Hospitalized prevalence and 5-year mortality for IBD: Record linkage study

[Inflammatory Bowel Diseases: Regional Deprivation, Disease Characteristics and Relevant Health Care]

HINTERGRUND

Regionale Deprivation ist als ökologischer Parameter eine Komponente der sozialen Determinanten von Gesundheit. Zu ihrer Messung stehen in Deutschland der "German Index of Multiple Deprivation" (GIMD) und der "German Index of Socioeconomic Deprivation" (GISD) zur Verfügung. Chronisch entzündliche Darmerkrankungen (CED) sind keine häufigen, aber ernste körperliche Erkrankungen unklarer Ätiologie, mit vergleichsweise frühem Auftreten im Erwachsenenalter, oft chronisch-behandlungsbedürftigem Verlauf und unsicherer Prognose. Daten einer kontrollierten Versorgungsstudie erlauben es, Assoziationen zwischen regio-naler Deprivation und Merkmalen der Krankheit und ihrer Versorgung zu untersuchen. Wir erwarteten ungünstigere Krankheitsverhältnisse bei höherer Deprivation.

METHODIK

Vorgestellt werden deskriptive Zusatzauswertungen (n=530) der 2016 bis 2019 durchgeführten MERCED-Studie zu Wirksamkeit und Nutzen einer stationären medizinischen Rehabilitation bei Sozialversicherten mit einer CED. Analysiert wurden Daten aus der Basisbefragung zu selbstberichteten Krankheitsmerkmalen, Krankheitsfolgen und Versorgungsleistungen in ihrem Zusammenhang mit dem Ausmaß regionaler Deprivation der Wohnregion (Kreisebene).

ERGEBNISSE

Die Zuordnung der Wohnregion der Kranken zu den Quintilen von GIMD und GISD korrelieren unter rho=0,76 miteinander (gewichtetes kappa=0,74). Regionale Deprivation zeigt, gemessen mit dem GIMD, überzufällige Unterschiede allein in den sozialen Teilhabeeinschränkungen (IMET) und der Zahl der "Einschränkungstage". Dabei schildern sich Personen aus dem niedrigsten Deprivationsquintil als am stärksten eingeschränkt. Für die Einschränkungstage findet sich ein irre-guläres Muster. Beim GISD wird eine unsystematische Variation der gesundheitsbezogenen Lebensqualität (EQ-VAS) statistisch auffällig. Auch hier berichten Personen mit der geringsten regionalen Deprivation von einer besonders schlechten Lebensqualität. In einem Extremgruppenvergleich weisen Personen, die in nach GIMD und GISD stark deprivierten Regionen leben, günstigere Werte im Krankheitsverlauf beim IMET und EQ-VAS auf. Auch für Parameter der medizinischen Versorgung lassen sich keine systematischen Zusammenhänge mit den Deprivationsindizes darstellen.

SCHLUSSFOLGERUNG

Krankheitsmerkmale, Krankheitsfolgen und die medizinische Versorgung von CED-Kranken zeigen sich weitgehend unabhängig vom Ausmaß der mit zwei Indizes bestimmten regionalen Deprivation. Die wenigen auffälligen Unterschiede weisen in eine überraschende Richtung: Personen aus deprivierten Regionen berichten günstigere Krankheitsverhältnisse.

BACKGROUND

As an ecological parameter, area deprivation is one component of the social determinants of health. For Germany two indices to measure area deprivation are currently available: The German Index of Multiple Deprivation (GIMD) and the German Index of Socioeconomic Deprivation (GISD). Inflammatory bowel diseases (IBD) are not frequent but severe diseases of so far unknown etiology, comparatively early manifestation in adulthood, often chronic course requiring long-lasting medical attention, and uncertain prognosis. Data of a controlled health care trial enable us to study associations between area deprivation and disease and treatment variables. We expected more unfavourable conditions with increasing level of deprivation.

METHODS

We present secondary descriptive analyses of an RCT on effectiveness and benefit of medical inpatient rehab of 530 socially insured IBD patients. We used data from the initial assessment of numerous self-reported disease characteristics, consequences of disease, and health care items in relation to the extent of area deprivation at patients' county ("Kreis") level.

RESULTS

Grouped into quintiles, patients' results from GIMD and GISD are closely correlated (rho=0.76; weighted kappa=0.74). Regional deprivation, as assessed by GIMD, shows noticeable associations only with participation restriction (IMET scale) and number of disability days. However, subjects from least deprived areas report highest restrictions whereas the distribution of disability days exhibits an irregular pattern. GISD data are weakly and unsystematically related to quality of life measurements. Again, patients from least deprived areas show a considerably low quality of life. A comparison of two extreme groups (very low vs. very high deprivation in GIMD and GISD combined) corroborates the finding: Subjects from highly deprived areas report in general more favourable disease characteristics. We found no association between deprivation and any health care item.

CONCLUSION

Disease characteristics, psychosocial consequences, and health care of IBD seem to be mainly independent of the extent of area deprivation. The few statistically noticeable associations are unexpected: Patients from more deprived counties give more favourable reports.

Association between socioeconomic status and mucosal healing in Japanese patients with ulcerative colitis: a cross-sectional study

Objective

Socioeconomic status is a risk factor for worse outcomes in many diseases. However, evidence on the association between socioeconomic status and clinical outcome in patients with ulcerative colitis (UC) is limited. In the clinical setting, the therapeutic goal for UC is to achieve mucosal healing (MH). Thus, the aim of this study is to examine the association between socioeconomic status and MH in patients with UC.

Methods

The study population consisted of 298 patients with UC. Education status and household income were divided into three groups based on a self-administered questionnaire. MH and complete MH were defined as a Mayo endoscopic subscore of 0–1 and 0, respectively. The association of socioeconomic status with MH and complete MH was assessed by multivariate logistic regression analysis. Patients with UC were divided into a younger group (<51 years old) and an older group (≥51 years old) based on median age.

Results

The percentage of MH and complete MH was 62.4% and 25.2%, respectively. In all patients, socioeconomic status was not associated with MH and complete MH, respectively. In the older group, education but not household income was independently positively associated with MH and complete MH. In contrast, in the younger group, no association between socioeconomic status and MH and complete MH was found.

Conclusion

In older Japanese patients with UC, education status but not household income was independently positively associated with MH and complete MH.

Cost-Effectiveness Analysis of Vedolizumab Compared With Infliximab in Anti-TNF-α-Naïve Patients With Moderate-to-Severe Ulcerative Colitis in China

Objective: To evaluate the cost effectiveness of vedolizumab vs. infliximab in the treatment of anti-tumor necrosis factor-alpha (TNF-α)-naïve patients with moderate-to-severe active ulcerative colitis (UC) in China. Methods: The costs and effectiveness of vedolizumab and infliximab in the treatment of anti-TNF-α naïve patients with moderate-to-severe active UC were compared using a hybrid decision tree model and a Markov model. From the perspective of the Chinese healthcare system, this study simulated the lifetime health benefits [quality-adjusted life-years (QALYs)] and costs (USD) for patients with UC from the induction phase to the maintenance phase, with an annual discount rate of 5%. The clinical efficacy and transition probability data were based on a previously published network meta-analysis. The health utility, surgical risk, biologic drug discontinuation rate, and mortality were derived from previous literature and the Chinese statistical yearbook. The cost data were based on China's drug purchase and biding platform and the results of a survey sent to clinicians in 18 tertiary hospitals. One-way and probabilistic sensitivity analyses (PSAs) were performed to validate the robustness of the models' assumptions and specific parameter estimates. Results: The results of the base-case analyses showed that compared with infliximab, vedolizumab led to a gain of 0.25 QALYs (9.56 vs. 9.31 QALYs) and was less expensive by $7,349 ($180,138 vs. 187,487), indicating that the use of vedolizumab was a dominant strategy. The results of one-way sensitivity analyses suggested that the annual discount rate and health-state costs had the greatest impact, but the results were otherwise consistent with those of the base-case analyses. The PSAs suggested that vedolizumab had a 98.6% probability of being effective at a threshold of 3 times the gross domestic product (GDP) per capita in China in 2020. Conclusion: Compared with infliximab, vedolizumab appears to be a more cost-effective option in the treatment of anti-TNF-α naïve adult patients with moderate-to-severe, active UC in China.

Systematic review with meta-analysis: mortality in acute severe ulcerative colitis

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a life-threatening condition. Mortality in ASUC decreased in published series but there is uncertainty as to whether this also applies to the real-life setting.

AIM

To perform a systematic review and meta-analysis of mortality in ASUC in studies from referral centres and in population-based studies, separately and combined. A second aim was to identify risk factors of mortality in ASUC.

METHODS

We searched pubmed and embase from 1998 to 2016, to identify studies that reported 3-month or 12-month mortalities of acute UC in adult patients treated in referral centres, and in population-based studies.

RESULTS

Six population-based studies with 741 743 patients and 47 referral centre-based studies with 2556 patients were included. The pooled 3-month and 12-month mortalities were respectively 0.84% and 1.01%. Advanced age was significantly associated with both 3 month and 12 month mortalities (OR = 1.15 per year, 95% CI: 1.10-1.20 and OR = 1.19 per year, 95% CI: 1.15-1.23 respectively). The pooled 3-month and 12-month mortalities were 0.78% and 0.85% in studies with median age of less than 50 and 2.81% and 4.17% in studies with median age of 50 or more, respectively. After adjustment for age, 3-month and 12-month mortalities did not differ between population-based and referral centre-based studies.

CONCLUSIONS

Mortality in acute severe ulcerative colitis is approximately 1%; it is higher in older patients. Efforts should be made to improve the care of elderly patients with severe UC.

Predictors for poor outcome of hospitalized children with inflammatory bowel disease

Inflammatory bowel disease (IBD) exacerbations may lead to prolonged and complicated hospitalizations. The characteristics of exacerbation-related hospitalizations and predictors for poor outcome of pediatric patients hospitalized due to IBD have not been thoroughly described. All children who were hospitalized due to IBD exacerbation in a tertiary referral center between 2004 and 2017 were enrolled. Data on demographic and disease characteristics before and during hospitalization were retrospectively reviewed, as was the course of hospitalization, including laboratory findings, diagnostic work-up, and management. Poor outcomes were defined as prolonged hospitalization (≥ 7 days) and/or the need for surgery during hospitalization. There were 181 hospitalizations of 78 IBD children with a median (IQR) age of 14.8 (11.8-16.2) years. They included 53 (67.9%) with Crohn's disease and 25 (32.1%) with ulcerative colitis. In a multivariate analysis, severe disease activity at hospitalization (odds ratio [OR] = 3.33, P = 0.013), lower weight percentile (OR = 0.98, P = 0.009), treatment with antibiotics (OR = 5.03, P = 0.001), blood transfusion (OR = 8.03, P = 0.003), undergoing endoscopy (OR = 2.73, P = 0.027), and imaging studies during hospitalization (OR = 3.61, P = 0.001) predicted prolonged hospitalization. Surgical intervention was performed in 16 patients (8.8%), due to penetrating (OR = 7.73, P = 0.019) and stricturing disease (OR = 12.38, P < 0.001).Conclusion: We identified predictors for poor outcomes of children hospitalized due to IBD. Among the variables that can be measured at the beginning of the admission, severe disease activity was the most significant predictor recognition of these predictors that may contribute to modification of patient management.What is Known:• Inflammatory bowel disease (IBD) patients may require hospitalization due to disease exacerbation or treatment-related complications.• Hospitalizations of IBD patients constitute a heavy emotional burden on patients and families.What is New:• Lower weight percentile, severe disease activity, and a lower albumin level were predictors for prolonged hospitalization in children with IBD.• Recognition of these predictors may contribute to modification of patient management.

A Simple Noninvasive Score Predicts Disease Activity and Deep Remission in Ulcerative Colitis

Background

There is a need to use noninvasive markers in refining the management of ulcerative colitis to reduce the number of unnecessary colonoscopies, which facilitates the follow-up of activity and the response to treatment.

Aim

Postulation of a sensitive, specific, simple and noninvasive score to monitor disease activity in ulcerative colitis.

Methods

A case-control study was conducted: 168 patients with ulcerative colitis, 40 healthy individuals, and 60 patients for validation. Patients were divided into new diagnosis (n = 50), clinical remission (n = 60), and relapse (n = 58). The main outcome measures if the score correlates with clinical, endoscopic and histopathological characteristics and if it correlates with deep remission.

Results

A scoring system was established composed of lactoferrin at a cutoff of 148.5 μg/mL, neutrophil lymphocyte ratio at a cutoff of 2.35, erythrocyte sedimentation rate at the first hour at a cutoff of 29.5 mm/h, C-reactive protein at a cutoff of 3.85 mg/L, mean platelet volume at a cutoff of 8.8 fL, fecal white blood cells at a cutoff of 9 cells/HPF, and fecal red blood cells at a cutoff of 6 cells/HPF. A score ≥5 can detect 94% of cases of UC as determined by the receiver operating characteristic curve with a sensitivity of 94% and a specificity 100%, AUC 0.92, SE 0.05, p = 0.001, 95% CI 0.82-1.1. In the validation group, it identified severely affected patients with a sensitivity of 95% and a specificity of 85.7%.

Conclusions

This easily applied and reproducible noninvasive activity score showed high performance in predicting disease activity and deep remission in ulcerative colitis.

Literature review: impacts of socioeconomic status on the risk of inflammatory bowel disease and its outcomes

The relationship between socioeconomic status (SES) and inflammatory bowel disease (IBD) is controversial. To date, research has focused on effects on incidence and prevalence, disease management and clinical outcomes; however, conclusions remain uncertain. This review examines current evidence, identifies what remains to be understood and explores the practical implications this has for today. A structured literature search in Ovid, Medline, the Cochrane library, Google Scholar and clinicaltrials.gov was performed using defined key words, including all articles up until 5 October 2016 assessing SES as a primary or secondary outcome measure. Twenty-one studies were identified, investigating incidence and prevalence (n=13), disease outcomes (n=5) and mortality (n=3). Data linking SES with IBD incidence are conflicting, with studies citing both positive and negative trends. Patients with low SES, particularly those with Crohn's disease, show higher rates of hospitalization, service usage and IBD-associated mortality. On the basis of the available study data, it is difficult to relate SES with the risk of IBD. For Crohn's disease, in particular, the link between deprivation and increased hospitalization and mortality observed from world-wide studies is alarming. It seems most likely that the cause links to well-documented behavioural, materialistic, psychosocial and life-course models used to explain social class inequalities in other diseases.

Myrrh attenuates oxidative and inflammatory processes in acetic acid-induced ulcerative colitis

The pathogenesis of ulcerative colitis (UC) has been associated with a weakened antioxidant capacity and increased inflammatory processes. Myrrh is traditionally used for the treatment of inflammatory diseases due to its antioxidant and anti-inflammatory properties. The present study aimed to evaluate the effects of myrrh on an experimental rat model of UC. UC was induced in rats using acetic acid (AA) after pre-treatment with myrrh (125, 250 or 500 mg/kg/day) or mesalazine (MES; 300 mg/kg/day) for 7 days. The levels of various inflammatory cytokines, prostaglandin E2 (PGE2) and nitric oxide (NO) in the rat colon tissues were assessed. In addition, the colonic levels of thiobarbituric acid reactive substances (TBARS) and non-protein sulfhydryl groups (NP-SH), as well as the activities of superoxide dismutase (SOD) and catalase (CAT), were estimated. Furthermore, total protein (TP) contents and the levels of DNA and RNA were measured, and histopathological changes in colonic tissues were analyzed. The results indicated that the levels of pro-inflammatory cytokines, PGE2, NO and TBARS were markedly increased. By contrast, the levels of interleukin-10, NP-SH, TP and nucleic acids, and the enzymatic activities of SOD and CAT were significantly decreased in the AA model group. In addition, pretreatment with myrrh and MES was able to attenuate the impaired oxidative stress response and upregulation of inflammatory biomarkers. Furthermore, the enzymatic activities of SOD and CAT were near to normal in the myrrh and MES pretreated groups. The ability of myrrh to protect against UC was further confirmed by histopathological analysis, and the high dose of myrrh exerted an effect comparable to MES. In conclusion, the results of the present study suggested that myrrh has potent therapeutic value in the amelioration of experimental colitis in laboratory animals by downregulating the expression of proinflammatory mediators and improving endogenous antioxidative activities.

Carvedilol attenuates inflammatory biomarkers and oxidative stress in a rat model of ulcerative colitis

Preclinical Research This study evaluated the effects of the carvedilol, a nonselective β-adrenoceptor anatgonist with α1-adrenoceptor antagonist activity, in a rat model of experimentally induced ulcerative colitis (UC). UC was produced using acetic acid (AA) in animals previously treated with carvedilol (30 mg/kg po, qd) for seven days. Mucus content, lipid peroxidation (LPO) products, sulfhydryl groups, antioxidant enzyme activities, proinflammatory cytokines, prostaglandin E2 and nitric oxide levels were measured in colonic tissues and histopathological changes were assessed. LPO and proinflammatory biomarkers were markedly increased, while mucus content, sulfhydryl groups and enzymatic activities were inhibited in animals administered AA. Pretreatment with carvedilol attenuated LPO elevation, mucus content and sulfhydryl group inhibitions. Antioxidant enzymatic activity and proinflammatory biomarker levels were also restored in carvedilol-pretreated animals. Colonic protection associated with carvedilol pretreatment was further confirmed by histopathological assessment and found to be similar to the standard therapy of mesalazine (100 mg/kg po qd), suggesting that the effects of carvedilol action may be attributable to its anti-inflammatory and antioxidant properties.

Influence of urban/rural and coastal/inland environment on the prevalence, phenotype, and clinical course of inflammatory bowel disease patients from northwest of Spain: a cross-sectional study

BACKGROUND

Data on the influence of rural/urban and coastal/inland environment on inflammatory bowel disease (IBD) are either conflicting or lacking. Our aim was to analyze whether the environment has any influence on the prevalence, phenotype, and course of IBD.

MATERIALS AND METHODS

We carried out a multicenter retrospective study in 1194 IBD patients from Galicia, Spain. Urban areas were defined as those with over 25,000 inhabitants. Sex, age, family history, smoking, Montreal classification, extraintestinal manifestations, steroid dependence/refractoriness, and treatment were assessed. We used the Student's t-test/Mann-Whitney U tests to compare continuous variables and χ to compare categorical variables. Logistic regression was also used.

RESULTS

Living in urban municipalities was a risk factor for Crohn's disease [relative risk (RR) 1.47; 95% confidence interval (CI) 1.25-1.73; P<0.001]; living in coastal municipalities was a protective factor for ulcerative colitis (RR 0.71; 95% CI 0.60-0.85; P<0.001). Crohn's disease patients living on the coast had more frequent ileocolonic disease and needed immunosuppressives more frequently than inland patients (RR for inland 0.65; 95% CI 0.47-0.90; P=0.008). Urban Crohn's disease patients needed immunosuppressives more frequently than rural patients (RR 1.41; 95% CI 1.04-1.92; P=0.027). Urban ulcerative colitis patients had left-sided colitis less frequently. Coastal ulcerative colitis patients more frequently had extensive colitis.

CONCLUSION

Crohn's disease was found more frequently in urban and coastal areas and ulcerative colitis in inland municipalities. Place of residence may also influence phenotype and clinical course as patients living on the coast have more frequent ileocolonic Crohn's disease phenotype, extensive ulcerative colitis, and greater need for immunosuppressive therapy.

The economic and quality-of-life burden of Crohn's disease in Europe and the United States, 2000 to 2013: a systematic review

BACKGROUND

Crohn's disease (CD) is associated with a substantial healthcare burden that affects the patient, healthcare systems and society in general.

AIM

To provide a systematic evaluation of published data relating to the economic and health-related quality-of-life (HRQoL) burden of CD in selected European countries (Germany, France, UK, Italy, Spain) and the USA since 2000.

METHODS

We undertook a systematic review of publications relating to CD, its economic burden and impact on HRQoL. Research questions focused on the disease costs from a societal perspective and HRQoL burden in adults and pediatric/adolescent patients according to disease stage/severity. Total, direct and indirect costs were identified, as well as the impact of CD on HRQoL measured using both generic and disease-specific instruments.

RESULTS

Overall, 61 publications met the research criteria (38 on costs, 23 on HRQoL). CD in the USA and Europe together was associated with annual total costs of nearly <euro>30 billion, more than half due to indirect costs. HRQoL was consistently and statistically significantly lower among CD patients compared with normal populations, due to physical, emotional and social effects.

CONCLUSIONS

CD is a global health problem with high societal costs and substantial HRQoL burden. High-value care pathways including cost-effective therapies will help to induce and maintain remission, reduce complications of disease and improve HRQoL.

Mortality following acute pancreatitis: social deprivation, hospital size and time of admission: record linkage study

Background

Very little is known about whether mortality following acute pancreatitis may be influenced by the following five factors: social deprivation, week day of admission, recruitment of junior doctors in August each year, European Working Time Directives (EWTDs) for junior doctors’ working hours and hospital size. The aim of this study was to establish how mortality following acute pancreatitis may be influenced by these five factors in a large cohort study.

Methods

Systematic record linkage of inpatient, mortality and primary care data for 10 589 cases of acute pancreatitis in Wales, UK (population 3.0 million), from 1999 to 2010. The main study outcome measure was mortality at 60 days following the date of admission.

Results

Mortality was 6.4% at 60 days. There was no significant variation in mortality according to social deprivation or the week day of admission. There was also no significant variation according to calendar month for acute pancreatitis overall or for gallstone aetiology, but for alcoholic acute pancreatitis, mortality was increased significantly by 93% for admissions during the months of August and September and 102% from August to October when compared with all other calendar months. Mortality was increased significantly for alcoholic aetiology in August 2004, the official month that the first EWTD was implemented, but there were no other increases following the first or second EWTDs. There were also indications of increased mortality in large hospitals when compared with small hospitals, for acute pancreatitis overall and for gallstone aetiology but not for alcoholic acute pancreatitis, although these increases in mortality were of quite marginal significance.

Conclusions

Although we found some evidence of increased mortality for patients admitted with alcoholic acute pancreatitis during August to October, in August 2004, and in large hospitals for acute pancreatitis overall and for gallstone aetiology, the study factors had limited impact on mortality following acute pancreatitis and no significant impact when adjusted for multiple comparisons.

Mortality after total colectomy in 3084 patients with inflammatory bowel disease: a population-based cohort study

BACKGROUND

A high post-operative mortality has been reported following colectomy in patients with inflammatory bowel disease (IBD), especially in some patient groups.

AIMS

To investigate the 40-day mortality following colectomy in patients with IBD. The secondary aim was to assess whether colectomised IBD patients have an increased mortality compared to the general population.

METHODS

This is a population-based register study of all patients with IBD in Sweden who underwent total colectomy in 2000-2010. The cohort was identified using international classification codes for ulcerative colitis (UC) and Crohn's disease (CD). Patients registered with both UC and CD before colectomy (UCCD) were analysed separately. Each patient was followed-up to the date of death, migration or 31st of December 2010, whichever came first. Kaplan-Meier survival curves, Cox proportional hazards models and relative mortality rates were used to describe mortality.

RESULTS

In the cohort of 3084 patients, 2424 were diagnosed with UC, 326 with CD and 334 with UCCD. The 40-day, 1-year and 3-year mortality was 1.3%, 3.1% and 6.0%, respectively. The highest 40-day mortality was seen in patients ≥59 years of age (4.4%). Colectomy at the primary hospitalisation for IBD did not significantly increase the risk of post-operative mortality, nor did hospital volume. The relative survival after 3 years was 0.99, 0.98, 0.97 and 0.90 in those <30, 30-43, 44-58 and ≥59 years old, respectively.

CONCLUSION

The 40-day mortality following total colectomy in IBD patients in Sweden is low, except in patients ≥59 years old.

Clinical and epidemiological characteristics of inflammatory bowel disease in Guangxi: Analysis of 325 cases

AIM: To explore the clinical and epidemiological characteristics of inflammatory bowel disease (IBD) in Guangxi.

METHODS: A total of 325 patients with IBD treated at the First Affiliated Hospital of Guangxi Medical University from May 2003 to May 2013 were analyzed retrospectively.

RESULTS: Among the 325 patients, 266 had ulcerative colitis (UC) and 59 had Crohn's disease (CD). The sex ratio of the entire group was 1.3:1. The high-risk age ranged from 30 to 39 years, and the average age was 39.62 years ± 18.09 years. Patients with IBD were diagnosed mainly in brain workers (64.9%). The incidence of smoking habit, alcohol abuse, or appendix operation was higher in CD patients than in UC patients (P < 0.05). The extensive colon was the most common site affected by UC, while the terminal ileum was the most commonly affected site in CD. According to the severity of disease activity, severe activity (53.1%) was the most common in UC, while moderate activity (54.2%) was predominant in CD. The incidence of CD disease was significantly higher (P < 0.05) in the last 5 years, especially in male patients.

CONCLUSION: The number of IBD patients in Guangxi Zhuang Autonomous region is on a rise, especially CD patients. Males have a higher incidence than females, and during the recent 5 years, the number of male CD patients has increased significantly. The IBD patients in Guangxi are mainly brain workers. Patients with smoking habit, alcohol abuse or appendix operation may be more susceptible to CD.

Pretreatment of Gymnema sylvestre revealed the protection against acetic acid-induced ulcerative colitis in rats

Background

Overproduction of free radicals and decreased antioxidant capacity are well-known risk factors for inflammatory bowel diseases. Gymnema sylvestre (GS) leaves extract is distinguished for its anti-diabetic, antioxidant and anti-inflammatory properties. Present study is designed to evaluate the preventative activities of GS against acetic acid (AA)-induced ulcerative colitis in Wistar rats.

Methods

Experimentally ulcerative colitis (UC) was induced by AA in animals pretreated with three different doses of GS leaves extract (50, 100, 200 mg/kg/day) and a single dose of mesalazine (MES, 300 mg/kg/day) for seven days. Twenty four hours later, animals were sacrificed and the colonic tissues were collected. Colonic mucus content was determined using Alcian blue dye binding technique. Levels of thiobarbituric acid reactive substances (TBARS), total glutathione sulfhydryl group (T-GSH) and non-protein sulfhydryl group (NPSH) as well as the activity of the antioxidant enzymes superoxide dismutase (SOD) and catalase (CAT) were estimated in colon tissues. Colonic nucleic acids (DNA and RNA) and total protein (TP) concentrations were also determined. Levels of pro-inflammatory cytokines including interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) as well as prostaglandin E₂ (PGE₂) and nitric oxide (NO) were estimated in colonic tissues. The histopathological changes of the colonic tissues were also observed.

Results

In AA administered group TBARS levels were increased, while colonic mucus content, T-GSH and NP-SH, SOD and CAT were reduced in colon. Pretreatment with GS inhibited TBARS elevation as well as mucus content, T-GSH and NP-SH reduction. Enzymatic activities of SOD and CAT were brought back to their normal levels in GS pretreated group. A significant reduction in DNA, RNA and TP levels was seen following AA administration and this inhibition was significantly eliminated by GS treatment. GS pretreatment also inhibited AA-induced elevation of pro-inflammatory cytokines, PGE₂ and NO levels in colon. The apparent UC protection was further confirmed by the histopathological screening.

Conclusion

The GS leaves extract showed significant amelioration of experimentally induced colitis, which may be attributed to its anti-inflammatory and antioxidant property.

Epidemiological and clinical characteristics of inflammatory bowel diseases in Cairo, Egypt

AIM: To study the natural history, patterns and clinical characteristics of inflammatory bowel diseases (IBD) in Egypt.

METHODS: We designed a case-series study in the gastroenterology centre of the Internal Medicine department of Cairo University, which is a tertiary care referral centre in Egypt. We included all patients in whom the diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) was confirmed by clinical, laboratory, endoscopic, histological and/or radiological criteria over the 15 year period from 1995 to 2009, and we studied their sociodemographic and clinical characteristics. Endoscopic examinations were performed by 2 senior experts. This hospital centre serves patients from Cairo, as well as patients referred from all other parts of Egypt. Our centre received 24156 patients over the described time period for gastro-intestinal consultations and/or interventions.

RESULTS: A total of 157 patients with established IBD were included in this study. Of these, 135 patients were diagnosed with UC (86% of the total), and 22 patients, with CD (14% of the total). The mean ages at diagnosis were 27.3 and 29.7, respectively. Strikingly, we noticed a marked increase in the frequency of both UC and CD diagnoses during the most recent 10 years of the 15 year period studied. Regarding the gender distribution, the male:female ratio was 1:1.15 for UC and 2.6:1 for CD. The mean duration of follow up for patients with UC was 6.2 ± 5.18 years, while the mean duration of follow up for patients with CD was 5.52 ± 2.83 years. For patients with UC we found no correlation between the severity of the disease and the presence of extraintestinal manifestations. Eleven patients had surgical interventions during the studied years: 4 cases of total colectomy and 7 cases of anal surgery.

CONCLUSION: We observed a ratio of 6:1 for UC to CD in our series. The incidence of IBD seems to be rising in Egypt.

A nationwide population-based study of the inflammatory bowel diseases between 1998 and 2008 in Taiwan

Background

The incidence of the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn’s disease (CD), has been increasing in Asia. We probed the nationwide registered database to assess the incidence, prevalence, gender distribution, age of diagnosis and the survival status of IBD patients in Taiwan.

Methods

A retrospective study was conducted to analyze the registered database compiled by the National Health Insurance provided by the Department of Health, Taiwan, from January 1998 through December 2008.

Results

A total of 1591 IBD patients were registered from 1998 to 2008 in Taiwan (CD: 385; UC: 1206). The incidence of CD increased from 0.19/100,000 in 1998 to 0.24/100,000 in 2008. The incidence of UC increased from 0.61/100,000 in 1998 to 0.94/100,000 in 2008. The prevalence of CD increased from 0.19/100,000 in 1998 to 1.78/100,000 in 2008. The prevalence of UC increased from 0.61/100,000 in 1998 to 7.62/100,000 in 2008. Male to female ratio for CD was 2.22 and 1.64 for UC. Age of registered for CD was predominantly between 20 to 39, and for UC between 30 to 49 years of age. The standardized mortality ratio (95% CI) was 4.97 (3.72–6.63) for CD and 1.78 (1.46–2.17) for UC, from 1998 to 2008 in Taiwan.

Conclusions

Using the Taiwan nationwide database for IBD, the incidence and prevalence of IBD in Taiwan significantly increased from 1998 to 2008. The mortality rate was higher for CD patients than UC patients, and both were higher than the general population.

Effect of aqueous extract of Aegle marmelos unripe fruit on inflammatory bowel disease

Objective:

The present study was designed to evaluate the effect of Aegle marmelos unripe fruit extract (AMFE) on inflammatory bowel disease (IBD) in Wistar albino rats.

Materials and Methods:

Effect of AMFE was studied on acetic acid induced ulcerative colitis (1 ml of 4% acetic acid solution, transrectal) and indomethacin-induced enterocolitis (10 mg/kg, single dose, p.o) in Wistar albino rats. The extract was administered orally at different dose of 150, 200 and 250 mg/kg body weight. Disease pathogenesis was assessed by measuring disease activity index (DAI), macroscopic score, microscopic score, mesenteric mast cell protection, superoxide dismutase (SOD), and malonaldehyde (MDA) levels in the above two models.

Results:

The results showed a dose dependent decrease in intestinal inflammation following treatment with AMFE. Significant protection in mast cell degranulation was observed in acetic acid and indomethacin-induced IBD models. Treatment with AMFE significantly decreased the MDA levels and increased SOD activity.

Conclusion:

In our study, AMFE produced anti-inflammatory, antioxidant, and mast cell stabilizing effects demonstrating protective effect in inflammatory bowel disease.

The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors

BACKGROUND

The incidence of acute pancreatitis has increased sharply in many European countries and the USA in recent years.

AIM

To establish trends in incidence and mortality for acute pancreatitis in Wales, UK, and to assess how incidence may be linked to factors including social deprivation, seasonal effects and alcohol consumption.

METHODS

Use of record linked inpatient, mortality and primary care data for 10,589 hospitalised cases of acute pancreatitis between 1999 and 2010.

RESULTS

The incidence of acute pancreatitis was 30.0 per 100,000 population overall, mortality was 6.4% at 60 days. Incidence increased significantly from 27.6 per 100,000 in 1999 to 36.4 in 2010 (average annual increase = 2.7% per year), there was little trend in mortality (0.2% average annual reduction). The largest increases in incidence were among women aged <35 years (7.9% per year) and men aged 35-44 (5.7%) and 45-54 (5.3%). Incidence was 1.9 times higher among the most deprived quintile of patients compared with the most affluent (3.9 times higher for alcoholic acute pancreatitis and 1.5 for gallstone acute pancreatitis). Acute pancreatitis was increased significantly during the Christmas and New Year weeks by 48% (95% CI = 24-77%) for alcoholic aetiology, but not for gallstone aetiology (9%). Alcoholic admissions were increased with higher consumption of spirits and beer, but not wine.

CONCLUSIONS

The study shows an elevated rate of alcoholic acute pancreatitis during the Christmas and New Year period. Acute pancreatitis continues to rise, most rapidly for young women, while alcoholic acute pancreatitis is linked strongly with social deprivation.

Prognosis following upper gastrointestinal bleeding

Background

Upper gastrointestinal (GI) bleeding is one of the most common, high risk emergency disorders in the western world. Almost nothing has been reported on longer term prognosis following upper GI bleeding. The aim of this study was to establish mortality up to three years following hospital admission with upper GI bleeding and its relationship with aetiology, co-morbidities and socio-demographic factors.

Methods

Systematic record linkage of hospital inpatient and mortality data for 14 212 people in Wales, UK, hospitalised with upper GI bleeding between 1999 and 2004 with three year follow-up to 2007. The main outcome measures were mortality rates, standardised mortality ratios (SMRs) and relative survival.

Results

Mortality at three years was 36.7% overall, based on 5215 fatalities. It was highest for upper GI malignancy (95% died within three years) and varices (52%). Compared with the general population, mortality was increased 27-fold during the first month after admission. It fell to 4.3 by month four, but remained significantly elevated during every month throughout the three years following admission.

The most important independent prognostic predictors of mortality at three years were older age (mortality increased 53 fold for people aged 85 years and over compared with those under 40 years); oesophageal and gastric/duodenal malignancy (48 and 32 respectively) and gastric varices aetiologies (2.8) when compared with other bleeds; non-upper GI malignancy, liver disease and renal failure co-morbidities (15, 7.9 and 3.9); social deprivation (29% increase for quintile V vs I); incident bleeds as an inpatient (31% vs admitted with bleeding) and male patients (25% vs female).

Conclusion

Our study shows a high late as well as early mortality for upper GI bleeding, with very poor longer term prognosis following bleeding due to malignancies and varices. Aetiologies with the worst prognosis were often associated with high levels of social deprivation.

Perinatal and early life risk factors for inflammatory bowel disease

AIM: To investigate associations between perinatal risk factors and subsequent inflammatory bowel disease (IBD) in children and young adults.

METHODS: Record linked abstracts of birth registrations, maternity, day case and inpatient admissions in a defined population of southern England. Investigation of 20 perinatal factors relating to the maternity or the birth: maternal age, Crohn’s disease (CD) or ulcerative colitis (UC) in the mother, maternal social class, marital status, smoking in pregnancy, ABO blood group and rhesus status, pre-eclampsia, parity, the infant’s presentation at birth, caesarean delivery, forceps delivery, sex, number of babies delivered, gestational age, birthweight, head circumference, breastfeeding and Apgar scores at one and five minutes.

RESULTS: Maternity records were present for 180 children who subsequently developed IBD. Univariate analysis showed increased risks of CD among children of mothers with CD (P = 0.011, based on two cases of CD in both mother and child) and children of mothers who smoked during pregnancy. Multivariate analysis confirmed increased risks of CD among children of mothers who smoked (odds ratio = 2.04, 95% CI = 1.06-3.92) and for older mothers aged 35+ years (4.81, 2.32-9.98). Multivariate analysis showed that there were no significant associations between CD and 17 other perinatal risk factors investigated. It also showed that, for UC, there were no significant associations with the perinatal factors studied.

CONCLUSION: This study shows an association between CD in mother and child; and elevated risks of CD in children of older mothers and of mothers who smoked.

Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study

BACKGROUND

Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists.

AIM

To establish the hospitalized incidence and case fatality for upper GI bleeding, and to determine how they are associated with factors including day of admission, hospital size, social deprivation and distance from hospital.

METHODS

Systematic record linkage of hospital in-patient and mortality data for 24 421 admissions for upper GI bleeding among 22 299 people in Wales from 1999 to 2007.

RESULTS

The hospitalized incidence of upper GI bleeding was 134 per 100 000. Case fatality was 10.0%. Incidence was stable from 1999 to 2007; case fatality fell from 11.4% in 1999-2000 to 8.6% in 2006-7. Incidence was associated significantly with social deprivation. Compared with weekday admissions, case fatality was 13% higher for weekend admissions and 41% higher for admissions on public holidays. There was little variation in case fatality according to social deprivation, hospital size or distance from hospital.

CONCLUSIONS

Incidence, but not case fatality, was associated significantly with social deprivation. The higher mortality for weekend and public holiday admissions could not be explained by measures of case mix and may indicate a possible impact of reduced staffing levels and delays to endoscopy at weekends in some hospitals.

Inflammatory bowel disease in the elderly

Although inflammatory bowel disease (IBD) is generally considered a disease of young adults, it can occur in elderly individuals. The clinical features and treatment considerations in older patients are similar to those in younger patients, with some notable exceptions, which are reviewed in this article. Consideration of appropriate differential diagnoses is critical in older IBD patients to achieve the correct diagnosis and appropriate therapy. The risks associated with use of some IBD medications may be increased in older patients, but so is the risk of under-treated IBD and surgery. Therefore, in older IBD patients, as in younger patients, a thorough understanding of the indications, contraindications, and potential adverse effects of the various medications used to treat the condition is essential.

Protocol for a population-based ankylosing spondylitis (PAS) cohort in Wales

Background

To develop a population-based cohort of people with ankylosing spondylitis (AS) in Wales using (1) secondary care clinical datasets, (2) patient-derived questionnaire data and (3) routinely-collected information in order to examine disease history and the health economic cost of AS.

Methods

This data model will include and link (1) secondary care clinician datasets (i.e. electronic patient notes from the rheumatologist) (2) patient completed questionnaires (giving information on disease activity, medication, function, quality of life, work limitations and health service utilisation) and (3) a broad range of routinely collected data (including; GP records, in-patient hospital admission data, emergency department data, laboratory/pathology data and social services databases). The protocol involves the use of a unique and powerful data linkage system which allows datasets to be interlinked and to complement each other.

Discussion

This cohort can integrate patient supplied, primary and secondary care data into a unified data model. This can be used to study a range of issues such as; the true economic costs to the health care system and the patient, factors associated with the development of severe disease, long term adverse events of new and existing medication and to understand the disease history of this condition. It will benefit patients, clinicians and health care managers. This study forms a pilot project for the use of routine data/patient data linked cohorts for other chronic conditions.

Geographical variation of Crohn's disease residual incidence in the Province of Quebec, Canada

Background

Crohn's disease (CD) is clinically expressed as a chronic affection of the gastrointestinal tract currently known to have a multifactorial etiology involving a complex pathophysiological host response modulated by genetic susceptibilities, demographic determinants and environmental factors. With more than 20 cases per 100,000 person-years, the province of Quebec, Canada is among regions of the world with highest reported occurrence of CD in relation to other places where comparable estimates are available. This ecological study was designed to provide a medium-scale spatial exploration of CD incidence after accounting for the influence of known population and regional determinants. Health records of consulting patients in southern Quebec were compiled from 1995 to 2000 and used to estimate age and sex standardized rates per health area (n = 156). Various statistical models taking into account the regional effect of Jewish ethnicity, aboriginal ancestry, material deprivation, prescription for oral contraceptives, reportable enteric infection incidence, smoking as well as latitude and longitude locations were fitted.

Results

The final regression model presented a coefficient of determination of 22.8% and there was evidence of an eastern trend in the residual incidence (p = 0.018). Overall, the smoothed residual incidence presented a heterogeneous spatial pattern with evidence of patches (multiple health areas) of high, low and contrasting values. Health areas with most extreme incidence residuals where also distributed over the whole province including one area in the metropolitan area of Montreal and others in surrounding areas.

Conclusions

These findings suggest that known populational and regional factors derived through census information only explain a limited fraction of the geographical variation of CD incidence and lead to speculate that the effects of these factors may be incompletely captured (imperfect construction of proxy variables) or that other important factors remain unmeasured. In this view, markers of genetic profiles of homogeneous sub-populations, and other factors linked to agroenvironmental microbial exposure should be further investigated. Once accounting for known factors, it would also be worth comparing adjacent geographical areas demonstrating abrupt changes in residual incidence rates to further explore effect linked to regional factors from those resulting from various reporting systems.