[Aspects of pulmonary involvement in inflammatory bowel disease]

The incidence of pulmonary manifestations of inflammatory bowel disease (IBD) appears to be much higher than previously assumed. In prospective studies, subclinical pulmonary interstitial infiltrates or pathological lung function were found in 40%-60% of IBD patients, both in children and adults. Pulmonary disorders can affect any part of the respiratory system, the most frequent pattern being inflammation of the large airways often associated with bronchiectasis. The differential diagnosis should include drug-related pulmonary disease and infectious causes when receiving immunosuppressive therapy. The diagnostic approach consists of a thorough history and clinical status as well as lung function tests including body plethysmography and high-resolution computed tomography of the thorax. Bronchoscopy with broncheoalveolar lavage and sample collection for histology as well as exclusion of pulmonary embolism may be indicated. Pulmonary disease in association with IBD can develop at any time during the course of IBD: in rare cases, symptoms can evolve even before gastrointestinal symptoms appear. On the other hand, there are frequent reports on the occurrence of pulmonary inflammation after proctocolectomy in patients with ulcerative colitis. The pathophysiologic background is largely unknown, but there seems to be an interaction between gastrointestinal and pulmonary inflammation. The mainstay of therapy are inhaled or systemic corticosteroids. Most patterns of pulmonary involvement in IBD respond well to corticosteroid therapy. Rarely, serious and persisting complications occur, such as strictures or stenosis of the large airways.

Knockdown of A-kinase anchor protein 4 inhibits hypoxia-induced epithelial-to-mesenchymal transition via suppression of the Wnt/β-catenin pathway in human gastric cancer cells

Hypoxia induces epithelial-mesenchymal transition (EMT) in tumorigenesis. A-kinase anchor protein 4 (AKAP4) is a member of AKAPs family and plays a critical role in tumorigenesis. However, the biological role of AKAP4 in gastric cancer remains unknown. Thus, we investigated the effect of AKAP4 on EMT in human gastric cancer cells under hypoxic conditions. Our results showed that AKAP4 expression was significantly upregulated in human gastric cancer cell lines. In addition, silenced expression of hypoxia-inducible factor-1α markedly suppressed AKAP4 expression in gastric cancer cells under hypoxia. Furthermore, knockdown of AKAP4 significantly prevented hypoxia-induced migration, invasion, and EMT process in gastric cancer cells. Mechanistically, knockdown of AKAP4 prevented the activation of the Wnt/β-catenin pathway in gastric cancer cells under hypoxia condition. These findings indicate that knockdown of AKAP4 inhibits hypoxia-induced EMT in human gastric cancer cells, at least in part, via inactivation of the Wnt/β-catenin signaling pathway. It is, therefore, AKAP4 may be a potential therapeutic target for the treatment of gastric cancer.

Assessment of Quality of Life in Chinese Patients With Inflammatory Bowel Disease and their Caregivers

BACKGROUND

Chronic diseases such as inflammatory bowel disease (IBD) usually affect the psychological status and health-related quality of life (HRQOL) of patients and their caregivers. The aim of this study was to evaluate the level of anxiety, depression, and HRQOL and find the risk factors predictive of HRQOL in IBD patients and their caregivers in a Chinese population.

METHODS

One hundred four adult patients with IBD, 102 family caregivers, and 99 healthy controls were enrolled. They completed self-administered surveys related to QOL and psychological questionnaires, including the Short Inflammatory Bowel Disease Questionnaire (patients only), the Short Form-36 Health Survey (SF-36), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS).

RESULTS

Both the mean SAS total score and the mean SDS total score among the patients and the caregivers were found to be significantly higher than those among the general population (P < 0.05). Total SF-36 score was significantly different between the patients and the general population (P = 0.001), and between caregivers and the general population (P = 0.011). The result showed that the total SF-36 score of the patients had a significant negative correlation with SAS score in the patients (P = 0.040), SDS score in the patients (P = 0.004), annual income (P = 0.036), use of biologicals (P = 0.028), frequency of hospitalization in the last year (P = 0.033), and severity of IBD (P = 0.021). The total SF-36 score of the caregivers was significantly and negatively correlated with SDS score in the caregivers (P = 0.010), SDS score in the patients (P = 0.010), use of biologicals (P = 0.013), and frequency of hospitalization in the last year (P = 0.010) of the patients.

CONCLUSIONS

A large proportion of IBD patients and their caregivers experience a high level of anxiety and depression and an impaired HRQOL. Higher levels of anxiety and depression, annual income, use of biologicals, higher frequency of hospitalization in the last year, and disease activity were independent predictors of reduced patient HRQOL; higher levels of depression in both caregivers and patients, use of biologicals, and frequency of hospitalization in the last year of the patients were independent predictors of reduced caregiver HRQOL.

Tanshinone IIA inhibits cell proliferation and tumor growth by downregulating STAT3 in human gastric cancer

Gastric cancer is the third leading cause of cancer-associated deaths worldwide. Research into the underlying mechanisms of gastric cancer is essential for the development of novel therapeutic agents to improve the prognoses of patients with gastric cancer. Tanshinone IIA (Tan IIA) is the pure extract of Danshen root (Salvia miltiorrhiza) and has been report to inhibit the proliferation of gastric cancer cells; however, the intrinsic underlying mechanisms remain unclear. The aim of the present study was to investigate whether Tan IIA has a direct anti-cancer effect in gastric cancer cells and determine the underlying mechanisms responsible. The results revealed that Tan IIA effectively inhibits proliferation in three human gastric cancer cell lines (SNU-638, MKN1 and AGS) in a time- and dose-dependent manner. Furthermore, Tan IIA treatment induced an increase in apoptosis, B-cell lymphoma (Bcl-2)-associated protein X expression and cleaved caspase-3 levels, as well as a decrease in Bcl-2 expression. Treatment with Tan IIA inhibited Furthermore, treatment with Tan IIA significantly inhibited the phosphorylation of signal transducer and activator of transcription 3 (STAT3), which may be responsible for the changes in apoptosis gene expression. However, overexpression of STAT3 significantly ameliorated the Tan IIA-induced suppression of cell growth and apoptosis. A nude mouse xenograft model was constructed and the results revealed that intraperitoneal Tan IIA treatment for 28 days significantly inhibited tumor growth and STAT3 activation. The results of the present study suggest that Tan IIA exerts potent anti-cancer activity in gastric cancer cells and this effect is mediated by the downregulation of STAT3 activation.

Non-invasive in vivo Imaging Grading of Liver Fibrosis

Liver fibrosis (LF), a common consequence of chronic liver diseases with various etiologies, is characterized by excessive accumulation of macromolecules, including collagen, glycoproteins and proteoglycans, in the liver. LF can result in hepatic dysfunction, cirrhosis, portal hypertension and, in some cases, hepatocellular carcinoma. As the current gold standard for diagnosing LF, liver biopsy, however, is invasive and prone to sampling errors and procedure-related complications. Therefore, developing noninvasive, precise and reproducible imaging tests for diagnosing and staging LF is of great significance. Conventional ultrasound (US), computed tomography (CT) and magnetic resonance (MR) imaging can depict morphological alterations of advanced LF, but have relatively limited capability characterizing early-stage LF. In order to optimize the diagnostic performances of noninvasive imaging techniques for LF across its entire spectrum of severity, a number of novel methods, including US elastography, CT perfusion imaging and various MR imaging-based techniques, have been established and introduced to clinical practice. In this review, we intended to summarize current noninvasive imaging techniques for LF, with special emphasis on the possible roles, advantages and limitations of the new emerging imaging modalities.

The prevalence and phenotype in Brazilian patients with inflammatory bowel disease

Background

The epidemiology of inflammatory bowel disease (IBD) varies in different countries. This study aimed to assess phenotype, medications, prevalence and incidence of IBD in the State of Espírito Santo, Brazil.

Methods

Patients with IBD who utilized the Public Medication-Dispensing System of the Department of Health of Espírito Santo, between August 2012 and July 2014. Of 1484 active patients, 1048 were analyzed, which included patients of all ages.

Results

The prevalence of IBD was 38.2 per 100,000 inhabitants, with ulcerative colitis (UC) being 24.1 per 100,000 and Crohn’s disease (CD), 14.1 per 100,000. The incidence of IBD was 7.7 per 100,000 inhabitants/year (UC – 5.3/100,000 inhabitants/year and CD – 2.4/100,000 inhabitants/year). Out of the 1048 patients analyzed, 669 had UC (63.84%), 357 had CD (34.06%), and 22 had unclassified inflammatory bowel disease (UIBD; 2.10%). There were 48/1048 (4.5%) pediatric patients (16 years of age or younger). On the UC phenotype (n = 654), we observed left-sided colitis in 247 (37.7%), pancolitis in 209 (31.9%), and proctitis in 198 patients (30.2%). Pancolitis was more frequent in pediatric patients (p = 0.007). CD showed a homogeneous distribution between ileitis (L1), colitis (L2), and ileocolitis (L3). Regarding the CD behavior (n = 352) observed the inflammatory type (B1) in 176 (50%); fistulizing (B3) in 75 (21.2%), isolated type (B3) in 29 (8.2%), and perianal fistulizing type (B3p) in 46 (13.1%). Biologic therapies were used in 154/357 (43.3%).

Conclusion

The prevalence of the IBD in the state of Espírito Santo, Brazil was higher than in two other brazilian studies. There was high utilization of biologic therapies in patients with CD.

Quality of care in inflammatory bowel diseases: What is the best way to better outcomes?

Inflammatory bowel disease (IBD) is a lifelong, progressive disease that has disabling impacts on patient's lives. Given the complex nature of the diagnosis of IBD and its management there is consequently a large economic burden seen across all health care systems. Quality indicators (QI) have been created to assess the different façades of disease management including structure, process and outcome components. Their development serves to provide a means to target and measure quality of care (QoC). Multiple different QI sets have been published in IBD, but all serve the same purpose of trying to achieve a standard of care that can be attained on a national and international level, since there is still a major variation in clinical practice. There have been many recent innovative developments that aim to improve QoC in IBD including telemedicine, home biomarker assessment and rapid access clinics. These are some of the novel advancements that have been shown to have great potential at improving QoC, while offloading some of the burden that IBD can have vis-a-vis emergency room visits and hospital admissions. The aim of the current review is to summarize and discuss available QI sets and recent developments in IBD care including telemedicine, and to give insight into how the utilization of these tools could benefit the QoC of IBD patients. Additionally, a treating-to-target structure as well as evidence surrounding aggressive management directed at tighter disease control will be presented.

Impact of Biologic Treatment of Crohn's Disease on the Rate of Surgeries and Other Healthcare Resources: An Analysis of a Nationwide Database From Poland

Background: There is conflicting evidence on the impact of biologic treatment on the rate of complications and surgeries in Crohn’s disease (CD). We aimed to assess real-world consequences of biologic treatment of CD.

Methods: All adult patients with CD treated with infliximab and adalimumab in the years 2012–2014 were identified from the database of the National Health Fund in Poland. Mixed models were used to assess the impact of biologics on medical resource utilization by comparing the periods before and after the first use of biologics (pre-index vs. post-index). The additional analyses including quintile of total exposure to biologic treatment were performed.

Results: Data on 1393 patients (age, 31.9 years; males, 52.6%) were analyzed over a median of 1064 days (range: 71, 1148). During the post-index period, patients received from one to four treatments with biologic agents (maximum allowed period of 12 months per treatment). We observed a reduction in the rates of surgeries (by 27%, p = 0.001), hospitalizations for CD excluding surgical procedures (by 45%, p < 0.001), as well as consumption of antibiotics (by 31%, p < 0.001) and steroids (by 35%, p < 0.001) in the post-index compared with the pre-index period. The reduction in the rate of surgeries, hospitalizations for CD, and steroid intake increased with the increase of exposure to biologic agents.

Conclusion: Biologic treatment changed the management patterns by lowering the rate of surgeries and other healthcare resources related to complications or worsening of CD. The reduction in the resource utilization was dependent on the level of exposure to treatment, suggesting that limitation of the treatment period itself may be inadequate.

Epidemiology and clinical course of inflammatory bowel disease in the Central Province of Sri Lanka: A hospital-based study

Background and Aim

There is increasing prevalence of inflammatory bowel disease (IBD) in Asia, but Sri Lankan data on the state of epidemiology and clinical course of IBD are scarce.

Methods

A hospital‐based study was done by recruiting IBD patients who permanently reside in the Central Province (population 2.57 million, 12.6% of Sri Lankan population) of Sri Lanka. Cases were confirmed by standard criteria and data were collected from health records and patient interviews at clinic visits and hospital admissions.

Results

There were 200 cases of IBD; (ulcerative colitis [UC]—140, Crohn's disease [CD]—60, microscopic colitis—7). The crude prevalence rate of UC was 5.44/100 000 (95% CI 5.41–5.47/100 000) and CD was 2.33/100 000 (95% CI 2.31–2.35/100 000). Female to male ratios were 1:0.8 for UC but 1:1.5 for CD.

Mean age at diagnosis was 42.0 and 31.9 years for UC and CD, respectively. One UC and one CD patient had positive family history of IBD. Among the UC patients, 60.7%, 24.3%, and 15% had proctitis, left sided, and extensive disease, respectively. At presentation, 62.1% of the UC patients have had moderately severe disease. 60% of the CD patients had only large bowel involvement and 80% had nonstricturing and nonpenetrating disease. Extra intestinal manifestations were present in 45.7% and 60.0% of UC and CD patients, respectively, in which peripheral arthralgia and arthritis being the commonest. 6.4% of UC and 23.3% of the CD patients (total of 23) required infliximab for induction of remission.

Conclusion

The prevalence of IBD in the Central Province of Sri Lanka is lower than other Asian and Western populations. There is a predominance of male gender and isolated colonic disease in CD patients. UC patients have an equal gender distribution and a higher proportion of proctitis. CD needed induction with infliximab than UC.

Promoter methylation of the MGAT3 and BACH2 genes correlates with the composition of the immunoglobulin G glycome in inflammatory bowel disease

BACKGROUND

Many genome- and epigenome-wide association studies (GWAS and EWAS) and studies of promoter methylation of candidate genes for inflammatory bowel disease (IBD) have demonstrated significant associations between genetic and epigenetic changes and IBD. Independent GWA studies have identified genetic variants in the BACH2, IL6ST, LAMB1, IKZF1, and MGAT3 loci to be associated with both IBD and immunoglobulin G (IgG) glycosylation.

METHODS

Using bisulfite pyrosequencing, we analyzed CpG methylation in promoter regions of these five genes from peripheral blood of several hundred IBD patients and healthy controls (HCs) from two independent cohorts, respectively.

RESULTS

We found significant differences in the methylation levels in the MGAT3 and BACH2 genes between both Crohn's disease and ulcerative colitis when compared to HC. The same pattern of methylation changes was identified for both genes in CD19+ B cells isolated from the whole blood of a subset of the IBD patients. A correlation analysis was performed between the MGAT3 and BACH2 promoter methylation and individual IgG glycans, measured in the same individuals of the two large cohorts. MGAT3 promoter methylation correlated significantly with galactosylation, sialylation, and bisecting GlcNAc on IgG of the same patients, suggesting that activity of the GnT-III enzyme, encoded by this gene, might be altered in IBD. The correlations between the BACH2 promoter methylation and IgG glycans were less obvious, since BACH2 is not a glycosyltransferase and therefore may affect IgG glycosylation only indirectly.

CONCLUSIONS

Our results suggest that epigenetic deregulation of key glycosylation genes might lead to an increase in pro-inflammatory properties of IgG in IBD through a decrease in galactosylation and sialylation and an increase of bisecting GlcNAc on digalactosylated glycan structures. Finally, we showed that CpG methylation in the promoter of the MGAT3 gene is altered in CD3+ T cells isolated from inflamed mucosa of patients with ulcerative colitis from a third smaller cohort, for which biopsies were available, suggesting a functional role of this glyco-gene in IBD pathogenesis.

The Importance of Sex Stratification in Autoimmune Disease Biomarker Research: A Systematic Review

The immune system is highly dynamic and regulated by many baseline characteristic factors. As such, significant variability may exist among different patient groups suffering from the same autoimmune disease (AD). However, contemporary research practices tend to take the reductionist aggregate approach: they do not segment AD patients before embarking on biomarker discovery. This approach has been productive: many novel AD biomarkers have recently been discovered. Yet, subsequent validation studies of these biomarkers tend to suffer from a lack of specificity, sensitivity, and reproducibility which hamper their translation for clinical use. To enhance reproducibility in validation studies, an optimal discovery-phase study design is paramount: one which takes into account different parameters affecting the immune system biology. In this systematic review, we highlight need for stratification in one such parameter, i.e., sex stratification. We will first explore sex differences in immune system biology and AD prevalence, followed by reported sex-bias in the clinical phenotypes of two ADs—one which more commonly affects females: systemic lupus erythematosus, and one which more commonly affects males: ankylosing spondylitis. The practice of sex stratification in biomarker research may not only advance the discovery of sex-specific AD biomarkers but more importantly, promote reproducibility in subsequent validation studies, thus easing the translation of these novel biomarkers from bench to bedside to improve AD diagnosis. In addition, such practice will also promote deeper understanding for differential AD pathophysiology in males and females, which will be useful for the development of more effective interventions for each sex type.

Epidemiology of inflammatory bowel disease in Málaga: incidence rate and follow-up of a cohort diagnosed between 2007-2008

BACKGROUND AND OBJECTIVES

The incidence of inflammatory bowel disease (IBD) in Spain has been traditionally lower than in Northern European countries. Recent epidemiological studies have found that these differences are diminishing. This study estimates the incidence of IBD in Málaga (Spain), a city in Southern Spain and relates its results to those found in our neighboring countries.

MATERIAL AND METHODS

This was a prospective study designed to collect new cases diagnosed during the period from 2007-2008 and follow up these patients. Incidence is expressed as number of patients per 100,000 population per year. The population distribution found in the European Collaborative Study was used to standardize incidence rates.

RESULTS

The gross incidence rate of IBD in Málaga is 9/105, the standardized incidence rate is 12.3/105 (9.7-15.6).

CONCLUSIONS

These data are similar to those found in our surroundings, although a higher incidence rate for Crohn's disease (CD) as compared to ulcerative colitis (UC) was found. The clinical characteristics and outcomes of our patients do not differ significantly from those described for other populations.

What Will We Expect From Novel Therapies to Esophageal and Gastric Malignancies?

Esophageal cancer and gastric cancer are aggressive diseases for which treatment approaches are facing a new era. Some molecular pathways, such as VEGF, EGFR, fibroblast growth factor receptor, PIK3CA, and PARP-1, have been studied, and novel targeted drugs are presumed to be developed in the near future. From The Cancer Genome Atlas report, 80% of Epstein-Barr virus tumors and 42% of tumors with microsatellite instability have PIK3CA mutations, suggesting that this pathway could be reevaluated as a possible target for new systemic treatment of gastric cancer. Notably, higher PARP-1 expression can be found in gastric cancer, which might be related to more advanced disease and worse prognosis. In addition, PD-L1 expression, high microsatellite instability, and mismatch repair deficiency can be found in gastric cancer, thus suggesting that immunotherapy may also play a role in those patients. We discuss trends related to the potential of novel therapies for patients with esophageal and gastric cancers in the near future.

Diagnosis of Helicobacter pylori Using Invasive and Noninvasive Approaches

Helicobacter pylori (H. pylori) as gram-negative and spiral microorganism is responsible for colonization in the gastric microniche for more than 50% of world population. Recent studies have shown a critical role of H. pylori in the development of peptic ulcers, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric cancer. Over the past decade, there has been a sharp interest to use noninvasive tests in diagnosis of the H. pylori infection. During the years after discovery by Marshall and Warren, it has been frequently declared that the rapid urease test (RUT) is one of the cheapest and rapid diagnostic approaches used in detecting the infection. Although the specificity and sensitivity are durable for this test, clinical experiences had shown that the ideal results are only achieved only if we take biopsies from both corpus and antrum at the same time. Given the diagnosis of the H. pylori in clinical samples, gastroenterologists are facing a long list of various molecular and nonmolecular tests. We need more in-depth researches and investigations to correctly generalize rapid and accurate molecular tests determining both bacterial identity and antibiotic resistance profile.

Sex-Related Differences in Patients With Inflammatory Bowel Disease: Results of 2 Prospective Cohort Studies

BACKGROUND

The understanding of gender differences in inflammatory bowel disease (IBD) patients is an important step towards tailored treatment for the individual patient. The aim of this study was to compare disease phenotype, clinical manifestations, disease activity, and healthcare utilization between men and women with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

Two multicenter observational cohort studies with a prospective design were used to explore the differences between men and women regarding demographic and phenotypic characteristics and healthcare utilization. Detailed data on IBD-phenotype was mainly available from the Dutch IBD Biobank, while the COIN cohort provided healthcare utilization data.

RESULTS

In the Dutch IBD Biobank study, 2118 CD patients and 1269 UC patients were analyzed. Female CD patients were more often current smokers, and male UC patients were more often previous smokers. Early onset CD (<16 years) was more frequently encountered in males than in females (20% versus 12%, P < 0.01). Male CD patients were more often diagnosed with ileal disease (28% versus 20%, P < 0.01) and underwent more often small bowel and ileocecal resection. Extraintestinal manifestations (EIMs) were more often encountered in female IBD patients. In the COIN study, 1139 CD patients and 1213 UC patients were analyzed. Male CD patients used prednisone more often and suffered more often from osteopenia. IBD-specific healthcare costs did not differ between male and female IBD patients.

CONCLUSIONS

Sex differences in patients with IBD include age of onset, disease location, and EIM prevalence. No large differences in therapeutic management of IBD were observed between men and women with IBD. 10.1093/ibd/izy004_video1izy004_Video_15786481854001.

The composition and variation of the BCR CDR3s in gastric cancer

Gastric cancer (GC) is the fourth most common type of cancer and the second most common cause of cancer-associated mortality worldwide. B cell-associated autoantibodies against tumor-associated antigens are attractive biomarkers for the development of noninvasive serological tests for the early detection of cancer. This is due to their specificity and stability in the sera. In the present study multiplex polymerase chain reaction and Illumina high-throughput sequencing (HTS) was used to study the composition and variation of the B cell receptor (BCR) complimentary-determining region 3 (CDR3) in GC. The peripheral blood, cancer tissues and peri-cancer tissues were included from 7 patients with GC. On average there was a total of 403,959 CDR3 sequences, with 72,367 unique CDR3 nt sequences and 61,709 unique CDR3 aa sequences per sample identified, which are critical for further understanding the BCR repertoire in GC. The details of GC CDR3s may accelerate the screening process for possible new autoantigens and may provide additional information necessary for generating effective B cell targeted diagnosis and therapeutic strategies.

Changes in liver stiffness and steatosis among patients with hepatitis C virus infection who received direct-acting antiviral therapy and achieved sustained virological response

AIM

Whether direct-acting antiviral (DAA) therapy can reduce liver fibrosis and steatosis in patients with chronic hepatitis C virus (HCV) infection remains unclear. We evaluated sequential changes in liver stiffness and steatosis using transient elastography (TE) and the TE-based controlled attenuation parameter (CAP) in patients with HCV who received DAA therapy.

PATIENTS AND METHODS

A total of 57 patients with HCV who received DAA therapy and achieved sustained virological response (SVR) were analyzed. Liver stiffness as evaluated with TE, steatosis as evaluated with CAP, and laboratory data were assessed before treatment (baseline), at end of treatment (EOT), 24 weeks after EOT (SVR24), and 48 weeks after EOT (SVR48).

RESULTS

Alanine aminotransferase levels, corresponding to the presence of necroinflammatory activity, significantly decreased overall, with significant differences between baseline and EOT, EOT, and SVR24, and baseline and SVR48. However, alanine aminotransferase levels showed no significant changes between SVR24 and SVR48. Median (interquartile range) liver stiffness values at baseline, EOT, SVR24, and SVR48 were 8.3 (5.0-14.8), 7.4 (4.6-14.7), 5.3 (4.1-11.8), and 5.4 (4.0-13.4) kPa, respectively (baseline vs. EOT, P=0.044; EOT vs. SVR24, P=0.011; and SVR24 vs. SVR48, P=0.054). In patients with fatty liver (CAP≥236 dB/m, n=14), CAP values at baseline and SVR48 were 253 (245-278) and 229 (209-249) dB/m, respectively (P=0.020).

CONCLUSION

Liver stiffness at SVR24 might reflect liver fibrosis in the patients who received DAA therapy and achieved SVR. In addition, liver steatosis reduces in the same cohort with fatty liver.

Validation of the 'United Registries for Clinical Assessment and Research' [UR-CARE], a European Online Registry for Clinical Care and Research in Inflammatory Bowel Disease

BACKGROUND

The 'United Registries for Clinical Assessment and Research' [UR-CARE] database is an initiative of the European Crohn's and Colitis Organisation [ECCO] to facilitate daily patient care and research studies in inflammatory bowel disease [IBD]. Herein, we sought to validate the database by using fictional case histories of patients with IBD that were to be entered by observers of varying experience in IBD.

METHODS

Nineteen observers entered five patient case histories into the database. After 6 weeks, all observers entered the same case histories again. For each case history, 20 key variables were selected to calculate the accuracy for each observer. We assumed that the database was such that ≥ 90% of the entered data would be correct. The overall proportion of correctly entered data was calculated using a beta-binomial regression model to account for inter-observer variation and compared to the expected level of validity. Re-test reliability was assessed using McNemar's test.

RESULTS

For all case histories, the overall proportion of correctly entered items and their confidence intervals included the target of 90% (Case 1: 92% [88-94%]; Case 2: 87% [83-91%]; Case 3: 93% [90-95%]; Case 4: 97% [94-99%]; Case 5: 91% [87-93%]). These numbers did not differ significantly from those found 6 weeks later [NcNemar's test p > 0.05].

CONCLUSION

The UR-CARE database appears to be feasible, valid and reliable as a tool and easy to use regardless of prior user experience and level of clinical IBD experience. UR-CARE has the potential to enhance future European collaborations regarding clinical research in IBD.

Reduced Risk of Inflammatory Bowel Disease-associated Colorectal Neoplasia with Use of Thiopurines: a Systematic Review and Meta-analysis

BACKGROUND AND AIMS

The association between thiopurines and colorectal neoplasia risk remains controversial in inflammatory bowel disease [IBD] patients. We performed a systematic review and meta-analysis examining this association.

METHODS

A comprehensive search of the PubMed, EMBASE and Cochrane Library databases was performed to identify relevant literature. Random-effects models were applied to calculate the pooled odds ratio [OR] and relative risk [RR] with corresponding 95% confidence intervals [CIs] among case-control and cohort studies.

RESULTS

Eleven cohort and 16 case-control studies involving 95397 patients were included in this study. Overall, the use of thiopurines was associated with a reduced risk of colorectal neoplasia both in case-control [OR = 0.49, 95% CI: 0.34-0.70] and cohort studies [RR = 0.96, 95% CI: 0.94-0.98]. Moreover, a protective effect of thiopurines against advanced neoplasia [high-grade dysplasia and cancer] [OR = 0.51, 95% CI: 0.31-0.84 for case-control studies; RR = 0.96, 95% CI: 0.94-0.98 for cohort studies] and colorectal cancer [CRC] [OR = 0.56, 95% CI: 0.34-0.93 for case-control studies; RR = 0.96, 95% CI: 0.94-0.98 for cohort studies] was also observed. Furthermore, when the analysis was conducted on patients at a high risk for colorectal neoplasia, the chemopreventive effect was confirmed in patients with long disease duration [> 8 years] but not in those with extensive colitis or primary sclerosing cholangitis.

CONCLUSIONS

This study demonstrated that thiopurine use was associated with a reduced risk of colorectal neoplasia, advanced neoplasia and CRC in IBD patients, especially those with long disease duration [> 8 years].

Quality of Life in Inflammatory Bowel Disease: A Systematic Review and Meta-analyses-Part II

BACKGROUND

There has been burgeoning interest in quality of life (QoL) in inflammatory bowel disease (IBD) in recent decades, with hundreds of studies each year now assessing this outcome. This paper is part 2 of a systematic review evaluating 5 key QoL comparisons within IBD states and relative to others without IBD. Part 1 examined QoL comparing IBD and a healthy/general population and other medically ill groups. Part 2, presented here, examines within-disease comparisons of active/inactive disease, Ulcerative colitis (UC) / Crohn's disease (CD), and change in QoL over time. Outcomes using generic versus IBD-specific QoL measures were also examined.

METHODS

Adult and pediatric studies were identified through systematic searches of 7 databases from the 1940s (where available) to October 2015.

RESULTS

Of 6173 abstracts identified, 466 were selected for final review based on controlled design and validated measurement, of which 83 unique studies (75 adult, 8 pediatric) addressed the within-disease comparisons. The pooled mean QoL scores were significantly lower in active versus inactive IBD (n = 26) and for those with CD versus UC (n = 37), consistent across IBD-specific and generic QoL measures, for almost all comparisons. There was significant improvement in QoL over time (n = 37). Study quality was generally low to moderate. The most common measures of QoL were the disease-specific Inflammatory Bowel Disease Questionnaire and generic 36-Item Short Form Survey (SF-36) (adults) and the IBD-specific IMPACT (children).

CONCLUSIONS

For adults in particular, there was strong confirmation that QoL is poorer during active disease and may be poorer for those with CD. The finding that QoL can improve over time may be encouraging for individuals with this chronic disease.

Effect of Meal Ingestion on Liver Stiffness and Controlled Attenuation Parameter

Background and Aims

Despite the increasing use of noninvasive methods for the assessment of liver fibrosis and steatosis, the effect of fasting and food intake on these parameters is not yet clear. Our aims were to evaluate the effect of food intake on liver stiffness (LS) (measured by transient elastography) and controlled attenuation parameter (CAP) in patients with different degrees of liver disease and healthy volunteers, and secondarily, to assess possible factors associated with variations of LS and CAP.

Methods

We performed a prospective single-center study including patients with liver disease and healthy volunteers. LS and CAP were evaluated using FibroScan® (Echosens, Paris, France), before (fasting ≥8 h) and 30 min after intake of a standardized breakfast. We used common cutoffs for LS: > 7 kPa for significant fibrosis (F2 to F4) and > 11 to 14 kPa (mean 12.5 kPa) for cirrhosis.

Results

Fifty-nine (72%) patients with liver disease and 22 (28%) healthy volunteers were included. LS significantly increased 30 min after food intake (pre-meal 6.1 kPa [IQR: 4.7-9.8] vs. after-meal 6.8 kPa [IQR: 5.5-10.6]; p < 0.001). This difference was only significant in patients with chronic liver disease (p = 0.02) and not in healthy volunteers (p = 0.106). CAP values did not increase significantly after food intake. Gender, body mass index, mass of body fat, lean body mass, and percent of body fat were not related with significant variations of LS and CAP values after meal intake.

Conclusions

Significant variations of LS were observed after ingestion of a standard meal, which may have consequences for patient management. CAP values were not significantly affected by food intake. Therefore, we consider that before the isolated evaluation of CAP, it is not necessary to perform any fasting period.

Phase II Study to Evaluate the Efficacy and Safety of Rilotumumab and Bevacizumab in Subjects with Recurrent Malignant Glioma

Lessons Learned.

Due to evolving imaging criteria in brain tumors and variation in magnetic resonance imaging evaluation, it is not ideal to use response rate as a primary objective. Future studies involving antiangiogenic agents should use overall survival.

Disease‐expected toxicities should be considered when defining the clinical significance of an adverse event. For example, vascular thromboembolic events are common in brain tumor patients and should not be attributed to the study drug in the safety analysis.

Background.

Recurrent malignant glioma (rMG) prognosis is poor, with a median patient survival of 3–11 months with bevacizumab (BEV)‐containing regimens. BEV in rMG has 6‐month progression free survival (PFS‐6) of ∼40% and an objective response rate of 21.2%. BEV‐containing regimens improve PFS‐6 to 42.6%–50.3%, indicating that BEV combination therapies may be superior to single agent. Rilotumumab, a hepatocyte growth factor (HGF) antibody, inhibits angiogenesis and expression of angiogenic autocrine factors (e.g., vascular endothelial growth factor [VEGF]) by c‐Met inhibition. Combination of rilotumumab with BEV to block vascular invasion and tumor proliferation may synergistically inhibit tumor growth.

Methods.

Thirty‐six BEV‐naïve rMG subjects received rilotumumab (20 mg/kg and BEV (10 mg/kg) every 2 weeks. Endpoints included objective response rate (using Response Assessment in Neuro‐Oncology [RANO] criteria), PFS‐6, overall survival (OS), and toxicity.

Results.

Median patient follow‐up was 65.0 months. Objective response rate was 27.8% (95% confidence interval [CI]: 15.7%–44.1%). Median OS was 11.2 months (95% CI: 7–17.5). PFS‐6 was 41.7% (95% CI: 25.6%–57.0%). Most frequent treatment‐related grade ≤2 events included weight gain, fatigue, allergic rhinitis, and voice alteration; grade ≥3 events included venous thromboembolism (four patients), including one death from pulmonary embolism.

Conclusion.

Rilotumumab with BEV did not significantly improve objective response compared with BEV alone, and toxicity may preclude the use of rilotumumab in combination BEV regimens.

The Clinical Difference in the Platelet Counts between Liver Cirrhosis with Nonalcoholic Fatty Liver Disease and Hepatitis C Virus

Objective The rate of platelet count reduction appears to differ among different liver diseases. In the present study, we investigated the difference in the platelet counts of patients with nonalcoholic fatty liver disease (NAFLD) and those with chronic liver disease due to hepatitis C virus (CLD-HCV). Methods The study population included 620 patients with NAFLD and 405 patients with CLD-HCV, all of whom were diagnosed by liver biopsy. The relationships between the grade of fibrosis and the platelet count in the two diseases were compared. The optimal cut-off value for the diagnosis of liver cirrhosis (LC) was measured. The relationships between the platelet count and anti-platelet antibodies, the serum thrombopoietin level, the grade of splenomegaly and liver stiffness were also investigated in both LC groups. Results In NAFLD patients, the platelet count was significantly higher at each grade of fibrosis in comparison to CLD-HCV. The optimal cut-off value for the diagnosis of LC was 16.0×10⁴/μL [sensitivity, 86.7%; specificity, 87.6%; area under the curve (AUC), 0.930] in NAFLD and 12.7×10⁴/μL (sensitivity, 57.8%; specificity, 88.2%; AUC, 0.863) in CLD-HCV. No anti-platelet antibodies were detected in patients with either type of LC. The serum thrombopoietin levels, the distribution of splenomegaly grades, and liver stiffness did not differ between the two LC groups to a statistically significant extent. As the splenomegaly grade increased, the platelet count decreased. Conclusion The optimal cut-off values for diagnosing LC differed between the two diseases and should be determined separately. The reason for the difference in platelet reduction is still unclear, and requires further investigation.

Healthcare utilisation prior to the diagnosis of inflammatory bowel diseases and the influence of livestock exposure: A longitudinal case-control study

An increased prevalence of the inflammatory bowel diseases, ulcerative colitis and Crohn's disease, was found amongst residents in a livestock dense area. We hypothesised that exposure to livestock farms might be a substantial environmental factor that contributes to the development of these diseases and that in the lead up to inflammatory bowel diseases potential risk factors can be identified. This study aimed to investigate the contribution of livestock exposure to the development of these diseases and the clinical events prior to the diagnosis. Electronic health records from 2006-2013 of general practices were used. The study population consisted of patients with a new diagnosis of inflammatory bowel diseases resident in areas with a high (n = 141) or lower (n = 109) livestock density. Patients with low back pain (n = 10,469) were used as controls. For those in a livestock dense area, distance to livestock farms was determined. Associations between morbidities and drug prescriptions in the reporting year and three years previous to the diagnosis, and the residential proximity to livestock exposure were investigated with multivariable logistic regression analyses. Acute and chronic morbidity of the gastrointestinal tract and associated drug prescriptions were predictive for the development of inflammatory bowel diseases. In addition, a positive association was found between infections and living within 500 meter of poultry farms and the development of inflammatory bowel diseases [OR: 3.3 (1.1-9.9)]. Nonetheless, overall livestock exposure contributed little to the development of these diseases. These results suggest that exposure to livestock farms on its own contributes minimal to the development of inflammatory bowel diseases. Nonetheless, having infections appeared to be a risk factor for neighbouring residents of poultry farms. More research is warranted to explain the increased prevalence of inflammatory bowel diseases amongst residents in areas with a high density of livestock.

Glycosylation of Immunoglobulin G Associates With Clinical Features of Inflammatory Bowel Diseases

BACKGROUND AND AIMS

Causes of inflammatory bowel diseases are not well understood and the most prominent forms, Crohn's disease (CD) and ulcerative colitis (UC), are sometimes hard to distinguish. Glycosylation of IgG has been associated with CD and UC. IgG Fc-glycosylation affects IgG effector functions. We evaluated changes in IgG Fc-glycosylation associated with UC and CD, as well as with disease characteristics in different patient groups.

METHODS

We analyzed 3441 plasma samples obtained from 2 independent cohorts of patients with CD (874 patients from Italy and 391 from the United States) or UC (1056 from Italy and 253 from the US and healthy individuals [controls]; 427 in Italy and 440 from the United States). IgG Fc-glycosylation (tryptic glycopeptides) was analyzed by liquid chromatography coupled to mass spectrometry. We analyzed associations between disease status (UC vs controls, CD vs controls, and UC vs CD) and glycopeptide traits, and associations between clinical characteristics and glycopeptide traits, using a logistic regression model with age and sex included as covariates.

RESULTS

Patients with CD or UC had lower levels of IgG galactosylation than controls. For example, the odds ratio (OR) for IgG1 galactosylation in patients with CD was 0.59 (95% confidence interval [CI], 0.51-0.69) and for patients with UC was 0.81 (95% CI, 0.71-0.92). Fucosylation of IgG was increased in patients with CD vs controls (for IgG1: OR, 1.27; 95% CI, 1.12-1.44), but decreased in patients with UC vs controls (for IgG23: OR, 0.72; 95% CI, 0.63-0.82). Decreased galactosylation associated with more severe CD or UC, including the need for surgery in patients with UC vs controls (for IgG1: OR, 0.69; 95% CI, 0.54-0.89) and in patients with CD vs controls (for IgG23: OR, 0.78; 95% CI, 0.66-0.91).

CONCLUSIONS

In a retrospective analysis of plasma samples from patients with CD or UC, we associated levels of IgG Fc-glycosylation with disease (compared to controls) and its clinical features. These findings could increase our understanding of mechanisms of CD and UC pathogenesis and be used to develop diagnostics or guide treatment.

Prevalence and drug treatment practices of inflammatory bowel diseases in Poland in the years 2012-2014: an analysis of nationwide databases

BACKGROUND

Inflammatory bowel diseases (IBDs) such as ulcerative colitis (UC) and Crohn's disease (CD) are chronic autoimmune disorders that constitute a major societal and economic burden for individual patients, their families and the society. The aim of this study was to assess the current prevalence and treatment patterns of IBD in Poland.

PATIENTS AND METHODS

We carried out a retrospective analysis of the nationwide databases of the National Health Fund for the years from 2012 to 2014 to obtain data on the prevalence and treatment patterns of IBD. Patients with IBD were identified according to the ICD-10 codes indicated in medical records and the type of medical resource utilized during the study. Pharmacotherapy for IBD by age group, sex and IBD types was presented.

RESULTS

The prevalence of IBDs was 157/100 000 individuals, including 35 patients with CD per 100 000 individuals. The use of drugs differed by age and diagnosis (P<0.001). Biologics, steroids and immunosuppressants were used more often by patients with CD than those with UC (13.2 vs. 0.3%, 54.5 vs. 37.5%, and 44.8 vs. 15.1%, respectively). Aminosalicylates were used more often by patients with UC than those with CD. Biologics were used most often by the youngest patients (≤18 years) and seldom by patients aged 65 years or older (7.7 and 0.1%, respectively).

CONCLUSION

Our study showed a moderate prevalence of IBD in Poland. Treatment patterns depended on the patient's age and IBD type. The use of biologics was higher among young patients with CD than among older patients with other IBDs. Although not recommended, aminosalicylates were still commonly used in patients with CD, even during biologic and/or immunosuppressive treatment.

Patient Education in Inflammatory Bowel Disease: A Patient-Centred, Mixed Methodology Study

BACKGROUND

Consensus guidelines from the European Crohns and Colitis Organisation conclude that optimizing quality of care in inflammatory bowel disease [IBD] involves information and education. However, there is no standardized patient education programme in IBD and education varies from centre to centre.

AIM

To assess patients' education needs in IBD to facilitate design of a patient education programme.

METHODS

We created focus groups of 12 patients with IBD and used qualitative analysis to generate hypotheses. We then developed a quantitative questionnaire which was disseminated to 327 IBD patients attending three different centres. Five patients declined to participate and thus 322 patients (159 [49%] male, 180 [58%] Crohn's disease, median age 38 years and disease duration 7 years) were included.

RESULTS

Patients were most keen to receive education on medications, 'what to expect in future', living with IBD and diet. They wanted to receive this information from specialist doctors or nurses and believed it could improve their quality of life. Though the internet was the preferred source of general information [i.e. planning holidays], it was the least preferred source of IBD education. While there was a trend for females to prefer peer education, family history of IBD was the only statistically significant factor associated with information preferences.

CONCLUSION

This is a patient-centred, mixed methodology study on patient education in IBD. Patients' preferences for education include components such as what to expect and diet and patients seem to distrust the internet as an IBD information source. International validation would be valuable to create a consensus education programme.

Gastrointestinal diseases and their oro-dental manifestations: Part 2: Ulcerative colitis

Ulcerative colitis is a rather common inflammatory bowel disease, especially in the industrialised world. A limited number of studies have reported the prevalence of oral signs and symptoms in these patients, and widely varying prevalence rates have been reported ranging from 2 to 34%. Pyostomatitis vegetans is the most pathognomonic oral sign but also other abnormalities as oral ulcerations, caries and periodontitis are more often seen in patients with ulcerative colitis. In this review we describe the oral manifestations of ulcerative colitis and their potential dental implications.

Epidemiology and hospital resources use in the treatment of ulcerative colitis at gastroenterology units in Spain (EPICURE study)

Background and aim

Nationwide epidemiological data on ulcerative colitis (UC) in Spain are lacking. The primary objective was to assess the epidemiology of UC at hospital gastroenterology units and the use of hospital resources (characteristics and facilities) for the management of UC in Spain.

Methods

A retrospective, multicenter, epidemiological, cross-sectional study (EPICURE study) analyzed data from hospital registries and records from UC patients admitted and treated in 2011 at a representative selection of Spanish sites. The prevalence of UC in gastroenterology units was calculated as the total UC patients divided by the total inhabitants covered by those sites. Incidence was defined as the number of new UC cases during 2011 divided by the total inhabitants covered by those sites.

Results

In 2011, a total of 42,000 patients were attended for UC in gastroenterology units in Spain with a prevalence rate of 88.7 UC cases (95% CI: 69.6-106.0) per 100,000 inhabitants. The incidence rate was of 5.7 cases (95% CI: 1.2-10.8)/100,000 inhabitants. Six percent of patients being attended for UC were hospitalized in the 58 units analyzed in 2011. There were 1075 hospitalizations related to UC in total (approximately 14 per gastroenterology unit; median hospital stay length: 8 days). Six out of 1000 UC patients underwent colectomy in 2011. Near one third (32.7%) were emergency colectomies. Most hospitals had specific IBD units (87.9%) and colorectal surgeons (93.1%).

Conclusions

Our study provides the first national data on the prevalence and incidence of UC in gastroenterology units in Spain. Hospitalization and surgical burden associated with UC was low.

A novel microRNA signature predicts survival in stomach adenocarcinoma

Recent microRNA (miRNA) expression profiling studies suggest the clinical use of miRNAs as potential prognostic biomarkers in various malignancies. In this study, aiming to identify microRNAs with prognostic value for overall survival (OS) in stomach adenocarcinoma (STAD) patients, we analyzed the miRNA expression profiles and the associated clinical characteristics in 380 STAD samples from The Cancer Genome Atlas (TCGA) dataset. An eight-miRNA signature for predicting OS in STAD patients was identified and self-validated by survival analysis and semi-supervised principal components method. We developed a linear prognostic model composed of these miRNAs to divide patients into high- and low-risk groups according to the calculated prognostic scores. Kaplan-Meier analysis demonstrated that patients in the high-risk group had worse OS compared with patients in the low-risk group. Notably, this miRNA prognostic model showed prognostic significance to the STAD patients in early stages and the chemo-resistant patients, who would potentially benefit from additional medical interventions. Finally, this eight-miRNA signature is an independent prognostic biomarker and demonstrates a good predictive performance for 5-year survival. Thus, this signature may serve as a novel biomarker for predicting survival as well as chemotherapy response in STAD patients.

Long non-coding RNA PTENP1 functions as a ceRNA to modulate PTEN level by decoying miR-106b and miR-93 in gastric cancer

Recent studies have shown that competing endogenous RNAs (ceRNAs) play an important role in the regulation of gene expression, and participate in a wide range of biological processes, including carcinogenesis. Long non-coding RNA PTENP1, the pseudogene of PTEN tumor suppressor, has been reported to exert its tumor suppressive function via modulation of PTEN expression in many malignancies. However, whether a PTENP1∼miRNA∼PTEN ceRNA network exists and how it functions in gastric cancer (GC) remains elusive. In order to identify and characterize the PTENP1∼miRNA∼PTEN ceRNA network in GC, we first determined PTENP1 levels in clinical GC samples and found that PTENP1 and PTEN were concurrently downregulated in these samples. We further demonstrated that PTENP1 could act as a ceRNA to sponge miR-106b and miR-93 from targeting PTEN for downregulation using a novel ceRNA in vitro gradient assay. Thus, we revealed a tumor suppressive role of PTENP1 as ceRNA in GC and pinpointed the specific miRNAs decoyed by PTENP1, highlighting the emerging roles of ceRNAs in the biological regulation of GC cells and their possible clinical significance.

Long-Term Safety of In Utero Exposure to Anti-TNFα Drugs for the Treatment of Inflammatory Bowel Disease: Results from the Multicenter European TEDDY Study

OBJECTIVES

The long-term safety of exposure to anti-tumor necrosis factor (anti-TNFα) drugs during pregnancy has received little attention. We aimed to compare the relative risk of severe infections in children of mothers with inflammatory bowel disease (IBD) who were exposed to anti-TNFα drugs in utero with that of children who were not exposed to the drugs.

METHODS

Retrospective multicenter cohort study. Exposed cohort: children from mothers with IBD receiving anti-TNFα medication (with or without thiopurines) at any time during pregnancy or during the 3 months before conception. Non-exposed cohort: children from mothers with IBD not treated with anti-TNFα agents or thiopurines at any time during pregnancy or the 3 months before conception. The cumulative incidence of severe infections after birth was estimated using Kaplan-Meier curves, which were compared using the log-rank test. Cox-regression analysis was performed to identify potential predictive factors for severe infections in the offspring.

RESULTS

The study population comprised 841 children, of whom 388 (46%) had been exposed to anti-TNFα agents. Median follow-up after delivery was 47 months in the exposed group and 68 months in the non-exposed group. Both univariate and multivariate analysis showed the incidence rate of severe infections to be similar in non-exposed and exposed children (1.6% vs. 2.8% per person-year, hazard ratio 1.2 (95% confidence interval 0.8-1.8)). In the multivariate analysis, preterm delivery was the only variable associated with a higher risk of severe infection (2.5% (1.5-4.3)).

CONCLUSIONS

In utero exposure to anti-TNFα drugs does not seem to be associated with increased short-term or long-term risk of severe infections in children.

Natural History of Adult Ulcerative Colitis in Population-based Cohorts: A Systematic Review

BACKGROUND & AIMS

A comprehensive knowledge of the natural history of ulcerative colitis (UC) helps understand disease evolution, identify poor prognostic markers and impact of treatment strategies, and facilitates shared decision-making. We systematically reviewed the natural history of UC in adult population-based cohort studies with long-term follow-up.

METHODS

Through a systematic literature review of MEDLINE through March 31, 2016, we identified 60 studies performed in 17 population-based inception cohorts reporting the long-term course and outcomes of adult-onset UC (n = 15,316 UC patients).

RESULTS

Left-sided colitis is the most frequent location, and disease extension is observed in 10%-30% of patients. Majority of patients have a mild-moderate course, which is most active at diagnosis and then in varying periods of remission or mild activity; about 10%-15% of patients experience an aggressive course, and the cumulative risk of relapse is 70%-80% at 10 years. Almost 50% of patients require UC-related hospitalization, and 5-year risk of re-hospitalization is ∼50%. The 5-year and 10-year cumulative risk of colectomy is 10%-15%; achieving mucosal healing is associated with lower risk of colectomy. About 50% of patients receive corticosteroids, although this proportion has decreased over time, with a corresponding increase in the use of immunomodulators (20%) and anti-tumor necrosis factor (5%-10%). Although UC is not associated with an increased risk of mortality, it is associated with high morbidity and work disability, comparable to Crohn's disease.

CONCLUSIONS

UC is a disabling condition over time. Prospective cohorts are needed to evaluate the impact of recent strategies of early use of disease-modifying therapies and treat-to-target approach with immunomodulators and biologics. Long-term studies from low-incidence areas are also needed.

Rising incidence and prevalence of adult eosinophilic esophagitis in midwestern Spain (2007-2016)

OBJECTIVES

Epidemiologic studies on eosinophilic esophagitis (EoE) are scarce and patient responders to proton pump inhibitor (PPI) therapy have usually been excluded. We aimed to evaluate population-based incidence rates, prevalence and trends in adult EoE over the past decade, including responders to PPI therapy.

METHODS

We conducted an analysis of a prospectively established case registry in the health area of Cáceres, located in midwestern Spain. From the first EoE case diagnosed in 2007, endoscopy and pathology reports up to December 2016 were manually reviewed. A baseline diagnosis of EoE was confirmed upon symptoms of esophageal dysfunction (dysphagia/food impaction) and esophageal eosinophilia ≥ 15 eos/HPF. All patients were re-evaluated on PPI therapy during follow-up.

RESULTS

A total of 137 patients were diagnosed with EoE during the study period, of whom 63 (46%) achieved clinicohistologic remission on PPI therapy. The prevalence of autoimmune disorders was low. Mean incidence rate was 8.09 new cases/100,000 inhabitants/year, increasing to 9.95 during the last lustrum and peaking in 2016 with 13.7. This trend coincided with late declining of esophageal biopsies rate. Overall prevalence in 2016 was 81.73 patients/100,000 inhabitants, with the highest prevalence in males between age 35 and 44 years (273 cases/100,000). No seasonal variation was observed in the diagnosis of EoE (53% during pollen season vs. 47%, p = 0.4).

CONCLUSIONS

In midwestern Spain, incidence (13.7 cases/100,000 inhabitants/year) and prevalence (81.73 patients/100,000 inhabitants) in 2016 have grown remarkably in just one decade, coming closer to those figures recently reported for Crohn's disease in Spain.

Therapeutic preferences and outcomes in newly diagnosed patients with Crohn's diseases in the biological era in Hungary: a nationwide study based on the National Health Insurance Fund database

BACKGROUND

Accelerated treatment strategy, including tight disease control and early aggressive therapy with immunosuppressives (IS) and biological agents have become increasingly common in inflammatory bowel disease (IBD). The aim of the present study was to estimate the early treatment strategy and outcomes in newly diagnosed patients with Crohn's disease (CD) between 2004 and 2008 and 2009-2015 in the whole IBD population in Hungary based on the administrative database of the National Health Insurance Fund (OEP).

METHODS

We used the administrative database of the OEP, the only nationwide state-owned health insurance provider in Hungary. Patients were identified through previously reported algorithms using the ICD-10 codes for CD in the out-, inpatient (medical, surgical) non-primary care records and drug prescription databases between 2004 and 2015. Patients were stratified according to the year of diagnosis and maximum treatment steps during the first 3 years after diagnosis.

RESULTS

A total of 6173 (male/female: 46.12%/53.87%) newly diagnosed CD patients with physician-diagnosed IBD were found in the period of 2004-2015. The use of 5-ASA and steroids remained common in the biological era, while immunosuppressives and biologicals were started earlier and became more frequent among patients diagnosed after 2009. The probability of biological therapy was 2.9%/6.4% and 8.4%/13.7% after 1 and 3 years in patients diagnosed in 2004-2008/2009-2015. The probability of hospitalization in the first 3 years after diagnosis was different before and after 2009, according to the maximal treatment step (overall 55.7%vs. 47.4% (p = 0.001), anti-TNF: 73%vs. 66.7% (p = 0.103), IS: 64.6% vs. 56.1% (p = 0.001), steroid: 44.2%vs. 36.8% (p < 0.007), 5-ASA: 32.6% vs. 26.7% p = 0.157)). In contrast, surgery rates were not significantly different in patients diagnosed before and after 2009 according to the maximum treatment step (overall 16.0%vs.15.3%(p = 0.672) anti-TNF 26.7%vs.27.2% (p = 0.993), IS: 24.1%vs22.2% (p = 0.565), steroid 8.1%vs.7.9% (p = 0.896), 5-ASA 10%vs. 11% (p = 0.816)).

CONCLUSIONS

IS and biological exposure became more frequent, while hospitalization decreased and surgery remained low but constant during the observation period. Use of steroids and 5-ASA remained high after 2009. The association between the maximal treatment step and hospitalization/surgery rates suggests that maximal treatment step can be regarded as proxy severity marker in patients with IBD.

Reactive oxygen species and colorectal cancer

Colorectal cancer (CRC) has become the fourth leading cause of cancer-related death in the worldwide. It is urgent to find more effective therapeutic strategies for it. Reactive oxygen species (ROS) play multiple roles in normal cellular physiology processes. Thus, a certain level of ROS is essential to keep normal cellular function. However, the accumulation of ROS shows dual roles for cells, which is mainly dependent on the concentration of ROS, the origin of the cancer cell and the activated signaling pathways during tumor progression. In general, moderate level of ROS leads to cell damage, DNA mutation and inflammation, which promotes the initiation and development of cancer. Excessive high level of ROS induces cancer cell death, showing an anti-cancer role. ROS are commonly higher in CRC cells than their normal counterpart cells. Therefore, it is possible that ROS induce cell death in cancer cells while not affecting the normal cells, demonstrating lower side effects. Besides, ROS also play a role in tumor microenvironment and drug resistance. These multiple roles of ROS make them a promising therapeutic target for cancer. To explore potential ROS-target therapies against CRC, it is worth to comprehensively understanding the role of ROS in CRC and therapy. In this review, we mainly discuss the strategies of ROS in CRC therapy, including direct CRC cell target and indirect tumor environment target. In addition, the influences of ROS in drug resistance will also been discussed.

The Natural History of IBD: Lessons Learned

PURPOSE OF REVIEW

Inflammatory bowel diseases (IBD), which include Crohn's disease (CD) and ulcerative colitis (UC), are chronic, relapsing diseases with unknown etiologies. The purpose of this review is to present the natural disease course evidenced in the latest epidemiology data.

RECENT FINDINGS

The prevalence of IBD is rapidly increasing, affecting five million patients worldwide with the highest incidence observed in Northern Europe and Northern America. It has been shown that both CD and UC patients are at an increased risk for developing cancer of the gastrointestinal tract compared to the general population. Though the disease course of IBD is unpredictable, the rate of surgical treatment has declined potentially as a consequence of the introduction of immunomodulators and new biologic treatment options. Treatments with biological agents and/or immunosuppressive drugs as well as disease monitoring with eHealth devices seem to have a positive impact on the disease course. However, long-term follow-up studies are still lacking and therefore no reliable conclusions can be drawn as of yet. Medical compliance is paramount in the treatment of IBD, and continuous research focusing on approaches that increase compliance is also necessary.

Epidemiology of inflammatory bowel disease in racial and ethnic migrant groups

AIM

To summarise the current literature and define patterns of disease in migrant and racial groups.

METHODS

A structured key word search in Ovid Medline and EMBASE was undertaken in accordance with PRISMA guidelines. Studies on incidence, prevalence and disease phenotype of migrants and races compared with indigenous groups were eligible for inclusion.

RESULTS

Thirty-three studies met the inclusion criteria. Individual studies showed significant differences in incidence, prevalence and disease phenotype between migrants or race and indigenous groups. Pooled analysis could only be undertaken for incidence studies on South Asians where there was significant heterogeneity between the studies [95% for ulcerative colitis (UC), 83% for Crohn’s disease (CD)]. The difference between incidence rates was not significant with a rate ratio South Asian: Caucasian of 0.78 (95%CI: 0.22-2.78) for CD and 1.39 (95%CI: 0.84-2.32) for UC. South Asians showed consistently higher incidence and more extensive UC than the indigenous population in five countries. A similar pattern was observed for Hispanics in the United States. Bangladeshis and African Americans showed an increased risk of CD with perianal disease.

CONCLUSION

This review suggests that migration and race influence the risk of developing inflammatory bowel disease. This may be due to different inherent responses upon exposure to an environmental trigger in the adopted country. Further prospective studies on homogenous migrant populations are needed to validate these observations, with a parallel arm for in-depth investigation of putative drivers.

Identification of significant biomarkers and pathways associated with gastric carcinogenesis by whole genome-wide expression profiling analysis

The incidence of gastric cancer (GC) is extremely high in East Asia. GC is also one of the most common and lethal forms of cancer from a global perspective. However, to date, we have not been able to determine one or several genes as biomarkers in the diagnosis of GC and have also been unable to identify the genes which are important in the therapy of GC. In this study, we analyzed all genome-wide expression profiling arrays uploaded onto the Gene Expression Omnibus (GEO) database to filtrate the differentially expressed genes (DEGs) between normal stomach tissues and GC tissues. GSE13911, GSE19826 and GSE79973 were based on the GPL570 platform, and GSE29272 was based on the GPL96 platform. We screened out the DEGs from the two platforms and by selecting the intersection of these two platforms, we identified the common DEGs in the sequencing data from different laboratories. Finally, we obtained 3 upregulated and 34 downregulated DEGs in GC from 384 samples. As the number of downregulated DEGs was greater than that of the upregulated DEGs, functional analysis and pathway enrichment analysis were performed on the downregulated DEGs. Through our analysis, we identified the most significant genes associated with GC, such as secreted phosphoprotein 1 (SPP1), sulfatase 1 (SULF1), thrombospondin 2 (THBS2), ATPase H+/K+ transporting beta subunit (ATP4B), gastric intrinsic factor (GIF) and gastrokine 1 (GKN1). The prognostic power of these genes was corroborated in the Oncomine database and by Kaplan-Meier plotter (KM-plotter) analysis. Moreover, gastric acid secretion, collecting duct acid secretion, nitrogen metabolism and drug metabolism were significantly related to GC. Thus, these genes and pathways may be potential targets for improving the diagnosis and clinical effects in patients with GC.

vacA s1m1 genotype and cagA EPIYA-ABC pattern are predominant among Helicobacter pylori strains isolated from Mexican patients with chronic gastritis

Purpose

Virulent genotypes of Helicobacter pylori vacA s1m1/cagA⁺/babA2⁺ have been associated with severe gastric diseases. VacA, CagA and BabA are polymorphic proteins, and their association with the disease is allele-dependent. The aims of this work were: (i) to determine the prevalence of H. pylori by type of chronic gastritis; (ii) to describe the frequency of cagA, babA2 and vacA genotypes in strains from patients with different types of chronic gastritis; (iii) to characterize the variable region of cagA alleles.

Methodology

A total of 164 patients with chronic gastritis were studied. Altogether, 50 H. pylori strains were isolated, and the status of cagA, babA2 and vacA genotypes was examined by PCR. cagA EPIYA segment identification was performed using PCR and sequencing of cagA fragments of six randomly selected strains.

Results/Key findings

The overall prevalence of H. pylori was 30.5 %. Eighty percent of the isolated strains were vacA s1m1, and the cagA and babA2 genes were detected in 74 and 32 % of the strains, respectively. The most frequent genotypes were vacA s1m1/cagA⁺/babA2^- and vacA s1m1/cagA⁺/babA2⁺, with 40 % (20/50) and 28 % (14/50), respectively. In cagA⁺, the most frequent EPIYA motif was -ABC (78.4 %), and EPIYA-ABCC and -ABCCC motifs were found in 10.8 % of the strains. A modified EPIYT-B motif was found in 66.6 % of the sequenced strains.

Conclusion

H. pylori strains carrying vacA s1m1, cagA⁺ and babA2^- genotypes were the most prevalent in patients with chronic gastritis from the south of Mexico. In the cagA⁺ strains, the EPIYA-ABC motif was the most common.

European Crohn's and Colitis Organisation Topical Review on Treatment Withdrawal ['Exit Strategies'] in Inflammatory Bowel Disease

Clinically effective therapies now exist for remission maintenance in both ulcerative colitis [UC] and Crohn's Disease [CD]. For each major class of IBD medications [5-aminosalicyclates, immunomodulators, and biologic agents], used alone or in combination, there is a risk of relapse following reduction or cessation of treatment. A consensus expert panel convened by the European Crohn's and Colitis Organisation [ECCO] reviewed the published literature and agreed a series of consensus practice points. The objective of the expert consensus is to provide evidence-based guidance for clinical practice so that physicians can make informed decisions in partnership with their patients. The likelihood of relapse with stopping each class of IBD medication is reviewed. Factors associated with an altered risk of relapse with withdrawal are evaluated, and strategies to monitor and allow early identification of relapse are considered. In general, patients in clinical, biochemical, and endoscopic remission are more likely to remain well when treatments are stopped. Reintroduction of the same treatment is usually, but not always, successful. The decision to stop a treatment needs to be individualized, and shared decision making with the patient should take place.

Antibiotic Use and New-Onset Inflammatory Bowel Disease in Olmsted County, Minnesota: A Population-Based Case-Control Study

BACKGROUND AND AIMS

Several studies have suggested significant associations between environmental factors and the risk of developing inflammatory bowel disease [IBD]. However, data supporting the role of antibiotics are conflicting. The aim of this study was to evaluate the association between antibiotic use and new-onset IBD.

METHODS

We conducted a population-based case-control study using the Rochester Epidemiology Project of Olmsted County, Minnesota. We identified 736 county residents diagnosed with IBD between 1980 and 2010 who were matched to 1472 controls, based on age, sex and date of IBD diagnosis. Data on antibiotic use between 3 months and 5 years before IBD diagnosis were collected. Logistic regression models were used to estimate associations between antibiotic use and IBD, and were expressed as adjusted odds ratio [AOR] with 95% confidence interval [CI].

RESULTS

Antibiotic use occurred in 455 IBD cases [61.8%] and 495 controls [33.6%] [p < 0.001]. In multivariate analysis, there were statistically significant associations between antibiotic use and new-onset IBD [AOR, 2.93; 95% CI, 2.40-3.58], Crohn's disease [CD] [AOR, 3.01; 2.27-4.00] and ulcerative colitis [UC] [AOR, 2.94; 95% CI, 2.23-3.88]. A cumulative duration of antibiotic use ≥ 30 days had the strongest AOR [6.01; 95% CI, 4.34-8.45]. AOR for those receiving antibiotics under the age of 18 years was 4.27 [95% CI, 2.39-7.91], 2.97 for age 18-60 years [2.36-3.75] and 2.72 for age > 60 years [1.60-4.67].

CONCLUSIONS

This population-based case-control study suggests a strong association between antibiotic use and the risk of both new-onset CD and new-onset UC. The risk was increased among all age-onset IBD.

Direct health-care cost utilization in Hong Kong inflammatory bowel disease patients in the initial 2 years following diagnosis

BACKGROUND AND AIM

There are scanty data on the health-care utilization from Asia where the incidence of inflammatory bowel disease (IBD) is rising rapidly. We aim to determine the direct health-care costs in the first 2 years of diagnosis in an IBD cohort from Hong Kong and the factors associated with high cost outliers.

METHODS

This is a retrospective cohort study that included patients newly diagnosed with IBD in a territory-wide IBD registry. Patients' clinical information, hospitalization records, investigations, and IBD treatments were retrieved for up to 2 years following diagnosis of IBD.

RESULTS

Four hundred and thirty-five newly diagnosed IBD patients were included: 198 with Crohn's disease and 237 with ulcerative colitis. Total direct medical expenditure for this cohort 2 years after the IBD diagnosis was $7 072 710: hospitalizations (33%), 5-aminosalicylic acid (23%), imaging and endoscopy (17%), outpatient visits (10%), surgery (8%), and biologics (6%). Mean direct medical costs per patient-year were significantly higher for Crohn's disease ($9918) than ulcerative colitis ($6634; P, 0.001). The total direct health-care cost decreased significantly after transition to the second year (P < 0.01). High cost (> 90th percentile) outliers were associated with surgery (OR 7.1, 95% CI 2.9-17.2) and low hemoglobin on presentation (OR 0.83, 95% CI 0.70-0.96).

CONCLUSIONS

Hospitalization and 5-aminosalicylic acid usage accounted for 56% of total direct medical costs in the first 2 years of our newly diagnosed IBD patients. Direct health-care costs were higher in the first year compared with the second year of diagnosis. Surgery and low hemoglobin on presentation were associated with high cost outliers.

A model of an inflammatory bowel disease population-based registry: The Forlì experience (1993-2013)

BACKGROUND AND AIMS

The article presents a population-based registry designed to estimate incidence and prevalence of inflammatory bowel disease (IBD) in the area of Forlì (north-eastern Italy).

METHODS

The registry included all patients with IBD ulcerative colitis (UC) and Crohn's disease (CD) in the Forlì area from 1993 to 2013. A data manager matched records from various sources.

RESULTS

Seven hundred ninety-one patients were registered during the study period, 564 (71.3%) with UC and 227 (28.7%) with CD. The standardized annual incidence rate for UC was 12.8 per 100,000 females (95% CI 11.1-14.4) and 15.7 per 100,000 males (95% CI 13.9-17.5). That of CD was 7.0 per 100,000 for females (95% CI 5.7-8.3) and 5.4 per 100,000 males (95% CI 4.3-6.4). The prevalence of CD and UC on 1 January 2014 was 109.2 per 100,000 inhabitants (95% CI 94.3-124.2) and 266.4 per 100,000 inhabitants (95% CI 243.4-289.7), respectively.

CONCLUSIONS

Although further studies are needed, the data suggest that incidence and prevalence of IBD in Italy are underestimated.

Serological, genetic and clinical associations with increased health-care resource utilization in inflammatory bowel disease

OBJECTIVE

Inflammatory bowel diseases (IBD) are associated with significant morbidity and economic burden. The variable course of IBD creates a need for predictors of clinical outcomes and health resource utilization (HRU) to guide treatment decisions. We aimed to identify clinical, serological or genetic markers associated with inpatient resource utilization in patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Patients with IBD with available genetic and serological data who had at least one emergency department visit or hospitalization in a 3-year period were included. The primary outcome measure was HRU, as measured by the All Patient Refined Diagnosis Related Group classification system. Univariate and multivariate linear and logistic regression models were used to identify the associations with HRU.

RESULTS

Altogether 858 (562 CD and 296 UC) patients were included. Anti-CBir1 seropositivity (P = 0.002, effect size [ES]: 0.762, 95% confidence interval [CI] 0.512-1.012) and low socioeconomic status (P = 0.005, ES: 1.620 [95% CI 1.091-2.149]) were independently associated with a high HRU. CD diagnosis (P = 0.006, ES: -0.701 [95% CI -0.959 to -0.443]) was independently associated with a low inpatient HRU.

CONCLUSION

In patients with IBD who required at least one emergency department visit or hospitalization, anti-CBir1 antibody status may be a useful biomarker of HRU when formulating management strategies to reduce disease complications and resource utilization.

Quality of care indicators in inflammatory bowel disease in a tertiary referral center with open access and objective assessment policies

BACKGROUND

In the management of inflammatory bowel diseases, there is considerable variation in quality of care.

AIMS

The aim of this study was to evaluate structural, access/process components and outcome quality indicators in our tertiary referral IBD center.

METHODS

In the first phase, structural/process components were assessed, followed by the second phase of formal evaluation of access and management on a set of consecutive IBD patients with and without active disease (248CD/125UC patients, median age 35/39 years).

RESULTS

Structural/process components of our IBD center met the international recommendations. At or around the time of diagnosis usual procedures were full colonoscopy in all patients, with ileocolonoscopy/gastroscopy/CT/MRI in 81.8/45.5/66.1/49.6% of CD patients. A total of 86.7% of CD patients had any follow-up imaging evaluation or endoscopy. The median waiting time for non-emergency endoscopy/CT/MRI was 16/14/22 days. During the observational period patients with flares (CD/UC:50.6/54.6%) were seen by specialist at the IBD clinic within a median of 1day with same day laboratory assessment, abdominal US, CT scan/surgical consult and change in therapy if needed. Surgery and hospitalization rates were 20.1/1.4% and 17.3/3.2% of CD/UC patients.

CONCLUSION

Our results highlight that structural components and processes applied in our center are in line with international recommendations, including an open clinic concept and fast track access to specialist consultation, endoscopy and imaging.

Thiopurine Treatment in Ulcerative Colitis: A Critical Review of the Evidence for Current Clinical Practice

BACKGROUND

Due to toxicity problems and controversial evidence, thiopurine use in ulcerative colitis (UC) has faced a lot of criticism. We present a critical review of the literature on efficacy of thiopurines in UC.

METHODS

Studies evaluating therapeutic efficacy of thiopurine remission induction and/or maintenance treatment in UC were identified using the Cochrane Library, MEDLINE, and EMBASE.

RESULTS

Out of 5 randomized trials on thiopurine induction treatment, 3 demonstrated a significant effect of thiopurine treatment vs mesalamine or placebo in steroid-dependent UC patients: (1) lower endoscopic activity scores, (2) higher clinical remission rates, and (3) more patients who discontinued steroids. Two found no significant difference in clinical and endoscopic remission of azathioprine compared with sulfasalazine or placebo in patients with active UC. Out of 7 randomized trials on thiopurine maintenance treatment, 4 demonstrated significant higher clinical and endoscopic remission rates in thiopurine-treated patients compared with placebo or mesalamine. Three found no significant difference in clinical and endoscopic remission of thiopurine maintenance treatment compared with sulfasalazine or placebo.

CONCLUSIONS

All studies that investigated thiopurine treatment in UC had shortcomings, such as lack of sufficient power, no use of blinding, allowed concomitant treatment with steroids, and no endoscopy to confirm active disease at study entry or to evaluate therapeutic efficacy. Hence, current clinical practice of thiopurine treatment in UC is based on minimal and controversial evidence. This underscores the need for clinical studies with sufficient power and objective end points in order to determine efficacy of thiopurines in UC.

Management of anemia in inflammatory bowel disease: a challenge in everyday clinical practice

Anemia is the most common extraintestinal manifestation and complication of inflammatory bowel disease (IBD). Its etiology is multifactorial and mostly is a combination of iron deficiency anemia (IDA) and chronic anemia (ACD). Because of its high incidence in patients with IBD and its influence on their quality of life, regular screening is recommended. In case of IDA type of medication and route of administration should be determined by many factors such as general condition of the patient, IBD activity or anemia severity. Intravenous iron supplementation is the preferred route but may be associated with phosphate drop or even severe hypophosphatemia (HP). The mechanism of HP related to the intravenous iron infusions is not clearly known yet, but it might be related to the change of FGF-23 levels. What more not all parenteral forms of iron are equal and some may have a higher risk of HP than others.