East-West gradient in the incidence of inflammatory bowel disease in Europe: the ECCO-EpiCom inception cohort

OBJECTIVE

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe. The reasons for these changes remain unknown. The aim of this study was to investigate whether an East-West gradient in the incidence of IBD in Europe exists.

DESIGN

A prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people was created. One-third of the centres had previous experience with inception cohorts. Patients were entered into a low cost, web based epidemiological database, making participation possible regardless of socioeconomic status and prior experience.

RESULTS

1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The overall incidence rate ratios in all Western European centres were 1.9 (95% CI 1.5 to 2.4) for CD and 2.1 (95% CI 1.8 to 2.6) for UC compared with Eastern European centres. The median crude annual incidence rates per 100,000 in 2010 for CD were 6.5 (range 0-10.7) in Western European centres and 3.1 (range 0.4-11.5) in Eastern European centres, for UC 10.8 (range 2.9-31.5) and 4.1 (range 2.4-10.3), respectively, and for IBDU 1.9 (range 0-39.4) and 0 (range 0-1.2), respectively. In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively, in Eastern Europe. 8% of CD and 1% of UC patients in both regions underwent surgery within the first 3 months of the onset of disease. 7% of CD patients and 3% of UC patients from Western Europe received biological treatment as rescue therapy. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy.

CONCLUSIONS

An East-West gradient in IBD incidence exists in Europe. Among this inception cohort--including indolent and aggressive cases--international guidelines for diagnosis and initial treatment are not being followed uniformly by physicians.

Applications of bismuth(III) compounds in organic synthesis

This review article summarizes the applications of bismuth(III) compounds in organic synthesis since 2002. Although there are an increasing number of reports on applications of bismuth(III) salts in polymerization reactions, and their importance is acknowledged, they are not included in this review. This review is largely organized by the reaction type although some reactions can clearly be placed in multiple sections. While every effort has been made to include all relevant reports in this field, any omission is inadvertent and we apologize in advance for the same (358 references).

High incidence of undetected neoplasia in maldescended testes

Testicular biopsy specimens from 4 (8%) of 50 men previously treated for maldescended testes had a carcinoma-in-situ pattern. 2 of these men had adjacent invasive carcinoma (seminoma and embryonal carcinoma). The patient with embryonal carcinoma had an enlarged testis but the 3 other patients with neoplasia had no clinical signs or symptoms of malignancy. Routine follow-up including testicular biopsy in young men with maldescended testes is essential because of the increased risk of malignancy and may detect testicular neoplasia at a stage when orchidectomy alone is curative.

Effect of puberty on rates of bone growth and mineralisation: with observations in male delayed puberty

The bone mineral content (BMC) and body height were measured in 301 normal children and adolescents aged 7--20 years, and in 8 boys with constitutional delayed puberty aged 14--17 years. Serum testosterone was measured in the last group as well as in a subpopulation of the normal children and adolescents. The growth spurt, which coincided with a steep increase of serum testosterone in boys, indicated a great change in skeletal growth and mineralisation in both sexes. After the growth spurt, linear growth slowed down considerably while bone mineralisation rose steeply. When low levels of serum testosterone were maintained, as in delayed puberty, these combined changes of skeletal growth and mineralisation did not occur. It is suggested that gonadal hormones are the true initiators of the short-lived growth spurt as well as of prolonged acceleration of bone mineralisation.

Environmental factors in a population-based inception cohort of inflammatory bowel disease patients in Europe--an ECCO-EpiCom study

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe possibly due to changes in environmental factors towards a more "westernised" standard of living. The aim of this study was to investigate differences in exposure to environmental factors prior to diagnosis in Eastern and Western European IBD patients.

METHODS

The EpiCom cohort is a population-based, prospective inception cohort of 1560 unselected IBD patients from 31 European countries covering a background population of 10.1 million. At the time of diagnosis patients were asked to complete an 87-item questionnaire concerning environmental factors.

RESULTS

A total of 1182 patients (76%) answered the questionnaire, 444 (38%) had Crohn's disease (CD), 627 (53%) ulcerative colitis (UC), and 111 (9%) IBD unclassified. No geographic differences regarding smoking status, caffeine intake, use of oral contraceptives, or number of first-degree relatives with IBD were found. Sugar intake was higher in CD and UC patients from Eastern Europe than in Western Europe while fibre intake was lower (p<0.01). Daily consumption of fast food as well as appendectomy before the age of 20 was more frequent in Eastern European than in Western European UC patients (p<0.01). Eastern European CD and UC patients had received more vaccinations and experienced fewer childhood infections than Western European patients (p<0.01).

CONCLUSIONS

In this European population-based inception cohort of unselected IBD patients, Eastern and Western European patients differed in environmental factors prior to diagnosis. Eastern European patients exhibited higher occurrences of suspected risk factors for IBD included in the Western lifestyle.

Ligand-Controlled Synthesis of Azoles via Ir-Catalyzed Reactions of Sulfoxonium Ylides with 2-Amino Heterocycles

An iridium-catalyzed method was developed for the synthesis of imidazo-fused pyrrolopyrazines. The presence or absence of a nitrogenated ligand controlled the outcome of the reaction, leading to simple β-keto amine products in the absence of added ligand and the cyclized 7- and 8-substituted-imidazo[1,2-a]pyrrolo[2,3-e]pyrazine products in the presence of ligand. This catalyst control was conserved across a variety of ylide and amine coupling partners. The substrate was shown to act as a ligand for the iridium catalyst in the absence of other ligands via NMR spectroscopy. Kinetic studies indicated that formation of the Ir-carbene was reversible and the slow step of the reaction. These mechanistic investigations suggest that the β-keto amine products form via an intramolecular carbene N-H insertion, and the imidazopyrrolopyrazines form via an intermolecular carbene N-H insertion.

Fundamental voice frequency measured by electroglottography during continuous speech. A new exact secondary sex characteristic in boys in puberty

The variation of fundamental voice frequency measured by the average of 2000 consecutive electroglottographic cycles in a reading situation has been examined in relation to pubertal development and androgens. Fundamental frequency among other parameters was related to height (r -0.82), pubic hair stage (r -0.87), testis volume (r -0.78), total testosterone (r -0.73) and serum hormone binding globulin (r 0.75). Single observations of fundamental frequency show a clear grouping of results under and over 200 Hz. Fundamental frequency of more than 200 Hz and serum testosterone of more than 10 nmol/l probably represent values for a boy in puberty. There seem to be comparable relations with other androgens and with serum hormone binding globulin.

Health-related quality of life improves during one year of medical and surgical treatment in a European population-based inception cohort of patients with inflammatory bowel disease--an ECCO-EpiCom study

BACKGROUND & AIMS

Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe.

METHODS

The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1 million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up.

RESULTS

In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population.

CONCLUSION

Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.

Bone mineral homeostasis, bone growth, and mineralisation during years of pubertal growth: a unifying concept

Serum calcium, magnesium proteins, phosphate, and immunoparathyroid hormone were measured in 338 normal children and adolescents aged between 7 and 20 years and in 123 normal adults aged between 21 and 50 years. Protein corrected serum calcium and magnesium remained stable throughout the study. Despite hyperphosphataemia protein corrected calcium exceeded the concentrations of normal adults. Serum phosphate and the Ca X P product greatly exceeded adult values and fell rather slowly towards adult levels after the pubertal growth spurt. Serum immunoparathyroid hormone tended to exceed normal adult values and was judged high for the level of serum calcium. Similarities between mineral metabolism in childhood an adolescence and in acromegaly were striking. On this basis in the light of studies demonstrating stimulatory actions of gonadal hormones on growth hormone and of growth hormone on the secretion of parathyroid hormone and 1,25-dihydroxyvitamin D3, a unifying concept is developed. This concept places growth hormone in the unique position of being the main driver and co-ordinator during childhood and adolescence of bone growth an mineralisation on the one hand, and of blood mineral homeostasis on the other. Gonadal hormones probably express some of their actions through stimulation of growth hormone secretion and others by different mechanisms. According to this concept growth hormone is maintaining th Ca X P product at a suitable high level as long as growth hormone and gonadal hormones deliver bone matrix for mineralisation at a high rate.

Longitudinal study of calcium metabolism in male puberty. II. Relationship between mineralization and serum testosterone

Height velocity, bone mineral content (BMC), serum concentrations of alkaline phosphatase (AP), testosterone, dehydroepiandrosterone (DHEA) and androstenedione (A-dione) were determined as a part of a longitudinal study of calcium metabolism in normal male puberty. The time of maximal increase (Tm) in concentrations was calculated for 20 boys from a curve-fitting analysis program. Highly significant correlations were found between Tm testosterone and Tm BMC (r = 0.73, p less than 0.001); Tm AP and Tm BMC (r = 0.68, p less than 0.001). The mean difference in time between Tm testosterone and Tm BMC was 4.7 months and between Tm AP and Tm testosterone 0.7 month. Our data indicate a very close relationship between testosterone, osteoblastic activity, and mineralization in normal male puberty, whereas the adrenal androgens do not seem to have a major influence on the mineralization at the male puberty growth spurt phase.

Pubertal growth as reflected by simultaneous changes in bone mineral content and serum alkaline phosphatase

Bone mineral content and total serum alkaline phosphatase were measured simultaneously in 230 normal children and adolescents aged 7-20 years. The bone mineral content showed almost no variation from the age of 7 to 13 in boys a,d 7 to 11 in girls. Thereafter a sharp increase was seen in both sexes with a highly significant sex difference between the mean values. Bone mineral content showed a fairly high correlation with age, height, weight, and surface area in boys. Before the time of the growth spurt, however, these variables were poorly correlated or not correlated at all. Concentrations of total serum alkaline phosphatase increased up to the age of 14 in boys and 11 in girls. Thereafter a rapid fall was seen in both sexes, the mean levels being significantly higher in boys. The fall approximated adult levels in boys by the age of 20 and in girls by 18. A significant negative correlation between bone mineral content and serum alkaline phosphatase was seen both in boys (r=0.71, p less than 0.001) and in girls (r=0.79, p less than 0.001).

Bone turnover in male puberty: a longitudinal study

In a longitudinal study of male puberty, 18 boys were examined every 3 months for at least 2 years. Serum bone Gla protein (BGP), a biochemical marker of bone formation, was determined and related to changes in serum testosterone (T), serum alkaline phosphatase (AP), serum calcitonin, and bone mineral content (BMC). The data demonstrate a steep increase in serum T during puberty (P less than 0.001), with an almost concomitant increase in serum BGP (P less than 0.001) and serum AP (P less than 0.001). Ten months after the maximal increase in serum T, the increase in BMC reached its maximum, whereas there was no significant change in the serum calcitonin. The data demonstrate that the steep increase in serum T during puberty, directly or indirectly, produces acute stimulation of bone formation (estimated from BGP and AP) followed by a highly significant increase in the integrated measurement of bone apposition (BMC).

Longitudinal study of calcium metabolism in male puberty. I. Bone mineral content, and serum levels of alkaline phosphatase, phosphate and calcium

With the purpose of studying calcium metabolism at the growth spurt phase in puberty, bone mineral content (BMC) of the forearm, and serum concentrations of total alkaline phosphatase, phosphate, and calcium were determined in 36 boys every three months for about 2 years. BMC increased 35% throughout the study age period of 10.6 to 14.6 years, with a maximal rate between 12.8 and 13.8 years. In relation to growth velocity BMC rose steepest during the 12 months around peak height velocity (PHV) (p less than 0.001) and showed a progressive increase from 3 months before the first pubic hair stage (PH2) to PH4 (p less than 0.001). Serum alkaline phosphatase increased by a total of 55% throughout the age period with a diminished rate of increase from 13.5 to 14 years, around the PHV, and from PH3 to PH4.

Cu(II)-catalyzed aerobic hydroperoxidation of Meldrum's acid derivatives and application in intramolecular oxidation: a conceptual blueprint for O2/H2 dihydroxylation

Aerobic hydroperoxidation of Meldrum's acid derivatives via a Cu(II)-catalyzed process is presented. The mild reaction conditions are tolerant to pendant unsaturation allowing the formation of endoperoxides via electrophilic activation. Cleavage of the O-O bond provides 1,n-diols with differentiation of the hydroxy groups.

Prevalence of antibodies to Epstein-Barr virus (EBV) in childhood and adolescence in Denmark

A seroepidemiologic survey on the prevalence of antibodies to Epstein-Barr virus (EBV) in Denmark was carried out. Sera from 518 children and 178 adults were investigated for IgG antibodies to the viral capsid antigen by an immunofluorescence assay. The proportion of subjects with antibodies increased from 15% at 1 yr to 60-65% in the 4-6 yr age group, was stationary at the age of 7-14, and then increased further progressively with age, to reach about 95% in late adulthood. Among preschool children a significantly higher prevalence rate was demonstrated in the lower socioeconomic stratum, as well as a somewhat higher prevalence rate in children attending day nurseries. The study indicates that infections with EBV have a rather early and widespread occurrence in this country compared with other developed areas.

Relationship between haemoglobin and serum testosterone in normal children and adolescents and in boys with delayed puberty

The concentrations of haemoglobin and of serum testosterone were measured in 215 normal children and adolescents aged 7--20 years, and in 8 boys with constitutional delayed puberty. From the age of 14 years onward haemoglobin and testosterone rose in normal boys and differed significantly from the stable levels observed in prepubertal children and pubertal girls. In the entire series of normal boys (n = 118, age 7--20 years) concentrations of haemoglobin and testosterone were found to be closely correlated (r = 0.73, p less than 0.001). These results provide further evidence for a major role of testosterone in the control of erythropoiesis. Therefore, this correlation suggests the use of serum testosterone determination for the proper selection of haemoglobin reference ranges in boys. The respective reference ranges of haemoglobin corresponding to testosterone levels at 0 and 30 nmol/l were 120.5--148.5 and 143.5--171.5 g/l (95% confidence limits). Boys with delayed puberty were found to have significantly reduced median values of haemoglobin and testosterone for their chronological age, and 6 of the 8 boys investigated were truly anaemic on this background. Nevertheless, their haemoglobin concentration did appear appropriate as judged from their testosterone levels. This observation supports the idea that the selection of the relevant reference range for haemoglobin in boys should depend on the state of physical development as expressed by serum testosterone.

Copper-Catalyzed Aerobic Oxidative Amidation of Benzyl Alcohols

A Cu-catalyzed synthesis of amides from alcohols and secondary amines using the oxygen in air as the terminal oxidant has been developed. The methodology is operationally simple requiring no high pressure equipment or handling of pure oxygen. The commercially available, nonprecious metal catalyst, Cu(phen)Cl₂, in conjunction with di-tert-butyl hydrazine dicarboxylate and an inorganic base provides a variety of benzamides in moderate to excellent yields. The pK_a of amine conjugate acid and electronics of alcohol were shown to impact the selection of base for optimal reactivity. A mechanism consistent with the observed reactivity trends, KIE, and Hammett study is proposed.

Health care and patients' education in a European inflammatory bowel disease inception cohort: an ECCO-EpiCom study

BACKGROUND AND AIMS

The EpiCom study and inception cohort was initiated in 2010 in 31 centers from 14 Western and 8 Eastern European countries, covering a 10.1million person background population. Our aim was to investigate whether there is a difference between Eastern and Western Europe in health care and education of patients with inflammatory bowel disease (IBD).

METHODS

A quality of care (QoC) questionnaire was developed in the EpiCom group consisting of 16 questions covering 5 items: time interval between the onset of symptoms and diagnosis, information, education, empathy and access to health care providers.

RESULTS

Of 1,515 patients, 947 (217 east/730 west) answered the QoC questionnaire. Only 23% of all patients had knowledge about IBD before diagnosis. In Eastern Europe, significantly more patients searched out information about IBD themselves (77% vs. 68%, p<0.05), the main source was the Internet (92% vs. 88% p=0.23). In Western Europe, significantly more patients were educated by nurses (19% vs. 1%, p<0.05), while in Eastern Europe, gastroenterologists were easier to contact (80% vs. 68%, p<0.05).

CONCLUSION

Health care differed significantly between Eastern and Western Europe in all items, but satisfaction rates were high in both geographic regions. Because of the low awareness and the rising incidence of IBD, general information should be the focus of patient organizations and medical societies. In Western Europe IBD nurses play a very important role in reducing the burden of patient management.

Serum levels of vitamin D metabolites and testosterone in male puberty

We determined the serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D [1,25-(OH)2D], 24,25-(OH)2D, and 25,26-(OH)2D every third month in a 2-yr longitudinal study of 20 normal pubertal boys. Seasonal fluctuations and highly significant correlations with the hours of sunshine were found for 25-hydroxyvitamin D, 24,25-(OH)2D and 25,26-(OH)2D, whereas the serum concentrations of 1,25-(OH)2D were not related to sunshine duration. The boys were grouped according to the time at which the maximal increase in serum testosterone occurred, and the serum vitamin D metabolite levels were examined in relation to this point. No significant changes in the serum levels of the vitamin D metabolites were found. When compiling the data according to clinical evaluation of puberty estimated by pubic hair stages (PH1 to PH4), no significant changes in the serum levels of vitamin D metabolites were found. The present data indicate that the marked increase in serum testosterone in male puberty has no significant influence on circulating vitamin D metabolite levels.

Gonadotropin-releasing hormone (LH-RH) and human chorionic gonadotropin in the treatment of two boys with hypogonadotrophic hypogonadism

Two brothers, 16 and 14 years of age, with hypogonadotrophic hypogonadism and anosmia were treated with subcutaneous injections of 200 microng gonadotropin-releasing hormone at 8-hour intervals for 4 weeks. Serum FSH increased to the range of normal adult men, but serum LH and serum testosterone showed little change and no clinical signs of pubertal development occurred. Thereafter the 2 patients were given HCG for 11 months and a combination of HCG and HMG for a further 3 months. In response to this treatment, the serum testosterone levels increased to the range of normal adult men and marked development of the secondary sex characteristics was seen.

Treatment of girls with excessive height prediction. Follow-up of forty girls treated with intramuscular estradiol and progesterone

In a follow-up study of 40 tall girls treated with intramuscular estradiol and progesterone, the final height, bone age maturation, side effects and acceptance of treatment were evaluated. The mean duration of treatment was 18 months. During treatment, mean height increase was 6.5 cm (height velocity 3.7 cm/year), which is nearly 50% reduction of normal growth rate. The mean increase in bone age was 2.7 years (bone age velocity 1.8 years/year), which approximates twice the normal maturation rate. The mean reduction in final height was 5.0 cm as evaluated by the method of Bayley. Pinneau (BP), 2.9 cm by the method of Tanner et al. (TW) and 3.0 cm by the method of Roche et al. (RWT). The reduction was greatest when treatment was started before menarche, according to all three prediction methods. When treatment was started after menarch the calculated height reduction was greatest according to the BP method. There was good agreement between the three prediction methods in girls with a bone age below 12 years before treatment. In girls with a bone age above 12 years the height reduction by the BP method was much greater than when measured by the other methods. Side effects evaluated at follow-up were minimal and first menstruation occurred within 3 months (mean) after cessation of treatment. The number of pregnancies was estimated to be normal for age. All but three accepted the treatment. It is concluded that this type of treatment must be restricted to girls with severe psychological problems due to excessive height prognosis and selection for treatment must be based on an individualized evaluation.