Crohn’s disease in one mixed-race population in Brazil

Significant Racial and Ethnic Disparities Exist in Health Care Utilization in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

The incidence of inflammatory bowel disease (IBD) is rising worldwide, though the differences in health care utilization among different races and ethnicities remains uncertain. We aimed to better define this through a systematic review and meta-analysis.

METHODS

We explored the impact of race or ethnicity on the likelihood of needing an IBD-related surgery, hospitalization, and emergency department visit. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with I2 values reporting heterogeneity. Differences in IBD phenotype and treatment between racial and ethnic groups of IBD were reported.

RESULTS

Fifty-eight studies were included. Compared with White patients, Black patients were less likely to undergo a Crohn's disease (CD; OR, 0.69; 95% CI, 0.50-0.95; I2 = 68.0%) or ulcerative colitis (OR, 0.58; 95% CI, 0.40-0.83; I2 = 85.0%) surgery, more likely to have an IBD-hospitalization (OR, 1.54; 95% CI, 1.06-2.24; I2 = 77.0%), and more likely to visit the emergency department (OR, 1.74; 95% CI, 1.32-2.30; I2 = 0%). There were no significant differences in disease behavior or biologic exposure between Black and White patients. Hispanic patients were less likely to undergo a CD surgery (OR, 0.57; 95% CI, 0.48-0.68; I2 = 0%) but more likely to be hospitalized (OR, 1.38; 95% CI, 1.01-1.88; I2 = 37.0%) compared with White patients. There were no differences in health care utilization between White and Asian or South Asian patients with IBD.

CONCLUSIONS

There remain significant differences in health care utilization among races and ethnicities in IBD. Future research is required to determine factors behind these differences to achieve equitable care for persons living with IBD.

Hospitalizations and in-hospital mortality for inflammatory bowel disease in Brazil

BACKGROUND

Inflammatory bowel disease (IBD) is associated with complications, frequent hospitalizations, surgery and death. The introduction of biologic drugs into the therapeutic arsenal in the last two decades, combined with an expansion of immunosuppressant therapy, has changed IBD management and may have altered the profile of hospitalizations and in-hospital mortality (IHM) due to IBD.

AIM

To describe hospitalizations from 2008 to 2018 and to analyze IHM from 1998 to 2017 for IBD in Brazil.

METHODS

This observational, retrospective, ecological study used secondary data on hospitalizations for IBD in Brazil for 2008-2018 to describe hospitalizations and for 1998-2017 to analyze IHM. Hospitalization data were obtained from the Hospital Information System of the Brazilian Unified Health System and population data from demographic censuses. The following variables were analyzed: Number of deaths and hospitalizations, length of hospital stay, financial costs of hospitalization, sex, age, ethnicity and type of hospital admission.

RESULTS

There was a reduction in the number of IBD hospitalizations, from 6975 admissions in 1998 to 4113 in 2017 (trend: y = -0.1682x + 342.8; R² = 0.8197; P < 0.0001). The hospitalization rate also decreased, from 3.60/100000 in 2000 to 2.17 in 2010. IHM rates varied during the 20-year period, between 2.06 in 2017 and 3.64 in 2007, and did not follow a linear trend (y = -0.0005049x + 2.617; R² = 0,00006; P = 0.9741). IHM rates also varied between regions, increasing in all but the southeast, which showed a decreasing trend (y = -0.1122x + 4.427; R² = 0,728; P < 0.0001). The Southeast region accounted for 44.29% of all hospitalizations. The Northeast region had the highest IHM rate (2.86 deaths/100 admissions), with an increasing trend (y = 0.1105x + 1.110; R² = 0.6265; P < 0.0001), but the lowest hospitalization rate (1.15). The Midwest and South regions had the highest hospitalization rates (3.27 and 3.17, respectively). A higher IHM rate was observed for nonelective admissions (2.88), which accounted for 81% of IBD hospitalizations. The total cost of IBD hospitalizations in 2017 exhibited an increase of 37.5% compared to 2008.

CONCLUSION

There has been a notable reduction in the number of hospitalizations for IBD in Brazil over 20 years. IHM rates varied and did not follow a linear trend.

Latin Americans and US Hispanics show differences in IBD phenotype: a systematic review with meta-analysis

Latin America has experienced a rise in the prevalence and incidence of inflammatory bowel disease (IBD). Differences in IBD phenotype between Hispanics in Latin America and those in the USA have not been described. We conducted a systematic review with meta-analysis of population-based and cohort studies comparing the phenotype of ulcerative colitis (UC) and Crohn's disease (CD) in Latin Americans and US Hispanics. A systematic search was conducted up to March 2019 using MEDLINE, EMBASE and Google Scholar. Inclusion criterion includes studies describing IBD phenotype in Latin Americans or in US Hispanics. Exclusion criterion includes prevalence or incidence studies not describing phenotype. A random effects model was chosen "a priori" for analysis of pooled proportions. A total of 46 studies were included from Latin America and 7 studies from the USA. The predominant IBD subtype in Latin America was UC with a more balanced UC:CD ratio noted in Puerto Rico (0.53) and Brazil (0.56). UC-related extensive colitis was more common in US Hispanics (0.64) than in Latin Americans (0.38), p<0.001. CD phenotype was similar between US Hispanics and Latin Americans. UC is the predominant IBD subtype in Latin America, with the exception of Puerto Rico and Brazil which demonstrate a more balanced UC:CD ratio. In UC, extensive colitis was more frequently seen in US Hispanics than in Latin Americans. CD phenotype was similar in both US Hispanics and Latin Americans.

Systematic review with meta-analysis: The prevalence, risk factors and outcomes of upper gastrointestinal tract Crohn's disease

AIMS

Upper gastrointestinal Crohn's disease (UGI-CD) is an important subclassification of Crohn's Disease (CD). We performed a systematic review and meta-analysis to evaluate the prevalence, risk factors, and clinical outcomes associated with UGI-CD.

METHODS

We searched Embase and Medline for articles reporting the clinical information of UGI-CD in CD patients, through 27 October 2020. Disease location and phenotype were coded according to the Montreal classification, and results were pooled with random effects by DerSimonian and Laird model.

RESULTS

26 articles were included. The prevalence of UGI-CD was 13%. UGI-CD was most commonly found in the stomach (56%) and was associated with concurrent ileocolonic involvement (54%). Non-stricturing, non-penetrating UGI-CD was the most common behavioral phenotype (61%). L4-jejunal disease was associated with the highest rates of surgery. Region of origin did not significantly influence the location and phenotype of UGI-CD. Young, male patients presenting with erythema nodosum, aphthous ulcers and stricturing-phenotype are more likely to have UGI-CD, which in turn is linked to increased risk of hospitalization and surgery.

CONCLUSION

UGI-CD is present in 13% of patients with CD, and patients with L4-jejunal disease are more likely to require surgery. Further studies examining the effect of ethnicity and region on UGI-CD are needed.

Clinical and Demographic Profile of Inflammatory Bowel Disease Patients in a Reference Center of São Paulo, Brazil

Background

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract with an increasing incidence in developing countries.

Purpose

To report clinical and demographic data of CD and UC at a referral center for inflammatory bowel disease (IBD) in São Paulo.

Patients and Methods

We conducted a retrospective cross-sectional study on adult patients with established IBD. Demographic and clinical data were obtained by medical records analysis from the IBD Outpatient Clinic of EPM-UNIFESP, from October 1997 to October 2017.

Results

Of 658 patients included, 355 had UC (54%) and 303 had CD (46%). UC was more prevalent in women than CD (219 [61.7%] vs 152 [50.2%], p=0.003). The median time between the onset of symptoms and diagnosis was 13 (5-38) months, with a longer duration for CD patients. CD mostly affected the ileocolonic location (47.9%). CD patients with stricture, fistula and/or perianal disease (213/303, 70.3%) were younger at diagnosis, had a longer disease duration, higher rates of corticosteroid, immunomodulatory, and biological therapy, hospitalization, and referral to surgery, compared to patients without complication. Extensive colitis was the most common extension of UC (50.6%), which was more frequently associated with younger age at diagnosis, hepatobiliary disease, increased need for hospitalization, higher use of immunomodulatory, and biologic therapy, compared to patients with less extensive disease. In the last 5 years, CD patients were more frequently on biologic and/or immunomodulatory (70.9%) therapy, and UC patients often received salicylates (78.1%) and immunomodulatory (28.1%) treatments. There was a consistent reduction in salicylate usage for CD in the last 5 years compared to the total period of follow-up.

Conclusion

Despite the increasing incidence, we highlight the diagnostic delay and a more complicated CD and extensive UC in this cohort, reflecting a high need for immunomodulatory and biological treatment, hospitalization, and surgery.

Progression of Inflammatory Bowel Diseases Throughout Latin America and the Caribbean: A Systematic Review

BACKGROUND & AIMS

The incidence of inflammatory bowel diseases (IBD) is increasing in Latin America. We performed a systematic review to identify clinical and epidemiologic features of IBD in Latin America (including Mexico, Central America, and South America) and the Caribbean.

METHODS

We searched MEDLINE, EMBASE, and SciELO databases for clinical or epidemiologic studies of Crohn's disease (CD) or ulcerative colitis (UC) from Latin American and Caribbean countries and territories that reported incidence, prevalence, ratio of UC:CD, IBD phenotype, and treatment, through September 12, 2018. Data were extracted from 61 articles for analysis.

RESULTS

The incidence and prevalence of IBD have been steadily increasing in Latin America and the Caribbean. The incidence of CD in Brazil increased from 0.08 per 100,000 person-years in 1988 to 0.68 per 100,000 person-years in 1991-1995 to 5.5 per 100,000 person-years in 2015. The highest reported prevalence of IBD was in Argentina, in 2007, at 15 and 82 per 100,000 person-years for CD and UC, respectively. The ratio of UC:CD exceeded 1 in all regions throughout Latin America and the Caribbean with the exception of Brazil. Treatment with tumor necrosis factor antagonists increased steadily for patients with CD (43.4% of all patients in Brazil were treated in 2014) but less so for patients with UC (4.5% of all patients were treated in 2014). Surgery for IBD decreased with time. In Chile, surgeries were performed on 57.0% of patients with CD and 18.0% of patients with UC during the period of 1990-2002; these values decreased to 38.0% and 5.0%, respectively, during the period of 2012-2015. In Peru, 6.9% of patients with UC received colectomies in the period of 2001-2003 and 6.2% in 2004-2014.

CONCLUSIONS

In a systematic review, we found the incidence of IBD to be increasing throughout Latin America and the Caribbean. Population-based epidemiology studies are needed to evaluate the increase in IBD in these regions, which differ from other global regions in climate, culture, demographics, diet, healthcare delivery and infrastructure, and socioeconomic status.

Epidemiology of inflammatory bowel disease in Mexico and Colombia: Analysis of health databases, mathematical modelling and a case-series study

BACKGROUND AND AIMS

Ulcerative Colitis (UC) and Crohn's Disease (CD) have a major impact on quality of life and medical costs. The aim of the study was to estimate the prevalence, incidence and clinical phenotypes of Inflammatory Bowel Disease (IBD) cases in Mexico and Colombia.

METHODS

We analyzed official administrative and health databases, used mathematical modelling to estimate the incidence and complete prevalence, and performed a case-series of IBD patients at a referral center both in Mexico and Colombia.

RESULTS

The age-adjusted complete prevalence of UC per 100,000 inhabitants for 2015/2016 ranged from 15.65 to 71.19 in Mexico and from 27.40 to 69.97 in Colombia depending on the model considered. The prevalence of CD per 100,000 inhabitants in Mexico ranged from 15.45 to 18.08 and from 16.75 to 18.43 in Colombia. In Mexico, the age-adjusted incidence of UC per 100,000 inhabitants per year ranged from 0.90 to 2.30, and from 0.55 to 2.33 in Colombia. The incidence for CD in Mexico ranged from 0.35 to 0.66 whereas in Colombia, the age-adjusted incidence of CD ranged from 0.30 to 0.57. The case-series included 200 IBD patients from Mexico and 204 patients from Colombia. The UC/CD prevalence ratio in Mexico and Colombia was 1.50:1 and 4.5:1 respectively. In Mexico, the female/male prevalence ratio for UC was 1.50:1 and 1.28:1 for CD, while in Colombia this ratio was 0.68:1 for UC and 0.8:1 for CD. In Mexico the relapse rate for UC was 63.3% and 72.5% for CD, while those rates in Colombia were 58.2% for UC and 58.3% for CD.

CONCLUSIONS

The estimated burden of disease of IBD in Mexico and Colombia is not negligible. Although these findings need to be confirmed by population-based studies, they are useful for decision-makers, practitioners and patients with this condition.

Epidemiology of inflammatory bowel disease in South America: A systematic review

BACKGROUND

The worldwide epidemiology of inflammatory bowel disease (IBD) is rapidly changing. Increasing Crohn’s disease (CD) and ulcerative colitis (UC) incidence and prevalence have been recorded in developing regions such as Asia, Africa and Eastern Europe where it was previously thought to be uncommon. Whether this is also the case in South America is not well known. Demonstration that developing regions worldwide have increasing IBD incidence would indicate that environmental change plays a significant role in the development of IBD.

AIM

To report the incidence, prevalence and disease characteristics of CD and UC within the South American continent.

METHODS

A systematic review was conducted by searching published studies in major international and regional databases (MEDLINE, EMBASE and Scopus) between January 1990 and December 2018. Outcomes considered were incidence, prevalence, phenotype, environmental and genetic factors, ethnicity and gender. A pair of independent reviewers screened and reviewed all identified articles.

RESULTS

One hundred and sixty two citations were initially retrieved with 18 studies included in this systematic review. The majority of included studies were from Brazil (n =13, 72%). The incidence of UC ranged from 4.3-5.3/100000 person-years whilst the incidence of CD ranged from 0.74-3.5/100000 person-years. Prevalence ranged from 15.0-24.1/100000 inhabitants for UC and from 2.4-14.1/100000 inhabitants for CD. The incidence and prevalence of both UC and CD has increased significantly in Brazil over the past 21 years. Pancolitis was the most common disease distribution in patients with UC whilst colonic involvement was the most common distribution in CD. People residing in urban areas were at higher risk of developing both CD and UC.

CONCLUSION

The IBD burden in South America is increasing at a rate possibly even greater than other developing regions around the world. There is a paucity of high-quality epidemiological studies and further robust and representative data are required to further explore modifiable risk factors and disease phenotypes.

Evolution of Clinical Behavior in Crohn's Disease: Factors Associated with Complicated Disease and Surgery

BACKGROUND

The phenotypic expression of Crohn's disease may vary over time. Establishment of Crohn's disease phenotypes is important for definition of patient care strategies.

AIMS

The aim of the study was to evaluate the long-term evolution of patients based on disease phenotypes and the main factors associated with this evolution.

METHODS

Data from 179 patients were collected from a unicentric prospective database. Montreal classification was employed. Kaplan-Meier method was used to estimate the cumulative probability of complication development and surgery. Poisson regression for multivariate analysis was applied. The Local Institutional Review Board approved the research.

RESULTS

Female: 54.2%. Mean age at diagnosis: 32.7 (±13.7) years. Behavior at presentation: inflammatory 62.0%, stricturing 24.6%, penetrating 13.4%; perianal disease: 31.8%; median follow-up time: 65.2 months (IQR 31.0-108.8). Behavior at follow-up period end: inflammatory 43.6%, stricturing 38.0%, penetrating 18.4%; perianal disease: 46.4%. Cumulative probability of being complication free in 5, 10, and 20 years: 86.3, 66.4, and 52.2%, respectively. Cumulative probability of being surgery free in 5, 10, and 20 years: 87.3, 79.2, and 64.1%, respectively. L1 and L4 locations, use of immunosuppressive therapy, smoking, number of hospitalization/patient-year, abdominal surgery, age at diagnosis <40 years, and biological therapy were the factors associated with changes in phenotype or development of complications and perianal disease.

CONCLUSION

Clinical behavior altered in about one-third of patients. The most frequent complication was a change to stricturing pattern. Disease location, current smoker, immunosuppressive therapy use, hospitalization, and abdominal surgery were factors associated with an unfavorable clinical evolution.

Tonsillectomy and inflammatory bowel disease: a meta-analysis

AIM

The pathogenesis of inflammatory bowel diseases remains unclear. Genetic and environmental factors are involved. Studies of the association between tonsillectomy and inflammatory bowel disease have yielded conflicting results.

METHOD

PubMed and EMBASE were searched to identify studies evaluating the association between tonsillectomy and inflammatory bowel disease [Crohn's disease (CD) and ulcerative colitis (UC)]. Odds ratios with 95% CI were calculated using a random- or fixed-effects model. The χ(2) test and I(2) test were used to assess homogeneity. Egger's test was used to evaluate publication bias.

RESULTS

Thirteen observational case-control studies including 4122 patients (3035 UC/1087 CD) and 5103 controls were analysed. The summary odds ratio estimated for UC following a tonsillectomy was 0.932, 95% CI 0.819-1.062. The odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992-1.437. Publication bias was not detected (Egger's test coefficient -3.50 to 1.55; P = 0.39).

CONCLUSION

No obvious association between tonsillectomy and inflammatory bowel disease was identified in our meta-analysis.

The effects of race and socioeconomic status on immunomodulator and anti-tumor necrosis factor use among ambulatory patients with inflammatory bowel disease in the United States

OBJECTIVES

Health-care disparities exist for patients of minority race and low socioeconomic status (SES) in many chronic disease states, but little is known regarding health-care disparities for patients with inflammatory bowel disease (IBD). Using nationally representative data, we sought to determine whether use of immunomodulators and anti-tumor necrosis factor (TNF) agents differed by race/ethnicity and SES among ambulatory patients with IBD.

METHODS

We used data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 1998 to 2010. We identified visits associated with IBD and the medications associated with those visits. Race/ethnicity and SES were characterized. The frequency of immunomodulator and anti-TNF use over time was assessed. We performed analyses accounting for the survey's complex multistage probability sampling design. Associations between race/ethnicity, SES and IBD medication use were identified.

RESULTS

A total of 26,400,000 visits for patients with IBD occurred in the United States from 1998 to 2010. Seventy-six per cent of visits were for whites, 9% were for blacks, 7% were for Hispanics, and 2% were for Asians. Sixty-one per cent of visits were privately insured, whereas 7% had Medicaid coverage. From 1998 to 2010, the proportion of visits associated with immunomodulators increased from 6 to 13%, whereas the proportion associated with anti-TNF agents increased from <1 to 14%. In adjusted analyses, visits with Medicaid were three times more likely to be associated with immunomodulators than visits with private insurance, but there were no race/ethnicity-based differences in immunomodulator use. There were no race/ethnicity- or SES-based differences in anti-TNF therapy.

CONCLUSIONS

Using nationally representative data over a 13-year time period, we found no evidence of disparities in medical therapy for IBD among visits with minority race/ethnicity or low SES.

Systematic review: The role of race and socioeconomic factors on IBD healthcare delivery and effectiveness

BACKGROUND

Race and socioeconomic status (SES) significantly affect the content and delivery of healthcare for multiple chronic disease states. Inflammatory bowel disease (IBD) is a set of complex, chronic diseases with the potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to race, SES, and IBD remains fragmented.

METHODS

Using guidelines published by the Centre for Reviews and Dissemination, we performed a systematic review of the world's literature to identify studies related to: 1) IBD, 2) race/ethnicity, 3) SES, 4) healthcare delivery, and 5) healthcare effectiveness.

RESULTS

We identified 40 studies that met inclusion criteria. Twenty-four studies (60%) assessed the role of SES and 21 (53%) evaluated race. Topics addressed by these studies included: 1) Utilization of Medical and Surgical Therapy; 2) Adherence to Medical Therapy; 3) Clinical Outcomes; 4) Healthcare Access and Utilization; 5) Disease Perception and Knowledge; and 6) Employment/Insurance. We identified race- and SES-based disparities in the content of medical and surgical healthcare, utilization of inpatient and ambulatory medical care, adherence to medical therapy, and disease perceptions and knowledge. Several studies also identified race- and SES-based disparities in outcomes for IBD, including in-hospital mortality rates and health-related quality of life.

CONCLUSIONS

Race- and SES-based disparities in the delivery and effectiveness of healthcare for patients with IBD exist in numerous domains, yet studies remain limited in their scope and breadth. Concerted, prospective, multicenter efforts are needed to address underlying causes for disparities and to identify methods of reducing and eliminating disparities.

Analysis of fat and muscle mass in patients with inflammatory bowel disease during remission and active phase

Inflammatory bowel disease (IBD) is often associated with malnutrition. The aim of this study was to compare the body composition of outpatients with IBD during remission and active phase. In order to evaluate disease activity we used Crohn's Disease Activity Index for Crohn's disease (CD) patients and Lichtiger's Index for ulcerative colitis (UC) patients. All patients underwent the analysis of BMI, arm muscle area (AMA) and triceps plus subscapula skinfold thickness (TST+SST) to identify total, muscle and fat mass, respectively. In total 102 patients were evaluated (CD, n 50; UC, n 52) and the majority was young women. Malnutrition according to BMI was found in 14.0 % of patients with CD and 5.7 % of UC patients. Muscle mass depletion was detected in more than half of the CD and UC patients. The BMI, TST+SST and AMA values were lower in the active phase only in CD patients (P < 0.05). Fat mass depletion was associated with active phase in both CD and UC patients. Body composition parameters obtained using BMI, TST+SST and AMA were not correlated with the presence of fistula in CD patients (P>0.05). In conclusion, patients without signs of malnutrition had fat mass depletion especially in the active phase and muscle mass depletion occurred both in CD and UC patients.