Two-year delay in ulcerative colitis diagnosis is associated with anti-tumor necrosis factor alpha use

Genome-Wide DNA Methylation Identifies Potential Disease-Specific Biomarkers and Pathophysiologic Mechanisms in Irritable Bowel Syndrome, Inflammatory Bowel Disease, and Celiac Disease

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease (CeD) present with similar gastrointestinal (GI) symptoms. DNA methylation-based biomarkers have not been investigated as diagnostic biomarkers to classify these disorders. We aimed to study DNA methylation profiles of IBS, IBD, CeD, and healthy controls (HC), develop machine learning-based classifiers, and identify associated gene ontology (GO) terms.

METHODS

Genome-wide DNA methylation of peripheral blood mononuclear cells from 315 patients with IBS, IBD, CeD, and HC was measured using Illumina's 450K or EPIC arrays. A methylation dataset on 304 IBD and HC samples was used for external validation. Differential methylation was measured using general linear models. Classifiers were developed using penalized generalized linear models using double cross-validation controlling for confounders. Functional enrichment was assessed using GO.

RESULTS

Three hundred and fifteen participants (148 IBS, 47 IBD, 34 CeD, and 86 HC) had DNA methylation data. IBS-IBD and IBD-CeD showed the highest number of differentially methylated CpG sites followed by IBD-HC, CeD-HC, and IBS-HC. IBS-associated genes were enriched in cell adhesion and neuronal pathways, while IBD- and CeD-associated markers were enriched in inflammation and MHC class II pathways, respectively (p < 0.05). Classification performances assessed using area under the receiver operating characteristic curves (AUC) for IBS-IBD, IBS-CeD, and IBD-CeD were 0.80 (95% CI = 0.7-0.87, p = 6.75E-10), 0.78 (95% CI = 0.68-0.86, p = 4.57E-10), and 0.73 (95% CI = 0.62-0.83, p = 0.03), respectively. The performance of IBD-HC was successfully validated using external data (AUC = 0.74 [95% CI = 68-0.80, p < 0.001]).

CONCLUSIONS

Blood-based DNA methylation biomarkers can potentially distinguish chronic GI disorders that present with similar symptoms. GO suggested functional significance of the classifiers in disease-specific pathology.

Advances in oligosaccharides and polysaccharides with different structures as wall materials for probiotics delivery: A review

Probiotics are active microorganisms that are beneficial to the health of the host. However, probiotics are highly sensitive to the external environment, and are susceptible to a variety of factors that reduce their activity during production, storage, and use. Microencapsulation is an effective method that enhances probiotic activity. Macromolecules like polysaccharides, who classified as biologically active prebiotics, have attracted significant attention for their utility in probiotic microencapsulation. This article summarized the types of commonly used microencapsulation materials and their structural characteristics from the perspective of polysaccharides prebiotics. It also discussed recent advancements, probiotic-prebiotic microcapsule-based modulation of the immune system, as well as the associated limitations. Furthermore, the advantages and disadvantages of eight prebiotics as microencapsulation wall materials. The honeycomb structure of β-glucan enhances the bioavailability of probiotics, while, fructooligosaccharide and galactooligosaccharides improve microbead structure to tightly encapsulate probiotics. The terminal reducing groups of isomaltooligosaccharides and the free hydroxyl groups in xylooligosaccharides also positively affect the structure of microcapsules. Prebiotics not only enhance the survival rate and biological activity of probiotics as embedding materials during storage, but also exert their own probiotic effects. Collectively, prebiotics holds great promise as microencapsulation materials for probiotics delivery.

Associations between prior healthcare use, time to diagnosis, and clinical outcomes in inflammatory bowel disease: a nationally representative population-based cohort study

BACKGROUND

Timely diagnosis and treatment of inflammatory bowel disease (IBD) may improve clinical outcomes.

OBJECTIVE

Examine associations between time to diagnosis, patterns of prior healthcare use, and clinical outcomes in IBD.

DESIGN

Using the Clinical Practice Research Datalink we identified incident cases of Crohn's disease (CD) and ulcerative colitis (UC), diagnosed between January 2003 and May 2016, with a first primary care gastrointestinal consultation during the 3-year period prior to IBD diagnosis. We used multivariable Cox regression to examine the association of primary care consultation frequency (n=1, 2, >2), annual consultation intensity, hospitalisations for gastrointestinal symptoms, and time to diagnosis with a range of key clinical outcomes following diagnosis.

RESULTS

We identified 2645 incident IBD cases (CD: 782; UC: 1863). For CD, >2 consultations were associated with intestinal surgery (adjusted HR (aHR)=2.22, 95% CI 1.45 to 3.39) and subsequent CD-related hospitalisation (aHR=1.80, 95% CI 1.29 to 2.50). For UC, >2 consultations were associated with corticosteroid dependency (aHR=1.76, 95% CI 1.28 to 2.41), immunomodulator use (aHR=1.68, 95% CI 1.24 to 2.26), UC-related hospitalisation (aHR=1.43, 95% CI 1.05 to 1.95) and colectomy (aHR=2.01, 95% CI 1.22 to 3.27). For CD, hospitalisation prior to diagnosis was associated with CD-related hospitalisation (aHR=1.30, 95% CI 1.01 to 1.68) and intestinal surgery (aHR=1.71, 95% CI 1.13 to 2.58); for UC, it was associated with immunomodulator use (aHR=1.42, 95% CI 1.11 to 1.81), UC-related hospitalisation (aHR=1.36, 95% CI 1.06 to 1.95) and colectomy (aHR=1.54, 95% CI 1.01 to 2.34). For CD, consultation intensity in the year before diagnosis was associated with CD-related hospitalisation (aHR=1.19, 95% CI 1.12 to 1.28) and intestinal surgery (aHR=1.13, 95% CI 1.03 to 1.23); for UC, it was associated with corticosteroid use (aHR=1.08, 95% CI 1.04 to 1.13), corticosteroid dependency (aHR=1.05, 95% CI 1.00 to 1.11), and UC-related hospitalisation (aHR=1.12, 95% CI 1.03 to 1.21). For CD, time to diagnosis was associated with risk of CD-related hospitalisation (aHR=1.03, 95% CI 1.01 to 1.68); for UC, it was associated with reduced risk of UC-related hospitalisation (aHR=0.83, 95% CI 0.70 to 0.98) and colectomy (aHR=0.59, 95% CI 0.43 to 0.80).

CONCLUSION

Electronic records contain valuable information about patterns of healthcare use that can be used to expedite timely diagnosis and identify aggressive forms of IBD.

The diagnostic performance of serum αvβ6 autoantibodies for ulcerative colitis: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Currently, there is no single golden standard for diagnosing ulcerative colitis (UC). Now serum αvβ6 autoantibodies have shown promise as a diagnostic tool for UC. Here the aim was to determine the diagnostic performance of serum αvβ6 autoantibodies for UC.

METHODS

PubMed, the Cochrane Library, the Embase, and the Web of Science were searched comprehensively. STATA software was utilized to analyze the relevant data.

RESULTS

9 studies from 6 articles with 1827 subjects were eligible. The summary sensitivity and specificity of serum αvβ6 autoantibodies to diagnose UC were 0.82 (95 % confidence interval (CI): 0.65-0.92) and 0.94 (95 % CI: 0.90-0.97) with an area under the summary receiver operating characteristic curve of 0.96 (95 % CI: 0.94-0.97). Subgroup analysis was conducted owning to substantial heterogeneity between studies (I2 = 97 % and P < 0.001). The aggregate sensitivity and specificity to diagnose UC in adults were 0.75 (95 % CI: 0.61-0.86) and 0.95 (95 % CI: 0.90-0.97), and when using a threshold of mean control+3SD, 0.80 (95 % CI: 0.60-0.91) and 0.96 (95 % CI: 0.90-0.99), respectively. Additionally, to differentiate UC from healthy participants, non-inflammatory bowel disease, and Crohn's disease, the overall specificity was 0.96, 0.88, and 0.80, respectively.

CONCLUSIONS

serum αvβ6 autoantibodies, as a non-invasive tool, demonstrated good diagnostic accuracy for UC. However, their application may be limited in some immune-related disorders, and further studies are needed for validation.

Antibiotic use as a risk factor for inflammatory bowel disease across the ages: a population-based cohort study

BACKGROUND

There is an increasing incidence of inflammatory bowel disease (IBD) for which environmental factors are suspected. Antibiotics have been associated with development of IBD in earlier generations, but their influence on IBD risk in adults is uncertain.

OBJECTIVE

To assess the impact of antibiotic exposure, including dose-response, timing and antibiotic class, on the risk of IBD in all individuals aged ≥10 years.

DESIGN

Using Denmark nationwide registries, a population-based cohort of residents aged ≥10 years was established between 2000 and 2018. Incidence rate ratios (IRRs) for IBD following antibiotic exposure were calculated using Poisson regression.

RESULTS

There were a total of 6 104 245 individuals, resulting in 87 112 328 person-years of follow-up, and 52 898 new cases of IBD. Antibiotic exposure was associated with an increased risk of IBD as compared with no antibiotic exposure for all age groups, although was greatest among individuals aged 40-60 years and ≥60 years (age 10-40 years, IRR 1.28, 95% CI 1.25 to 1.32; age 40-60 years, IRR 1.48, 95% CI 1.43 to 1.54; age ≥60 years, IRR 1.47, 95% CI 1.42 to 1.53). For all age groups a positive dose-response was observed, with similar results seen for both ulcerative colitis and Crohn's disease. The highest risk of developing IBD was seen 1-2 years after antibiotic exposure, and after use of antibiotic classes often prescribed to treat gastrointestinal pathogens.

CONCLUSION

Antibiotic exposure is associated with an increased risk of IBD, and was highest among individuals aged 40 years and older. This risk increased with cumulative antibiotic exposure, with antibiotics targeting gastrointestinal pathogens and within 1-2 years after antibiotic exposure.

Systematic review with meta-analysis: Time to diagnosis and the impact of delayed diagnosis on clinical outcomes in inflammatory bowel disease

BACKGROUND

The impact of diagnostic delay on the clinical course of inflammatory bowel disease (IBD) remains uncertain.

AIM

To perform a systematic review of time to diagnosis and the impact of delayed diagnosis on clinical outcomes in Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

We searched EMBASE and Medline from inception to 30th November 2022 for studies reporting diagnostic interval, from symptom onset to IBD diagnosis. We calculated the median, interquartile range (IQR) and pooled weighted median, of median diagnostic intervals of eligible studies. We defined delayed diagnosis as individuals above the 75th centile of longest time to diagnosis in each study. Using random effects meta-analysis, we pooled odds ratios (ORs) with 95% confidence intervals (CI) for studies reporting clinical outcomes, according to delayed diagnosis.

RESULTS

One hundred and one studies representing 112,194 patients with IBD (CD = 59,359; UC = 52,835) met inclusion criteria. The median of median times to diagnosis was 8.0 (IQR: 5.0-15.2) and 3.7 months (IQR: 2.0-6.7) in CD and UC, respectively. In high-income countries, this was 6.2 (IQR: 5.0-12.3) and 3.2 months (IQR: 2.2-5.3), compared with 11.7 (IQR: 8.3-18.0) and 7.8 months (IQR: 5.2-21.8) in low-middle-income, countries, for CD and UC respectively. The pooled weighted median was 7.0 (95% CI: 3.0-26.4) and 4.6 (95% CI: 1.0-96.0) months, for CD and UC respectively. Eleven studies, representing 6164 patients (CD = 4858; UC = 1306), were included in the meta-analysis that examined the impact of diagnostic delay on clinical outcomes. In CD, delayed diagnosis was associated with higher odds of stricturing (OR = 1.88; CI: 1.35-2.62), penetrating disease (OR = 1.64; CI: 1.21-2.20) and intestinal surgery (OR = 2.24; CI: 1.57-3.19). In UC, delayed diagnosis was associated with higher odds of colectomy (OR = 4.13; CI: 1.04-16.40).

CONCLUSION

Delayed diagnosis is associated with disease progression in CD, and intestinal surgery in both CD and UC. Strategies are needed to achieve earlier diagnosis of IBD.

Diagnostic delay in adult inflammatory bowel disease: A systematic review

BACKGROUND

The extent of diagnostic delay in inflammatory bowel disease (IBD) is incompletely understood. We aimed to understand the extent of diagnostic delay of IBD in adults and identify associations between patient or healthcare characteristics and length of delay.

METHODS

Articles were sourced from EMBASE, Medline and CINAHL from inception to April 2021. Inclusion criteria were adult cohorts (18 ≥ years old) reporting median time periods between onset of symptoms for Crohn's disease (CD), ulcerative colitis (UC) or IBD (i.e. CD and UC together) and a final diagnosis (diagnostic delay). Narrative synthesis was used to examine the extent of diagnostic delay and characteristics associated with delay. Sensitivity analysis was applied by the removal of outliers.

RESULTS

Thirty-one articles reporting median diagnostic delay for IBD, CD or UC were included. After sensitivity analysis, the majority of IBD studies (7 of 8) reported a median delay of between 2 and 5.3 months. From the studies examining median delay in UC, three-quarters (12 of 16) reported a delay between 2 and 6 months. In contrast, three-quarters of the CD studies (17 of 23) reported a delay of between 2 and 12 months. No characteristic had been examined enough to understand their role in diagnostic delay in these populations.

CONCLUSIONS

This systematic review provides robust insight into the extent of diagnostic delay in IBD and suggests further intervention is needed to reduce delay in CD particularly. Furthermore, our findings provide a benchmark value range for diagnostic delay, which such future work can be measured against.

[Perimyocarditis as a complication of a multiple drug therapy in the treatment of a severe ulcerative colitis episode]

HISTORY AND CLINICAL FINDINGS

 A 19-year-old patient presented as an inpatient with an acute flare-up of ulcerative colitis for about six weeks and symptom progression for one and a half weeks. The patient was treated with topical and oral 5-aminosalicylic acid (5-ASA) preparations and oral prednisolone. With an intensification of the prednisolone dose, administration of a monoclonal antibody (Vedolizumab) and antibiotic therapy, inpatient discharge against medical advice. Oral administration of ciprofloxacin due to continued elevated infection parameters. The 5-ASA administration was continued. In the following two weeks, recurrent episodes of fever and renewed inpatient admission.

INVESTIGATIONS AND DIAGNOSIS

 Microbiological detection of Acinetobacter ursingii in blood cultures. Echocardiographic evidence of pericardial effusion. Transesophageal echocardiography revealed no evidence of infective endocarditis. Serological evidence of elevated cardiac enzyme levels. An MRI scan of the heart confirmed the diagnosis of perimyocarditis.

TREATMENT AND COURSE

 Intensive medical care and resistogram-based antibiotic therapy with meropenem, stopping the topical and oral 5-ASA doses and not continuing the integrin antagonist therapy. In addition, start of guideline-based cardiac insufficiency therapy and change of therapy to a tumor necrosis factor alpha blocker. Under the accelerated application scheme, stabilization and improvement of the general condition protracted. After two months of hospitalization, the patient was discharged to outpatient care.

DISCUSSION

 Perimyocarditis may occur after long-term administration of 5-ASA. The integrin antagonist as a new therapy can also be a causal factor. Therapeutic management when the cause of the complaint is unclear depends on the symptoms and the most likely cause of the disease. If there is no response to therapy, carry out early re-evaluations.

Diagnostic Delay of Inflammatory Bowel Disease Is Significantly Higher in Public versus Private Health Care System in Mexican Patients

Introduction

Inflammatory bowel disease (IBD) includes ulcerative colitis (UC) and Crohn's disease (CD) characterized by a fluctuating course with periods of clinical activity and remission. No previous studies have demonstrated the frequency of delay at diagnosis and its associated factors in Mexico and Latin America. The aim of this study was to evaluate diagnostic delay of IBD in the last 4 decades in 2 different health care systems (public vs. private) and its associated factors.

Methods

This is a cohort study that included 1,056 patients with a confirmed diagnosis of IBD from public and private health care systems. The diagnostic delay was defined as time >1 year from the onset of symptoms to the confirmed diagnosis for patients with UC and 2 years for patients with CD. Statistical analysis was performed with the SPSS v.24 program. A value of p ≤ 0.05 was taken as significant.

Results

The delay at diagnosis decreased significantly by 24.9% in the last 4 decades. The factors associated with the diagnostic delay were proctitis in UC, clinical course >2 relapses per year and IBD surgeries for CD. We found a delay at diagnosis in 35.2% of IBD patients in the public versus 16.9% in the private health care system (p = 0.00001).

Conclusions

We found a significant diagnosis delay of IBD in 35.2% from the public health care system versus 16.9% in the private health care system.

Screening of characteristic genes in ulcerative colitis by integrating gene expression profiles

Background

This study aimed to screen the feature modules and characteristic genes related to ulcerative colitis (UC) and construct a support vector machine (SVM) classifier to distinguish UC patients.

Methods

Four datasets that contained UC and control samples were obtained from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) with consistency were screened via the MetaDE method. The weighted gene coexpression network (WGCNA) was used to distinguish significant modules based on the four datasets. The protein–protein interaction network was established based on intersection genes. Enrichment analysis of Gene Ontology (GO) biological processes (BPs) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment were established based on DAVID. An SVM combined with recursive feature elimination was also applied to construct a disease classifier for the disease diagnosis of UC patients. The efficacy of the SVM classifier was evaluated through receiver operating characteristic curves.

Results

Twelve highly preserved modules were obtained using the WGCNA, and 2009 DEGs with significant consistency were selected using the MetaDE method. Sixteen significantly related GO BPs and 12 KEGG pathways were obtained, such as cytokine-cytokine receptor interaction, cell adhesion molecules, and leukocyte transendothelial migration. Subsequently, 41 genes were used to construct an SVM classifier, such as CXCL1, CCR2, IL1B, and IL1A. The area under the curve (AUC) was 0.999 in the training dataset, whereas the AUC was 0.886, 0.790, and 0.819 in the validation set (GSE65114, GSE37283, and GSE36807, respectively).

Conclusions

An SVM classifier based on feature genes might correctly identify healthy people or UC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01940-0.

Epidemiology and diagnosis of inflammatory bowel diseases

Background: Over the past three decades, inflammatory bowel diseases (IBD) have been rapidly increasing in the African, South American, and Asian countries, including Korea. However, in Korea, the public awareness of IBD remains low, and diagnostic delay is not uncommon due to the physicians' lack of clinical experience. It is essential to understand the trends and regional differences in the epidemiology of IBD for proper diagnosis and treatment.Current Concepts: Although lower than those of the West, the prevalence and incidence of IBD in Korea rank among the highest in Asia and are steadily increasing. In the past 10 years, the prevalence of IBD has almost doubled, while its incidence has decreased gradually. As compared to Western IBD patients, Korean patients have higher proportion of proctitis in ulcerative colitis, male predominance, more ileocolonic involvement, and higher incidence of perianal fistula in Crohn disease. There is no single gold standard for the diagnosis of IBD. Thus, diagnosis can be made by clinical evaluation, including a detailed history taking, physical examination, and a combination of endoscopic, radiologic, laboratory, and histologic findings.Discussion and Conclusion: Population-based studies have revealed the current trends and characteristics of the epidemiology of IBD in Korea. Continued education and development of diagnostic tools will help clinicians to diagnose IBD accurately and differentiate it from other diseases such as intestinal tuberculosis.

Diagnostic Delay Is Associated With Complicated Disease and Growth Impairment in Paediatric Crohn's Disease

BACKGROUND

Paediatric data on the association between diagnostic delay and inflammatory bowel disease [IBD] complications are lacking. We aimed to determine the effect of diagnostic delay on stricturing/fistulising complications, surgery, and growth impairment in a large paediatric cohort, and to identify predictors of diagnostic delay.

METHODS

We conducted a national, prospective, multicentre IBD inception cohort study including 1399 children. Diagnostic delay was defined as time from symptom onset to diagnosis >75th percentile. Multivariable proportional hazards [PH] regression was used to examine the association between diagnostic delay and stricturing/fistulising complications and surgery, and multivariable linear regression to examine the association between diagnostic delay and growth. Predictors of diagnostic delay were identified using Cox PH regression.

RESULTS

Overall (64% Crohn's disease [CD]; 36% ulcerative colitis/IBD unclassified [UC/IBD-U]; 57% male]), median time to diagnosis was 4.2 (interquartile range [IQR] 2.0-9.2) months. For the overall cohort, diagnostic delay was >9.2 months; in CD, >10.8 months and in UC/IBD-U, >6.6 months. In CD, diagnostic delay was associated with a 2.5-fold higher rate of strictures/internal fistulae (hazard ratio [HR] 2.53, 95% confidence interval [CI] 1.41-4.56). Every additional month of diagnostic delay was associated with a decrease in height-for-age z-score of 0.013 standard deviations [95% CI 0.005-0.021]. Associations persisted after adjusting for disease location and therapy. No independent association was observed between diagnostic delay and surgery in CD or UC/IBD-U. Diagnostic delay was more common in CD, particularly small bowel CD. Abdominal pain, including isolated abdominal pain in CD, was associated with diagnostic delay.

CONCLUSIONS

Diagnostic delay represents a risk factor for stricturing/internal fistulising complications and growth impairment in paediatric CD.

PODCAST

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