82/1049); enteric infection of 2% (21/1049) and adverse events of 16% (166/1049). Multivariate analysis in one cohort study suggested increased risk of surgical site infection with perioperative VDZ. Human experience in pregnancy is limited. CONCLUSIONS Post-marketing data confirm the excellent safety of vedolizumab observed in registration trials. The signal of post-operative complications should be interpreted with caution, but warrants further study. Although comparative studies are needed, Vedolizumab may be a safe alternative in patients who best avoid systematic immunosuppression, including those pre-disposed to infection, malignancy or the elderly.
Collapse
Affiliation(s)
- W A Bye
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - V Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - S P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
8
|
ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am J Gastroenterol 2017; 112:241-258. [PMID: 28071656 DOI: 10.1038/ajg.2016.537] [Citation(s) in RCA: 320] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.
Collapse
|
9
|
DeFilippis EM, Sockolow R, Barfield E. Health Care Maintenance for the Pediatric Patient With Inflammatory Bowel Disease. Pediatrics 2016; 138:peds.2015-1971. [PMID: 27489295 DOI: 10.1542/peds.2015-1971] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/24/2022] Open
Abstract
Nearly one-quarter of patients with inflammatory bowel disease (IBD) are younger than 20 years of age at diagnosis. Furthermore, the incidence of IBD in children continues to increase. Nevertheless, variation in management exists within the care of patients with IBD with regards to disease screening and preventive care. A multidisciplinary approach that involves the general practitioner and pediatric gastroenterologist is needed to routinely monitor growth, bone health, vitamin and mineral deficiencies, vaccination status, and endoscopic surveillance. It is also important to monitor for extraintestinal manifestations of IBD that may affect the liver, joints, skin, and eyes. The purpose of this article is to provide an updated overview of comprehensive care for pediatric patients with IBD.
Collapse
|
10
|
Fernandez-Martinez S, Cortes X, Borrás-Blasco J, Gracia-Pérez A, Casterá MDE. Effectiveness of a systematic vaccination program in patients with autoimmune inflammatory disease treated with anti-TNF alpha drugs. Expert Opin Biol Ther 2016; 16:1317-1322. [DOI: 10.1080/14712598.2016.1218844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
11
|
Abstract
PURPOSE OF REVIEW The treatment of inflammatory bowel disease (IBD) in the modern area has improved with more biological agents available. Although the efficacy of these drugs has been demonstrated, concerns about their safety profile have been raised, and new data have emerged in the past year. RECENT FINDINGS New data regarding the safety profile of anti-TNF were published over the last year, with a better identification of patients at risk of infection, and specific recommendations for the prevention of infections. There is a mild increase in malignancy in patients receiving anti-TNF, mainly lymphoma and skin cancer, which seems mainly attributable to combination with thiopurines. Specific recommendations for management of pregnancy were published. SUMMARY Biological treatments are effective and safe in the treatment of IBD, provided that the recommendations for their use and monitoring are followed.
Collapse
|
12
|
Cao Y, Zhao D, Xu AT, Shen J, Ran ZH. Effects of immunosuppressants on immune response to vaccine in inflammatory bowel disease. Chin Med J (Engl) 2015; 128:835-8. [PMID: 25758282 PMCID: PMC4833992 DOI: 10.4103/0366-6999.152683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To evaluate the response rate to vaccination in different treatment groups (nonimmunosuppressants and immunosuppressants). DATA SOURCES We completed an online systematic search using PubMed to identify all articles published in English between January 1990 and December 2013 assessing the effect of the response rate to vaccination in different treatment groups (with and without immunomodulators). The following terms were used: "inflammatory bowel disease (IBD)" OR "Crohn's disease" OR "ulcerative colitis" AND ("vaccination" OR "vaccine") AND ("corticosteroids" OR "mercaptopurine" OR "azathioprine" OR "methotrexate [MTX]") AND "immunomodulators." STUDY SELECTION The inclusion criteria of articles were that the studies: (1) Randomized controlled trials which included patients with a diagnosis of IBD (established by standard clinical, radiographic, endoscopic, and histologic criteria); (2) exposed patients received immunomodulators for maintenance (weight-appropriate doses of 6-mercaptopurine/azathioprine or within 3 months of stopping, 15 mg or more MTX per week or within 3 months of stopping; (3) exposed patients received nonimmunomodulators (no therapy, antibiotics only, mesalazine only, biological agent only such as infliximab, adalimumab, certolizumab or natalizumab or within 3 months of stopping one of these agents). The exclusion criteria of articles were that the studies: (1) History of hepatitis B virus (HBV), influenza or streptococcus pneumoniae infection; (2) patients who had previously been vaccinated against HBV, influenza or streptococcus pneumoniae; (3) any medical condition known to cause immunosuppression (e.g. chronic renal failure and human immunodeficiency virus infection); (4) individuals with positive hepatitis markers or liver cirrhosis; (5) patients with a known allergy to eggs or other components of the vaccines and (6) pregnancy. RESULTS Patients treated with immunomodulators were associated with lower response rates to vaccination. CONCLUSIONS Immunomodulators may impair the immune response to vaccination in patients with IBD. Vaccination should be made at the time of diagnosis or before starting immunosuppressed therapy.
Collapse
Affiliation(s)
- Yuan Cao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Jiaotong University, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Di Zhao
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Jiaotong University, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - An-Tao Xu
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Jiaotong University, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Jun Shen
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Jiaotong University, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| | - Zhi-Hua Ran
- Division of Gastroenterology and Hepatology, School of Medicine, Shanghai Jiaotong University, Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai 200001, China
| |
Collapse
|