Environmental triggers for inflammatory bowel disease. Curr Gastroenterol Rep. 2013;15:302. [PMID: 23250702 DOI: 10.1007/s11894-012-0302-4]

Best practices for the experimental design of one health studies on companion animal and owner microbiomes - From data collection to analysis

The relationship between owner and companion animal represents an underestimated opportunity for the studying of One Health relationships between humans, animals, and the environment they share. Microbiome exchanges between owner and pet have been documented for the gut, skin, oral, and nasal microbiomes. These studies give a unique insight into bacterial flows between humans and animals, but come with their specific challenges. This review discusses the data and sample collection challenges, as well as laboratory, bioinformatic and data analysis challenges specific to One Health studies on companion animal and owner microbiomes. We provide an overview of possible data to be collected and pitfalls to avoid during sample collection and conservation, DNA extraction, and library preparation. We present the main bioinformatics pipelines in sequencing-data microbiome analysis, as well as data analysis specific to pet-owner microbiome comparison. We review and compare three beta-diversity measures (Bray-Curtis dissimilarity, unweighted, and weighted UniFrac distances) for pet-owner distances and the tests to compare them. Finally, we propose a framework with key considerations to bear in mind when designing and carrying out owner-companion animal studies, as well as best practices to implement them. Although these studies come with additional difficulties compared to species-specific microbiome studies, they offer the opportunity to identify biomarkers, environmental triggers, and impacts of pet-owner interactions across species.

Sudden death due to Crohn's colitis: An autopsy case report

Crohn's colitis is an inflammatory bowel disease affecting the colon, which can result in serious complications such as intestinal perforation and peritonitis. Clinically, it presents with symptoms like abdominal pain, diarrhea, and vomiting, which can be misinterpreted or overlooked, leading to diagnostic delays. We present an autopsy case of a 43-year-old woman with no significant past medical history, who initially consulted the Emergency Department for persistent abdominal pain, vomiting, and diarrhea over a 10-day period. Despite symptomatic treatment, no further diagnostic investigations were conducted. Three days later, she presented a sudden loss of consciousness at home and she was declared dead shortly thereafter. A medico-legal autopsy was ordered to determine the cause of death. External examination revealed cyanosis of the face and nails, abdominal distension, and no signs of trauma. At the internal examination, there were a stercoral peritoneal effusion of approximately 400 ml and multiple perforations in the colon, specifically in the ascending colon and sigmoid regions. Further examination showed an inflamed, hemorrhagic colonic mucosa. Histological analysis revealed deep ulcerations and areas of transmural inflammation alternating with healthy mucosa, typical of Crohn's colitis. No other organ abnormalities were noted. Toxicology tests were negative. The cause of death was attributed to peritonitis secondary to colonic perforation due to undiagnosed Crohn's colitis.

Exploring diet categorizations and their influence on flare prediction in inflammatory bowel disease, using the Sparse Grouped Least Absolute Shrinkage and Selection Operator method

BACKGROUND & AIMS

Diet is an important environmental factor in inflammatory bowel disease (IBD) onset and disease course, but analyses are hindered by its complexity. We aim to explore the Sparse Grouped Least Absolute Shrinkage and Selection Operator (Sparse Grouped LASSO or SGL) method to study whether different food categorizations, representing different dietary patterns, can predict flares in IBD.

METHODS

Baseline data on habitual dietary intake and longitudinal data on disease course were collected over a 24 month-period in two distinct cohorts. Food items were classified into 22 food groups. These were further classified into three diet categorizations: 1. Plant vs animal vs mixed; 2. Potentially healthy vs potentially unhealthy vs neutral; 3. Ultra-processed vs not ultra-processed. The SGL parameter 'lambda' identifies important groups using a-priori group information, while allowing for only a subset of variables within a group to be important predictors.

RESULTS

Of 724 eligible patients, 427 were in remission at baseline and were included in the SGL analyses. 106 (24.8 %) included patients developed a flare within 11.2 ± 6.6 months (65.1 % female, 34 % ulcerative colitis, mean age 43.3 ± 14.7 years). They had a higher crude food intake of red meat (p = 0.028) and vegetables (p = 0.027) than those who stayed in remission. Prediction models for flare development were moderate with AUC varying between 0.425 and 0.542 for model 1, 0.512 and 0.562 for model 2 and 0.451 and 0.612 for model 3. All models showed red meat, legumes and vegetables as the first selected predicting variables. However, female sex and energy intake had the highest predictive values in all 3 models.

CONCLUSION

Categorization of the same food groups in different ways influences the predictive value of the SGL method. The current exploration of the SGL method shows that food might not be the most important predictor of flares in IBD.

Integrated Approaches in the Management of Gastrointestinal Disorders: A Biopsychosocial Perspective

Gastrointestinal (GI) disorders, including gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), gastritis/peptic ulcer disease (PUD), and celiac disease, significantly impact global health and economic stability. This review synthesizes current literature to elucidate the pathophysiology, clinical manifestations, diagnostic challenges, and management strategies of these prevalent conditions. Through a biopsychosocial lens, we examine the role of the gut microbiome in disease modulation and explore innovative therapeutic advancements, including microbiome-targeting interventions. The review highlights the necessity of a multidisciplinary approach to patient care, integrating medical treatment with dietary, psychological, and lifestyle modifications. By addressing these disorders holistically, the article aims to foster a deeper understanding of their biopsychosocial impacts and encourage more effective, patient-centered treatment paradigms. The findings underscore the imperative for continued research and interdisciplinary collaboration to enhance patient outcomes and reduce healthcare burdens associated with GI disorders.

Inflammatory bowel disease evolution in the past two decades: a chronological multinational study

Background

The multifactorial nature of inflammatory bowel disease (IBD), which manifests differently in individuals creates a need for a better understanding of the behaviour and pattern of the disease due to environmental factors. The current study aimed to study the changes in IBD behaviour, presentation, and characteristics in patients over the past two decades with a goal of improving patients' diagnosis, management and outcomes.

Methods

During a 6-month period (1/02/2022-30/07/2022), the information of patients with IBD who attended IBD outpatient clinics of 11 referral centre's in six countries was collected, and based on the first time of diagnosis with IBD, they were allocated as group A (those who were diagnosed more than 15 years ago), group B (those who were diagnosed with IBD between 5 and 15 years ago) and group C (IBD cases who diagnosed in recent 5 years). Then the most prevalent subtypes and characters of the disease are evaluated and compared to make clear if the presenting pattern and behaviour of the disease has changed in the last 2 decades.

Findings

Overall 1430 patients with IBD including 1207 patients with ulcerative colitis (UC) (84.5%) and 205 patients with Crohn's disease (CD; 14.3%) included. Mean age of participants at the first time of diagnosis with IBD was 30 years. The extra-intestinal involvement of IBD in groups A and B was more prevalent in comparison with group C. Most of those in groups A & B had academic education but in group C, the most prevalent educational status was high school or diploma (P = 0.012). In contrast to groups A and B, the relative prevalence of medium socioeconomic level in group C had decreased (65%). Relative prevalence of UC subtypes was similar among groups A and B (extensive colitis as most prevalent) but in group C, the most prevalent subtype is left side colitis (38.17%). The most prevalent subtype of CD in groups A and B was ileocolic involvement while in group C, upper GI involvement is significantly increased. The rate of food sensitivity among groups A and B was more than group C (P = 0.00001). The relative prevalence of patients with no flare has increased with a steady slope (P < 0.00001). Relative prevalence of presenting symptoms among patients with UC in group C differs and nowadays the rate abdominal pain (70.7%) and bloating (43.9%) have increased and frequency of diarrhoea (67.4%) has decreased.

Interpretation

In the recent 5 years, the pattern of UC presentation has changed. The rate of upper GI involvement in CD and relative prevalence of patients with no disease flare increased and the rate of extra intestinal involvement decreased.

Funding

None.

Helminth Lessons in Inflammatory Bowel Diseases (IBD)

Helminths are multicellular invertebrates that colonize the gut of many vertebrate animals including humans. This colonization can result in pathology, which requires treatment. It can also lead to a commensal and possibly even a symbiotic relationship where the helminth and the host benefit from each other's presence. Epidemiological data have linked helminth exposure to protection from immune disorders that include a wide range of diseases, such as allergies, autoimmune illnesses, and idiopathic inflammatory disorders of the gut, which are grouped as inflammatory bowel diseases (IBD). Treatment of moderate to severe IBD involves the use of immune modulators and biologics, which can cause life-threatening complications. In this setting, their safety profile makes helminths or helminth products attractive as novel therapeutic approaches to treat IBD or other immune disorders. Helminths stimulate T helper-2 (Th2) and immune regulatory pathways, which are targeted in IBD treatment. Epidemiological explorations, basic science studies, and clinical research on helminths can lead to the development of safe, potent, and novel therapeutic approaches to prevent or treat IBD in addition to other immune disorders.

Gut microbial metabolism of 5-ASA diminishes its clinical efficacy in inflammatory bowel disease

For decades, variability in clinical efficacy of the widely used inflammatory bowel disease (IBD) drug 5-aminosalicylic acid (5-ASA) has been attributed, in part, to its acetylation and inactivation by gut microbes. Identification of the responsible microbes and enzyme(s), however, has proved elusive. To uncover the source of this metabolism, we developed a multi-omics workflow combining gut microbiome metagenomics, metatranscriptomics and metabolomics from the longitudinal IBDMDB cohort of 132 controls and patients with IBD. This associated 12 previously uncharacterized microbial acetyltransferases with 5-ASA inactivation, belonging to two protein superfamilies: thiolases and acyl-CoA N-acyltransferases. In vitro characterization of representatives from both families confirmed the ability of these enzymes to acetylate 5-ASA. A cross-sectional analysis within the discovery cohort and subsequent prospective validation within the independent SPARC IBD cohort (n = 208) found three of these microbial thiolases and one acyl-CoA N-acyltransferase to be epidemiologically associated with an increased risk of treatment failure among 5-ASA users. Together, these data address a longstanding challenge in IBD management, outline a method for the discovery of previously uncharacterized gut microbial activities and advance the possibility of microbiome-based personalized medicine.

Obesity is associated with colitis in women but not necessarily causal relationship

The relationship between obesity and female risk of microscopic colitis remains to be discussed.

Varied Composition and Underlying Mechanisms of Gut Microbiome in Neuroinflammation

The human gut microbiome has been implicated in a host of bodily functions and their regulation, including brain development and cognition. Neuroinflammation is a relatively newer piece of the puzzle and is implicated in the pathogenesis of many neurological disorders. The microbiome of the gut may alter the inflammatory signaling inside the brain through the secretion of short-chain fatty acids, controlling the availability of amino acid tryptophan and altering vagal activation. Studies in Korea and elsewhere highlight a strong link between microbiome dynamics and neurocognitive states, including personality. For these reasons, re-establishing microbial flora of the gut looks critical for keeping neuroinflammation from putting the whole system aflame through probiotics and allotransplantation of the fecal microbiome. However, the numerosity of the microbiome remains a challenge. For this purpose, it is suggested that wherever possible, a fecal microbial auto-transplant may prove more effective. This review summarizes the current knowledge about the role of the microbiome in neuroinflammation and the various mechanism involved in this process. As an example, we have also discussed the autism spectrum disorder and the implication of neuroinflammation and microbiome in its pathogenesis.

Clinical factors to predict flare-up in patients with inflammatory bowel disease during international air travel: A prospective study

Backgrounds and aims

Inflammatory bowel disease (IBD) patients often experience disease flare-ups during international air travel. We aimed to identify risk factors associated with IBD flare-up during international air travel.

Methods

Patients with scheduled international air travel were enrolled in the study from the Seoul National University Bundang Hospital IBD clinic. Flight information and clinical data were collected via questionnaires and personal interviews, and risk factors associated with IBD flares were determined.

Results

Between May 2018 and February 2020, 94 patients were prospectively enrolled in the study (mean age, 33.0 years; males, 53.2%; mean disease duration, 56.7 months), including 56 (59.6%) with ulcerative colitis and 38 (40.4%) with Crohn’s disease. Of the 94 patients enrolled, 15 (16.0%) experienced an IBD flare-up and 79 (84.0%) remained in remission throughout travel. Logistic regression analysis revealed that high fecal calprotectin levels before travel (odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1.000–1.001, p = 0.016), the presence of a comorbidity (OR: 6.334, 95% CI: 1.129–35.526, p = 0.036), and history of emergency room visit (OR: 5.283, 95% CI: 1.085–25.724, p = 0.039) were positively associated with disease flare-up. The previous and current use of immunomodulators and biologics, time of flight, altitude, number countries visited, travel duration, objective of visit, and previous medical consultations were not associated with disease flare-up.

Conclusions

Elevated fecal calprotectin levels, history of emergency room visits, and the presence of a comorbidity predicted IBD flare-up during international air travel.

The association of the quality of sleep with proinflammatory cytokine profile in inflammatory bowel disease patients

BACKGROUND

The role of circadian rhythm abnormalities in patients with inflammatory bowel disease (IBD) remains relatively unknown. The aim of this study was to identify the inflammatory cytokine profile in the IBD patients and its relationship with the quality of sleep.

METHODS

Prospective, single-center observational cohort study was performed. In all enrolled adult IBD patients, the disease activity was assessed using Crohn's Disease Activity Index (CDAI) for Crohn's disease (CD) and Partial Mayo Score for ulcerative colitis (UC), respectively. To assess the quality of sleep, all patients were asked to respond to a questionnaire to define Pittsburgh Quality Sleep Index (PSQI). From all enrolled patients, 15 ml venous blood was taken to determine serum inflammatory cytokine levels and perform standard laboratory tests.

RESULTS

Fifty-two IBD patients were enrolled in the study: 32 with CD and 20 with UC. The poor sleep was noted in 69.4% of patients with clinically active and in 6.3% of patients with inactive disease. In the group of IBD patients with poor sleep, the significantly higher level of serum IL-6, IL-17, and IL-23 were observed. In IBD patients with exacerbation, the significantly higher level of serum IL-6, IL-17, and IL-23 were recorded.

CONCLUSIONS

The relationship between quality of sleep and proinflammatory cytokine profile may show us a predisposition for the development of inflammatory intestinal lesions in IBD patients with sleep disturbances. This knowledge may allow the pharmacological and behavioral therapies of circadian rhythm abnormalities to become new significant targets in IBD patients.

Post-inflammatory Abdominal Pain in Patients with Inflammatory Bowel Disease During Remission: A Comprehensive Review

Patients with inflammatory bowel disease often experience ongoing pain even after achieving mucosal healing (i.e., post-inflammatory pain). Factors related to the brain-gut axis, such as peripheral and central sensitization, altered sympatho-vagal balance, hypothalamic-pituitary-adrenal axis activation, and psychosocial factors, play a significant role in the development of post-inflammatory pain. A comprehensive study investigating the interaction between multiple predisposing factors, including clinical psycho-physiological phenotypes, molecular mechanisms, and multi-omics data, is still needed to fully understand the complex mechanism of post-inflammatory pain. Furthermore, current treatment options are limited and new treatments consistent with the underlying pathophysiology are needed to improve clinical outcomes.

Characterization of Crohn's disease patients in Egypt: Risk factors for postoperative recurrence (A cohort study)

BACKGROUND

The aim of study to identify the characterizations of Crohn's disease in Egyptian patients and to determine its predictors for postoperative recurrence.

METHODS

We conducted a retrospective observational cohort study on 15 patients diagnosed as Crohn's disease with surgical interventions. Different characteristics of studied patients were analyzed to determine the risk factors for postoperative recurrence such as age at diagnosis, gender, smoking, main presenting symptom, Montreal classification, perianal disease, laboratory findings and protocol of management including surgical characteristics like age at operation, surgical indication, preoperative medication, surgical approach, and operative findings.

RESULTS

Nine of the studied patients (60%) suffered from clinical postoperative recurrence with mean duration of 23.5 ± 40.6 months. In comparison the demographic, clinical, operative, and medical treatment data between patients with postoperative recurrence of Crohn's disease and those without recurrence, age at diagnosis (mean age 42.9 years) and age at operation (mean 44.7 years) were found statistically significant in postoperative recurrence group (p-value = 0.001). According to Montreal classification of Crohn's disease, patients >40 years were significantly found in postoperative recurrence group, while patients between 17 and 40 years were significantly found in postoperative non-recurrence group (p-value=0.007) and ileal location of Crohn's disease was found significantly in postoperative recurrent group (p-value=0.044). Postoperative biological therapy significantly decreased the incidence of postoperative recurrence in the current study (p-value= 0.041).

CONCLUSIONS

Age at diagnosis, age at operation, ileal location of Crohn's disease can significantly predict postoperative recurrence. Also, postoperative biological therapy can significantly decrease the incidence of postoperative recurrence.

Systematic Review of Self-Management Assessment Tools for Children With Inflammatory Bowel Disease

The relapsing pattern of illness and diverse management strategies for children with inflammatory bowel disease (IBD) may inhibit their opportunities to develop self-management skills. Interventions focused on the development of these skills require population-specific outcome measures. We provide a comprehensive overview of self-management skills assessment tools that are available for children with IBD that target processes and behaviors outlined as beneficial for the development of these skills. Seven health literature databases were searched using terms related to self-management, transition, IBD, Crohn's disease, ulcerative colitis, and children. Identified studies underwent a process of title and then full text review. Included studies underwent data extraction using a priori quality assessment criteria related to self-management skills, health literacy, suitability for the target population, validity and reliability testing. The searches identified 523 papers, 123 of which underwent full-text review and 10 included in the final analysis. The assessment tools identified showed great diversity in their development approach, content, methodological rigor, and health literacy considerations. The most frequently included self-management skills were related to adherence, communication, attending clinic, and disease/treatment knowledge. None of the tools satisfied the criteria of selection for use in the target population. While many chronic diseases of childhood follow a predictable disease course with established treatment pathways, IBD presents a unique set of challenges. The development of self-management skills is vital for successful disease management, but these skills should be assessed by a tool appropriate for the population and their diverse needs.

Eosinophilic esophagitis-established facts and new horizons

Despite dramatic advances in our understanding of the pathogenesis and course of disease in the relatively short timeframe since the discovery and first description of eosinophilic esophagitis (EoE) less than three decades ago, many open questions remain to be elucidated. For instance, we will need to better characterize atypical clinical presentations of EoE and other forms of esophageal inflammatory conditions with often similar clinical presentations, nut fulfilling current diagnostic criteria for EoE and to determine their significance and interrelationship with genuine EoE. In addition, the interrelationship of EoE with other immune-mediated diseases remains to be clarified. Hopefully, a closer look at the role of environmental factors and their interaction with genetic susceptibility often in context of atopic predisposition may enable identifying the candidate substances/agents/allergens and potentially earlier (childhood) events to trigger the condition. It appears plausible to assume that in the end—comparable to current concepts in other immune-mediated chronic diseases, such as for instance inflammatory bowel disease or asthma bronchiale—we will not be rewarded with the identification of a “one-and-only” underlying pathogenetic trigger factor, with causal responsibility for the disease in each and every EoE patient. Rather, the relative contribution and importance of intrinsic susceptibility, i.e., patient-driven factors (genetics, aberrant immune response) and external trigger factors, such as food (or aero-) allergens as well as early childhood events (e.g., infection and exposure to antibiotics and other drugs) may substantially differ among given individuals with EoE. Accordingly, selection and treatment duration of medical therapy, success rates and extent of required restriction in dietary treatment, and the need for mechanical treatment to address strictures and stenosis require an individualized approach, tailored to each patient. With the advances of emerging treatment options, the importance of such an individualized and patient-centered assessment will increase even further.

A Review of Inflammatory Bowel Disease: A Model of Microbial, Immune and Neuropsychological Integration

Objective: Inflammatory bowel diseases (IBDs) are complex chronic inflammatory disorders of the gastro-intestinal (GI) tract with uncertain etiology. IBDs comprise two idiopathic disorders: Crohn's disease (CD) and ulcerative colitis (UC). The aetiology, severity and progression of such disorders are still poorly understood but thought to be influenced by multiple factors (including genetic, environmental, immunological, physiological, psychological factors and gut microbiome) and their interactions. The overarching aim of this review is to evaluate the extent and nature of the interrelationship between these factors with the disease course. A broader conceptual and longitudinal framework of possible neuro-visceral integration, core microbiome analysis and immune modulation assessment may be useful in accurately documenting and characterizing the nature and temporal continuity of crosstalk between these factors and the role of their interaction (s) in IBD disease activity. Characterization of these interactions holds the promise of identifying novel diagnostic, interventions, and therapeutic strategies. Material and Methods: A search of published literature was conducted by exploring PubMed, EMBASE, MEDLINE, Medline Plus, CDSR library databases. Following search terms relating to key question were set for the search included: "Inflammatory bowel diseases," "gut microbiota," "psychological distress and IBD," "autonomic reactivity and IBD," "immune modulation," "chronic inflammation," "gut inflammation," "enteric nervous system," "gut nervous system," "Crohn's disease," "Ulcerative colitis", "depression and IBD", "anxiety and IBD", "quality of life in IBD patients," "relapse in IBDs," "remission in IBDs," "IBD disease activity," "brain-gut-axis," "microbial signature in IBD," "validated questionnaires in IBD," "IBD activity indices," "IBD aetiology," "IBDs and stress," "epidemiology of IBDs", "autonomic nervous system and gut inflammation", "IBD and environment," "genetics of IBDs," "pathways of immune response in IBDs," "sleep disturbances in IBD," "hypothalamic-pituitary-adrenal axis (HPA)," "sympatho-adrenal axis," "CNS and its control of gut function" "mucosal immune response," "commensal and pathogenic bacteria in the gut," "innate and adaptive immunity." Studies evaluating any possible associations between gut microbiome, psychological state, immune modulation, and autonomic function with IBDs were identified. Commonly cited published literatures with high quality research methodology/results and additional articles from bibliographies of recovered papers were examined and included where relevant. Results: Although there is a substantial literature identifying major contributing factors with IBD, there has been little attempt to integrate some factors over time and assess their interplay and relationship with IBD disease activity. Such contributing factors include genetic and environmental factors, gut microbiota composition and function, physiological factors, psychological state and gut immune response. Interdependences are evident across psychological and biological factors and IBD disease activity. Although from the available evidence, it is implausible that a single explanatory model could elucidate the interplay between such factors and the disease course as well as the sequence of the effect during the pathophysiology of IBD. Conclusion: Longitudinal monitoring of IBD patients and integrating data related to the contributing/risk factors including psychological state, physiological conditions, inflammatory/immune modulations, and microbiome composition/function, could help to explain how major factors associate and interrelate leading to exacerbation of symptoms and disease activity. Identifying the temporal trajectory of biological and psychosocial disturbances may also help to assess their effects and interdependence on individuals' disease status. Moreover, this allows greater insight into understanding the temporal progressions of subclinical events as potential ground for disease severity in IBD. Furthermore, understanding the interaction between these risk factors may help better interventions in controlling the disease, reducing the costs related to disease management, further implications for clinical practice and research approaches in addition to improving patients' mental health and quality of life.

Associations between participation in, intensity of, and time spent on leisure time physical activity and risk of inflammatory bowel disease among older adults (PA-IBD): a prospective cohort study

Background

Inflammatory bowel diseases (IBDs) are diseases of the immune system that share some genetic and lifestyle-related predisposing factors. Increasing incidences have been reported in all age groups. Based on experimental studies suggesting a role of physical activity on intestinal inflammation, this study aimed to investigate the association between leisure time physical activity and the risk of IBD in older adults.

Methods

The study is a prospective cohort study using Danish registry data and questionnaire data from the Danish “Diet, Cancer and Health” cohort. The outcome IBD was defined as having at least two main diagnoses of Crohn’s disease or ulcerative colitis registered in the National Patient Registry from the period between December 1993 and May 1997 with an average follow-up of 25 years. Cox proportional hazard models were used to estimate hazard-ratios for IBD onset associated with being physically active and with levels of the metabolic equivalent of task (MET) hours/week of physical activity and hours/week spent on six types of physical activity. All analyses were adjusted for potential confounders. Furthermore, the analyses were stratified according to age-group, occupational physical activity, smoking, BMI and work status to test for effect modification.

Results

In total, 54,645 men and women aged between 50 and 64 years were included, and of which there were 529 cases. When comparing physically active with inactive participants measured by MET hours/week there was no statistically significant difference in risk of IBD (0.89 [0.13; 6.27]), regardless of how participation was measured. Results did not indicate any dose-response effect when comparing quartile groups of MET hours/week (HR = 0.97 [0.76; 1.22], HR = 0.82 [0.64; 1.05] and HR = 0.83 [0.65; 1.07] or whether five of the six types of activities were compared with the lowest quartile as reference. For do-it-yourself-work, the third quartile of hours/week was associated with a higher risk of IBD compared to the second quartile of hours/week (HR = 1.44 [1.10; 1.90]. No effect modification was found.

Conclusions

There was no association between physical activity and risk of IBD when comparing physically active with inactive participants. Neither did the results indicate any dose-response effect when comparing quartile groups of MET hours/week with the lowest quartile as reference. Do-it-yourself work, however, appeared to be associated with a higher risk of IBD when comparing the third quartile with the second quartile of hours/week. The study has clinical relevance by its contribution to the explanatory field of the causes of IBD. However, the study has some limitations, and further research is needed to clarify associations between physical activity and risk of IBD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10492-7.

Prognostic tools for identification of high risk in people with Crohn's disease: systematic review and cost-effectiveness study

BACKGROUND

Crohn's disease is a lifelong condition that can affect any segment of the gastrointestinal tract. Some people with Crohn's disease may be at higher risk of following a severe course of disease than others and being able to identify the level of risk a patient has could lead to personalised management.

OBJECTIVE

To assess the prognostic test accuracy, clinical impact and cost-effectiveness of two tools for the stratification of people with a diagnosis of Crohn's disease by risk of following a severe course of disease.

DATA SOURCES

The data sources MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched to inform the systematic reviews on prognostic accuracy, clinical impact of the prognostic tools, and economic evaluations. Additional data sources to inform the review of economic evaluations were NHS Economic Evaluation Database, Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database.

REVIEW METHODS

Systematic reviews of electronic databases were carried out from inception to June 2019 for studies assessing the prognostic accuracy and clinical impact of the IBDX® (Crohn's disease Prognosis Test; Glycominds Ltd, Lod, Israel) biomarker stratification tool and the PredictSURE-IBD™ (PredictImmune Ltd, Cambridge, UK) tool. Systematic reviews of studies reporting on the cost-effectiveness of treatments for Crohn's disease were run from inception to July 2019. Two reviewers independently agreed on studies for inclusion, assessed the quality of included studies and validated the data extracted from studies. Clinical and methodological heterogeneity across studies precluded the synthesis of data for prognostic accuracy. A de novo economic model was developed to compare the costs and consequences of two treatment approaches - the 'top-down' and 'step-up' strategies, with step-up considered standard care - in people at high risk of following a severe course of Crohn's disease. The model comprised a decision tree and a Markov cohort model.

RESULTS

Sixteen publications, including eight original studies (n = 1478), were deemed relevant to the review of prognostic accuracy. Documents supplied by the companies marketing the prognostic tools were also reviewed. No study meeting the eligibility criteria reported on the sensitivity or specificity of the IBDX biomarker stratification tool, whereas one study provided estimates of sensitivity, specificity and negative predictive value for the PredictSURE-IBD tool. All identified studies were observational and were considered to provide weak evidence on the effectiveness of the tools. Owing to the paucity of data on the two tools, in the base-case analysis the accuracy of PredictSURE-IBD was assumed to be 100%. Accuracy of IBDX was assumed to be 100% in a scenario analysis, with the cost of the tests being the only difference between the analyses. The incremental analysis of cost-effectiveness demonstrated that top-down (via the use of PredictSURE-IBD in the model) is more expensive and generates fewer quality-adjusted life-years than step-up (via the standard care arm of the model).

LIMITATIONS

Despite extensive systematic searches of the literature, no robust evidence was identified of the prognostic accuracy of the biomarker stratification tools IBDX and PredictSURE-IBD.

CONCLUSIONS

Although the model indicates that standard care dominates the tests, the lack of evidence of prognostic accuracy of the two tests and the uncertainty around the benefits of the top-down and step-up treatment approaches mean that the results should be interpreted as indicative rather than definitive.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019138737.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 23. See the NIHR Journals Library website for further project information.

Diet and Inflammatory Bowel Disease: What Quality Standards Should Be Applied in Clinical and Laboratory Studies?

Many patients suffering from inflammatory bowel disease (IBD) follow restrictive diets, as many respective recommendations circulate. Efforts are made to evaluate and summarize the published information, for example, in a recent consensus manuscript by the International Organization for the Study of IBD (IOIBD). However, the standards that should be applied to make claims about dietary effects are poorly defined. In this manuscript, the scientific basis of recommendations for nutritional interventions in IBD is analyzed. Epidemiological evidence on diet in IBD is always biased by numerous factors, and the number of robust dietary intervention studies is limited due to methodological difficulties. Therefore, animal models are used to test hypotheses with respect to dietary factors and intestinal inflammation. Naturally, animal models have limitations, and knowledge of key characteristics of colitis animal models is crucial to understand their advantages and disadvantages. In recent years the important role of the microbiota for IBD and dietary factors has been discovered. Microbiota data are added to many publications on IBD and nutrition. The quality of those data varies largely. Subsequently, quality standards for microbiota analyses also are discussed. Finally, quality requirements to be applied on recommendations for dietary changes in patients with IBD are suggested.

Neutrophil Extracellular Traps and Their Implications in Cardiovascular and Inflammatory Disease

Neutrophils are primary effector cells of innate immunity and fight infection by phagocytosis and degranulation. Activated neutrophils also release neutrophil extracellular traps (NETs) in response to a variety of stimuli. These NETs are net-like complexes composed of cell-free DNA, histones and neutrophil granule proteins. Besides the evolutionarily conserved mechanism to capture and eliminate pathogens, NETs are also associated with pathophysiological processes of various diseases. Here, we elucidate the mechanisms of NET formation and their different implications in disease. We focused on autoinflammatory and cardiovascular disorders as the leading cause of death. Neutrophil extracellular traps are not only present in various cardiovascular diseases but play an essential role in atherosclerotic plaque formation, arterial and venous thrombosis, as well as in the development and progression of abdominal aortic aneurysms. Furthermore, NETosis can be considered as a source of autoantigens and maintains an inflammatory milieu promoting autoimmune diseases. Indeed, there is further need for research into the balance between NET induction, inhibition, and degradation in order to pharmacologically target NETs and their compounds without impairing the patient’s immune defense. This review may be of interest to both basic scientists and clinicians to stimulate translational research and innovative clinical approaches.

Disrupted Circadian Rest-Activity Cycles in Inflammatory Bowel Disease Are Associated With Aggressive Disease Phenotype, Subclinical Inflammation, and Dysbiosis

Patients with inflammatory bowel disease (IBD)-Crohn's disease (CD), and ulcerative colitis (UC), have poor sleep quality. Sleep and multiple immunologic and gastrointestinal processes in the body are orchestrated by the circadian clock, and we recently reported that a later category or chronotype of the circadian clock was associated with worse IBD specific outcomes. The goal of this study was to determine if circadian misalignment by rest-activity cycles is associated with markers of aggressive disease, subclinical inflammation, and dysbiosis in IBD. A total of 42 patients with inactive but biopsy-proven CD or UC and 10 healthy controls participated in this prospective cohort study. Subjects were defined as having an aggressive IBD disease history (steroid dependence, use of biologic or immunomodulator, and/or surgery) or non-aggressive history. All participants did two weeks of wrist actigraphy, followed by measurement of intestinal permeability and stool microbiota. Wrist actigraphy was used to calculate circadian markers of rest-activity- interdaily stability (IS), intradaily variability (IV), and relative amplitude (RA). Aggressive IBD history was associated with decrease rest-activity stability (IS) and increased fragmentation compared to non-aggressive IBD and health controls at 0.39 ±.15 vs. 0.51 ± 0.10 vs. 0.55 ± 0.09 (P < 0.05) and 0.83 ± 0.20 vs. 0.72 ± 0.14 (P < 0.05) but not HC at 0.72 ± 0.14 (P = 0.08); respectively. There was not a significant difference in RA by IBD disease history. Increased intestinal permeability and increased TNF-α levels correlated with an increased rest activity fragmentation (IV) at R = 0.35, P < 0.05 and R = 0.37, P < 0.05, respectively; and decreased rest-activity amplitude (RA) was associated with increased stool calprotectin at R = 0.40, P < 0.05. Analysis of intestinal microbiota showed a significant decrease in commensal butyrate producing taxa and increased pro-inflammatory bacteria with disrupted rest-activity cycles. In this study, different components of circadian misalignment by rest-activity cycles were associated with a more aggressive IBD disease history, increased intestinal permeability, stool calprotectin, increased pro-inflammatory cytokines, and dysbiosis. Wrist activity allows for an easy non-invasive assessment of circadian activity which may be an important biomarker of inflammation in IB.

Inflammatory Bowel Disease Environmental Risk Factors: Diet and Gut Microbiota

PURPOSE OF REVIEW

This review specifically explores the affect that diet has on the gut microbiota and its role on the increasing incidence of IBD around the world in developing countries.

RECENT FINDINGS

This is a The emergence of IBD is consistently observed as a society becomes developed and westernized implicating the critical role that environmental factors play. Environmental factors that could play a significant role in the pathogenesis of IBD include westernization of diet and improved hygiene statust. Westernization of diet is associated with changes in the gastrointestinal microbiota, which could affect the development of the immune system and thus influence the risk of disease occurrence. There remains an important need for extensive and rigorous studies focused on the role of environmental exposures on IBD management. Specifically, if environmental factors can be modified to decrease the possibility of relapse or improve patient quality of life.

Serum Serotonin Differentiates Between Disease Activity States in Crohn's Patients

BACKGROUND

Diagnosis and monitoring of inflammatory bowel diseases (IBDs) utilize invasive methods including endoscopy and tissue biopsy, with blood tests being less specific for IBDs. Substantial evidence has implicated involvement of the neurohormone serotonin (5-hydroxytryptamine, 5-HT) in the pathophysiology of IBDs. The current study investigated whether serum 5-HT is elevated in patients with active ulcerative colitis (UC) or Crohn's disease (CD).

METHODS

Serum samples were obtained from a German cohort of 96 CD and UC patients with active disease, refractory disease, or remission of disease based upon their disease activity index (DAI) and disease history. High pressure liquid chromatography with tandemmass spectrometry was used to measure 5-HT, tryptophan (TRP), and kynurenine (KYN) levels in the serum samples, and Luminex Multiplex ELISA was used to measure cytokine levels. Intestinal mucosal biopsies were obtained from a separate cohort of healthy and CD patients, and the immunoreactivity of the serotonin transporter (SERT) was determined.

RESULTS

There was no statistically significant difference in TRP or KYN levels between disease categories in either UC or CD. Interestingly, 5-HT levels were significantly elevated in patients with active CD but not active UC when compared with the levels in remission or refractory disease. Serum 5-HT was superior to C-reactive protein and circulating cytokines in differentiating between disease categories in CD. Additionally, SERT immunoreactivity was decreased in the ileum and colon of patients with CD compared to healthy controls.

CONCLUSION

We have shown that the serum 5-HT can differentiate between active disease and refractory disease or remission among CD patients, emphasizing the potential suitability of serum 5-HT as an auxiliary measure in diagnosing active CD.

Ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.

Ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.

The Influence of Breastfeeding, Cesarean Section, Pet Animals, and Urbanization on the Development of Inflammatory Bowel Disease: Data from the Swiss IBD Cohort Study

Introduction

The pathophysiology of inflammatory bowel disease (IBD) is incompletely understood. Current concepts imply that environmental factors (EFs) trigger disease onset as well as flares in genetically susceptible individuals.

Objective

The objective of this study is to analyze the association between IBD and various EFs, which may influence the pathogenesis of the disease.

Methods

2,294 patients from the Swiss IBD Cohort Study (SIBDCS) received a questionnaire regarding EF including mode of delivery, breastfeeding, animals in household, and place of residence. The control group comprised patients' childhood friends, who grew up in a similar environment ("friends cohort").

Results

A total of 1,111 questionnaires were returned from SIBDCS patients (response rate: 48.4%). Breastfeeding for <6 months was associated with a decreased risk for ulcerative colitis/indeterminate colitis (UC/IC) (OR: 0.473, p = 0.006). IBD patients reported less pet animals in the household than the control group (p = 0.004). The presence of cats or dogs (OR: 0.688, p = 0.015) and pet rodents (OR: 0.598, p = 0.001) in the household before the age of 20 was inversely associated with the risk for UC/IC.

Conclusion

The present study underlines the importance of EFs in the pathogenesis of IBD. Overall, the development of UC/IC seems to be more affected from environmental influences than from Crohn's disease. Our results imply a protective effect of possessing pet animals in household and short breastfeeding regarding the onset of UC/IC.

Crohn's disease and environmental contamination: Current challenges and perspectives in exposure evaluation

Although the incidence of Crohn's disease has increased worldwide over the past 30 years, the disorder's exact causes and physiological mechanisms have yet to be determined. Given that genetic determinants alone do not explain the development of Crohn's disease, there is growing interest in "environmental" determinants. In medical science, the term "environment" refers to both the ecological and social surroundings; however, most published studies have focused on the latter. In environmental and exposure sciences, the term "environment" mostly relates to contamination of the biotope. There are many unanswered questions on how environmental hazards might contribute to the pathogenesis of Crohn's disease. Which pollutants should be considered? Which mechanisms are involved? And how should environmental contamination and exposure be evaluated? The objective was to perform a systematic review of the literature on Crohn's disease and environmental contamination. We searched the PubMed, Google Scholar, Scopus, ISI Web of Science and Prospero databases. We considered all field studies previous to April 2019 conducted on human health indicators, and evaluating exposure to all type of physical, biological and chemical contamination of the environment. The lack of clear answers to date can be ascribed to the small total number of field studies (n = 16 of 39 publications, most of which were conducted by pioneering medical scientists), methodological differences, and the small number of contaminants evaluated. This make it impossible to conduct a coherent and efficient meta-analysis. Based on individual analysis of available studies, we formulated five recommendations on improving future research: (i) follow up the currently identified leads - especially metals and endocrine disruptors; (ii) explore soil contamination; (iii) gain a better knowledge of exposure mechanisms by developing transdisciplinary studies; (iv) identify the most plausible contaminants by developing approaches based on the source-to-target distance; and (v) develop registries and cohort-based analyses.

Circadian rhythm abnormalities in patients with inflammatory bowel disease - association with adipokine profile

Background: The role of sleep disturbances in patients with inflammatory bowel disease (IBD) remained relatively unknown. The aim of this study was to identify the adipokine profile in the patients with IBD and its relationship with the circadian rhythm disorders.Methods: Prospective, observational cohort study was performed. In all the enrolled adult IBD patients, the disease activity was assessed by using Crohn's Disease Activity Index (CDAI) for Crohn's disease (CD) and Partial Mayo Score for ulcerative colitis (UC), respectively. All patients were also asked to respond to a questionnaire to define Pittsburgh Quality Sleep Index (PSQI). From all the enrolled patients, 15 mL venous blood was taken to determine adipokine levels and perform standard laboratory tests.Results: Sixty-five IBD patients were enrolled in our study: 30 with CD and 35 with UC. Poor sleep was noted in 69.2% patients with clinically active and in 7.7% patients with inactive disease (p = .0023). In the group of IBD patients with poor sleep, the significantly higher level of serum resistin (p = .0458), and lower level of serum adiponectin and leptin (p = .0215, p = .0201; respectively) were observed. In the IBD patients with exacerbation, the significantly higher level of serum resistin (p = .0396), significantly lower serum level of leptin (p = .0453) and tendency to lower serum level of adiponectin (p = .1214) were recorded.Conclusions: The relationship between circadian rhythm abnormalities and specific adipokine profile may show us a risk factor of developing inflammatory intestinal lesions in IBD patients. This knowledge may allow the treatment of sleep disturbances, body weight-control and dietary habits become new targets in IBD therapy.

Adherence in inflammatory bowel disease (IBD): a clinical review

Adherence to treatment can be challenging, especially in chronic diseases. In inflammatory bowel disease (IBD), maintenance therapy is common to prevent a disease relapse, and adherence becomes even more of a challenge during remission. Furthermore, practical problems with taking topical treatment can increase the likelihood of non-adherence. In IBD, the definition adherence can be expanded beyond taking medication to factors like leaving blood or stool samples, keeping appointments or adjusting behaviour regarding smoking or diet. This review provides a taxonomy of different types of non-adherence and indicates how these types call for different interventions. Furthermore, the article describes how IBD nurses can open up conversations with patients that will hopefully lead to improvements in their adherence.

Impact of chronic immobilization stress on parameters of colonic homeostasis in BALB/c mice

The intestinal epithelium is a monolayer of cells arranged side‑by‑side and connected by tight junction (TJ) proteins expressed at the apical extreme of the paracellular membrane. This layer prevents stress‑induced inflammatory responses, thus helping to maintain gut barrier function and gut homeostasis. The aim of the present study was to evaluate the effects of chronic immobilization stress on the colonic expression of various parameters of homeostasis. A total of two groups of female BALB/c mice (n=6) were included: A stressed group (short‑term immobilization for 2 h/day for 4 consecutive days) and an unstressed (control) group. Colon samples were obtained to detect neutrophils and goblet cells by optical microscopy, TJ protein expression (occludin, and claudin ‑2, ‑4, ‑7, ‑12 and ‑15) by western blotting, mRNA levels of TJ genes and proinflammatory cytokines [tumor necrosis factor (TNF)‑α, interleukin (IL)‑1β, ‑6 and ‑8] by reverse transcription‑quantitative PCR, fecal lactoferrin by ELISA and the number of colony‑forming units of aerobic bacteria. Compared with goblet cells in control mice, goblet cells were enlarged and reduced in number in stressed mice, whereas neutrophil cellularity was unaltered. Stressed mice exhibited reduced mRNA expression for all evaluated TJ mRNAs, with the exception of claudin‑7, which was upregulated. Protein levels of occludin and all claudins (with the exception of claudin‑12) were decreased in stressed mice. Fecal lactoferrin, proinflammatory cytokine mRNA levels and aerobic bacterial counts were all increased in the stressed group. These results indicated that immobilization stress induced proinflammatory and potential remodeling effects in the colon by decreasing TJ protein expression. The present study may be a useful reference for therapies aiming to regulate the effects of stress on intestinal inflammatory dysfunction.

Seasonal Clock Changes Are Underappreciated Health Risks-Also in IBD?

Today, daylight saving time is observed in nearly 80 countries around the world, including the European Union, the USA, Canada, and Russia. The benefits of daylight saving time in energy management have been questioned since it was first introduced during World War I and the latest research has led to varying results. Meanwhile, adverse effects of seasonal time shifts on human biology have been postulated and the European Union is planning to abandon the biannual clock change completely. Medical studies have revealed a correlation of seasonal time shifts with increased incidences of several diseases including stroke, myocardial infarction, and unipolar depressive episodes. Moreover, studies in mice have provided convincing evidence, that circadian rhythm disruption may be involved in the pathogenesis of inflammatory bowel diseases, mainly by disturbing the intestinal barrier integrity. Here, we present previously unpublished data from a large German cohort indicating a correlation of seasonal clock changes and medical leaves due to ulcerative colitis and Crohn's disease. Furthermore, we discuss the health risks of clock changes and the current attempts on reforming daylight saving time from a medical perspective.

The association between serum vitamin D and inflammatory bowel disease

Patients with inflammatory bowel disease have an increased risk of vitamin D deficiency and this may impact upon the disease activity. This study explored the association between serum vitamin D levels and inflammatory bowel disease in a Chinese population.Sixty-five patients with ulcerative colitis (UC) and 50 with Crohn's disease (CD) were investigated between January 2015 and December 2016 at the Kunshan Second People's Hospital, China. A control group of 120 healthy volunteers was also selected. Serum vitamin D levels were detected and compared between groups and among patients with different disease activity.The serum vitamin D levels in the UC (10.27 ± 4.05 ng/mL) and CD (11.13 ± 3.96 ng/mL) groups were lower than in the control group (12.96 ± 5.18 ng/mL) (P < .05). In the UC group, during the moderate (9.21 ± 3.26 ng/mL) and severe (7.58 ± 3.81 ng/mL) periods, serum vitamin D levels were significantly lower compared with during remission (12.18 ± 3.69 ng/mL) and the mild period (11.35 ± 4.08 ng/mL) (P < .05). In the CD group, serum vitamin D levels were significantly lower during the moderate (10.28 ± 3.57 ng/mL) and severe (8.52 ± 3.72 ng/mL) periods compared with remission (13.97 ± 5.61 ng/mL) (P < .05).Patients with UC and CD are both prone to vitamin D deficiency. Serum vitamin D was significantly lower with aggravating disease status. Therefore, vitamin D may be involved in the development of inflammatory bowel disease in a Chinese population.

Serum vitamin D but not zinc levels are associated with different disease activity status in patients with inflammatory bowel disease

The incidence of inflammatory bowel disease (IBD) is increasing and the pathogenesis is still not completely understood. Micronutrients like vitamin D [25 (OH)D] and zinc play an important role in enzyme activities and the immune system. As the 25 (OH)D-receptor has been shown to be downregulated in patients with IBD, 25 (OH)D may emerge as a predictive marker for disease improvement. Studies on relationship of both micronutrients in IBD patients are lacking.We retrospectively evaluated serum levels of 25(OH)D and zinc together with baseline characteristics of 232 IBD patients. Uni- and multivariate analyses were performed for association between serum levels of 25(OH)D and zinc with clinical and deep remission (CR and DR).155 Crohn's disease (CD) and 77 ulcerative colitis (UC) patients were included. 54% (n = 125) and 6% (n = 14) of IBD patients showed deficient serum 25(OH)D levels below 20 ng/mL and zinc levels below 7 μmol/L. Serum 25(OH)D levels were significantly higher in IBD patients with CR (P = .02) and DR (P < .001) but not serum zinc levels, respectively. Serum 25(OH)D levels (P = .008), anti-tumor-necrosis-factor-α-trough-concentration (anti-TNF-α-TC) (P = .02) and CRP level (P = .02) were independently associated with CR in CD patients. Serum 25(OH)D threshold of 19 ng/mL discriminated CD patients with or without CR, having an area under the receiver operating curve analysis (AUROC) of 0.77 [95%-confidence interval (CI): 0.68-0.85]. In multivariate analysis serum 25(OH)D levels (P = .04) and anti-TNF-α-TC (P = .04) were associated with DR in CD patients. Serum 25(OH)D threshold of 26 ng/mL discriminated CD patients with or without DR, having an AUROC of 0.75 (95%-CI: 0.68-0.83).Serum 25(OH)D (P = .04) and fecal calprotectin levels (P = .04) were independently correlated with CR in UC patients. Serum 25(OH)D threshold of 32 ng/mL discriminated UC patients in CR with an AUROC of 0.83 (95%-CI: 0.71-0.95). Zinc levels did not correlate with disease activity status in CD or UC patients either.In conclusion, beside CRP and fecal calprotectin, serum 25(OH)D levels, but not serum zinc levels, may be an additional useful and noninvasive marker for characterizing different disease activity status of IBD patients. Measurement of serum 25(OH)D in IBD patients may be warranted. 25(OH)D supplementation in deficient IBD patients is recommended.

The Relationship Between Sleep Disturbance and Disease Activity in Pediatric Patients With Inflammatory Bowel Disease

OBJECTIVE

The aim of this prospective cross sectional study was to assess the prevalence of sleep disturbance in children with inflammatory bowel disease (IBD), including the relationships between sleep, inflammatory markers, and disease activity of pediatric patients with IBD.

METHODS

Pediatric patients with IBD and parents were enrolled in the study. Patients completed the Pittsburgh Sleep Quality Index (PSQI), the Pediatric Daytime Sleepiness Scale, and the Adolescent Sleep Wake Scale (ASWS) surveys. Parents completed the Child Sleep Habits Questionnaire (CSHQ). Disease activity for Crohn disease (CD) was determined by the Pediatric Crohn Disease Activity Index and the Pediatric Ulcerative Colitis Activity Index was used to define disease activity in ulcerative colitis (UC)/indeterminate colitis patients.

RESULTS

Fifty-three pediatric patients with IBD (38 CD, 12 UC, and 3 indeterminate colitis) participated in the study. The significant correlations between the CSHQ and Pediatric Crohn Disease Activity Index (P = 0.002) and the PSQI and Pediatric Ulcerative Colitis Activity Index (P = 0.04) were found. Youth with UC and indeterminate colitis significantly reported more sleep disturbance than patients with CD, (P = 0.03, 0.05, and 0.04; PSQI, Pediatric Daytime Sleepiness Scale, ASWS, respectively). Patients self-reported significantly more sleep disturbance than was observed by parents (P < 0.0001). This study showed the significant correlations between CSHQ score compared to erythrocyte sedimentation rate and albumin (P = 0.001 and 0.03, respectively).

CONCLUSIONS

Results suggest that increased disease activity is associated with adverse effects on sleep quality. Based on the results of this study, pediatric patients with IBD should be screened for sleep disturbance.

Long-term course of inflammatory bowel disease after the Great East Japan Earthquake

BACKGROUND AND AIM

This study analyzed inflammatory bowel disease activity for 2 years after the Great East Japan Earthquake.

METHODS

We compared the relapse rates of patients with ulcerative colitis or Crohn's disease 1 and 2 years after the earthquake with rates immediately after the earthquake. To evaluate continuous disease courses, we also performed multivariate time-to-event analyses from the time of the earthquake to the onset of additional treatments.

RESULTS

Of 903 patients with ulcerative colitis or Crohn's disease in our previous study, we could evaluate 2-year courses in 677 patients (394 ulcerative colitis and 283 Crohn's disease). Compared with the relapse rates of ulcerative colitis and Crohn's disease immediately after the earthquake (15.8% and 7.0%, respectively), those in the corresponding periods in 2012 (2.5% and 1.1%, respectively) and 2013 (2.3% and 2.5%, respectively) significantly decreased. There were 226 patients who required additional treatments after the earthquake. Multivariate time-to-event analyses revealed that only patients who had experienced the death of family members or friends were likely to need additional treatments (hazard ratio = 1.77, 95% confidence interval = 1.25-2.47). No other factors had a significant influence.

CONCLUSIONS

The relapse rates 1 and 2 years after the earthquake significantly decreased. The factors that influenced long-term relapse were different from those that influenced short-term relapse.

The Effect of Early-Life Environmental Exposures on Disease Phenotype and Clinical Course of Crohn's Disease in Children

OBJECTIVES

Environmental factors play an important role in the pathogenesis of Crohn's Disease (CD). In particular, by virtue of the instability of the microbiome and development of immunologic tolerance, early life factors may exert the strongest influence on disease risk and phenotype.

METHODS

We used data from 1119 CD subjects recruited from RISK inception cohort to examine the impact of early life environment on disease progression. Our primary exposures of interest were breastfeeding in infancy and exposure to maternal, active, or passive smoke. Our primary outcomes were development of complicated (stricturing or penetrating) disease, and need for CD-related hospitalization, and surgery. Multivariable logistic regression models were used to define independent associations, adjusting for relevant covariates.

RESULTS

Our study cohort included 1119 patients with CD among whom 15% had stricturing (B2) or penetrating disease (B3) by 3 years. 331 patients (35%) and 95 patients (10.6%) required CD-related hospitalizations and surgery respectively. 74.5% were breastfed in infancy and 31% were exposed to smoking among whom 7% were exposed to maternal smoke. On multivariable analysis, a history of breastfeeding was inversely associated with complicated (B2/B3 disease) 0.65, CI 95% 0.44-96; P = 0.03) in pediatric CD. Maternal smoking during pregnancy was associated with increased risk of hospitalization during the 3-year follow-up period (OR 1.75, CI 95% 1.05-2.89; P = 0.03).

CONCLUSIONS

Early life environmental factors influence the eventual phenotypes and disease course in CD.

Current, experimental, and future treatments in inflammatory bowel disease: a clinical review

Inflammatory bowel diseases (IBDs) may result from dysregulated mucosal immune responses directed toward the resident intestinal microbiota. This review describes the hallmark immunobiology of Crohn's disease and ulcerative colitis as well as therapeutic targets and mechanisms of action for current, experimental, and future treatments in IBD. Conventional therapies include 5-aminosalicylic acid, glucocorticosteroids, thiopurines, and methotrexate. Since 1997, monoclonal antibodies have gained widespread use. These consist of antibodies directed against pro-inflammatory cytokines such as tumor necrosis factor α, interleukin (IL)-12, and IL-23, or anti-homing antibodies directed against α4β7 integrin. Emerging oral therapies include modulators of intracellular signal transduction such as Janus kinase inhibitors. Vitamin D may help to regulate innate and adaptive immune responses. Modulation of the intestinal microbiota, using live microorganisms (probiotics), substrates for the colonic microbiota (prebiotics), or fecal microbiota transplantation (FMT), is in development. Dietary supplements are in widespread use, but providing evidence for their benefit is challenging. Stem cell treatment and nervous stimulation are promising future treatments.

Crohn's Disease Candidate Gene Alleles Predict Time to Progression from Inflammatory B1 to Stricturing B2, or Penetrating B3 Phenotype

AIM

Crohn's disease (CD) patients are mostly diagnosed with the uncomplicated inflammatory form of disease; however, the majority will progress to complicated stricturing or penetrating disease over time. It is important to identify patients at risk for disease progression at an early stage. The aim of our study was to examine the role of 33 candidate CD genes as possible predictors of disease progression and their influence on time to progression from an inflammatory to a stricturing or penetrating phenotype.

METHODS

Patients with an inflammatory phenotype at diagnosis were followed for 10 years and 33 CD-associated polymorphisms were genotyped. To test for association with CD, 449 healthy individuals were analyzed as the control group.

RESULTS

Ten years after diagnosis, 39.1% of patients had not progressed beyond an inflammatory phenotype, but 60.9% had progressed to complicated disease, with average time to progression being 5.91 years. Association analyses of selected single nucleotide polymorphisms (SNPs) confirmed associations with CD for 12 SNPs. Furthermore, seven loci were associated with disease progression, out of which SNP rs4263839 in the gene TNFSF15 showed the strongest association with disease progression and the frameshift mutation rs2066847 in the gene NOD2 showed the strongest association with time to progression.

CONCLUSIONS

The results of our study identified specific genetic biomarkers as useful predictors of both disease progression and speed of disease progression in patients with CD.

Inflammatory Bowel Diseases: Review of Known Environmental Protective and Risk Factors Involved

Inflammatory bowel diseases consisting of Crohn's disease and ulcerative colitis are chronic inflammatory diseases of the gastrointestinal tract. In addition to genetic susceptibility and disturbances of the microbiome, environmental exposures forming the exposome play an important role. Starting at birth, the cumulative effect of different environmental exposures combined with a predetermined genetic susceptibility is thought to cause inflammatory bowel disease. All these environmental factors are part of a Western lifestyle, suiting the high incidence rates in Europe and the United States. Whereas receiving breastfeeding, evidence of a Helicobacter pylori infection and vitamin D are important protective factors in Crohn's disease as well as ulcerative colitis, increased hygiene, experiencing a bacterial gastroenteritis in the past, urban living surroundings, air pollution, the use of antibiotics, nonsteroidal anti-inflammatory drugs, and oral contraceptives are likely to be the most important risk factors for both diseases. Current cigarette smoking yields a divergent effect by protecting against ulcerative colitis but increasing risk of Crohn's disease, whereas former smoking increases chances of both diseases. This review gives a clear overview of the current state of knowledge concerning the exposome. Future studies should focus on measuring this exposome yielding the possibility of combining all involved factors to one exposome risk score and our knowledge on genetic susceptibility.

Inflammatory bowel disease and venous thromboembolism during pregnancy and the postpartum period

Essentials Risk of pregnancy-related venous thromboembolism may be increased in inflammatory bowel disease. We performed a study on inflammatory bowel disease and pregnancy-related venous thromboembolism. Inflammatory bowel disease is a risk factor for pregnancy-related venous thromboembolism. Proper disease control before conception is pivotal to avoid venous thromboembolism.

SUMMARY

Background The incidence of inflammatory bowel disease (IBD) increases, and thus is more common, in pregnant women. IBD is a risk factor for venous thromboembolism (VTE) but it is not clear whether IBD predisposes women to an excess risk of VTE during pregnancy and the postpartum period. Methods This was a nationwide population-based cohort study of all deliveries during 1980-2013 in Denmark, using data from two nationwide health registries: the Danish National Patient Registry and the Medical Birth Registry. We computed incidence rates (IRs) per 1000 person-years, and crude and adjusted relative risks (RRs) with 95% confidence intervals (CIs) for VTE during pregnancy and the first 12 postpartum weeks in women with and without IBD. Results We included 1 046 754 women with 1 978 701 deliveries. We identified 3465 VTE events during pregnancy and 1302 VTE events postpartum. The IR for VTE during pregnancy was 4.20 (95% CI, 2.83-5.58) in IBD patients and 2.41 (95% CI, 2.33-2.50) in women without IBD, corresponding to an RR of 1.72 (95% CI, 1.22-2.43). Adjustment for maternal age and smoking (pregnancies during 1991-2013) yielded an adjusted RR of 1.67 (95% CI, 1.15-2.41). IBD flare was associated with an RR of 2.64 (95% CI, 1.69-4.14) for VTE during pregnancy. The IR for postpartum VTE was 7.03 (95% CI, 3.87-10.20) among IBD patients and 2.88 (95% CI, 2.72-3.04) in women without IBD, corresponding to an adjusted RR of 2.10 (95% CI, 1.33-3.30). Conclusions IBD is a risk factor for VTE during pregnancy and postpartum.

Impact of Environmental and Familial Factors in a Cohort of Pediatric Patients With Inflammatory Bowel Disease

OBJECTIVES

The primary role of environment on inflammatory bowel disease (IBD) onset has been recently stressed. We aimed to investigate the effect of environmental factors in an IBD pediatric cohort.

METHODS

A total of 467 subjects (264 IBD and 203 controls) were enrolled. All patients underwent a questionnaire including 5 different groups of environmental risk factors: family history of IBD and autoimmune diseases, perinatal period, home amenities and domestic hygiene, childhood diseases and vaccinations, and diet.

RESULTS

In a multivariate model, mother's degree (odds ratio [OR]: 5.5; 2.5-11.6), duration of breast feeding >3rd month (OR: 4.3; 1.6-10.5), father's employment (OR: 3.7; 1.2-8.7), gluten introduction <6th month (OR: 2.8; 1.5-5), number of siblings <2 (OR: 2.8; 1.5-5.3), and family history of autoimmune diseases (OR: 2.7; 1.4-5.3) were significant risk factors for Crohn disease. Low adherence to Mediterranean diet (OR: 2.3; 1.2-4.5), gluten introduction <6th month (OR: 2.8; 1.6-4.9), and number of siblings <2 (OR: 2; 1.1-3.6) were significant risk factors for ulcerative colitis. Owning pets (OR: 0.3; 0.1-0.7) and bed sharing (OR: 0.2; 0.1-0.6) were protective factors for Crohn disease, whereas owning pets (OR: 0.4; 0.2-0.8) and family parasitosis (OR: 0.07; 0.01-0.4) were protective factors for ulcerative colitis.

CONCLUSIONS

Our study confirms that environmental factors are closely linked to IBD onset and may partly explain IBD rise in developed countries.

Inflammatory bowel disease and airway diseases

Airway diseases are the most commonly described lung manifestations of inflammatory bowel disease (IBD). However, the similarities in disease pathogenesis and the sharing of important environmental risk factors and genetic susceptibility suggest that there is a complex interplay between IBD and airway diseases. Recent evidence of IBD occurrence among patients with airway diseases and the higher than estimated prevalence of subclinical airway injuries among IBD patients support the hypothesis of a two-way association. Future research efforts should be directed toward further exploration of this association, as airway diseases are highly prevalent conditions with a substantial public health impact.

Avoidance of Fiber Is Associated With Greater Risk of Crohn's Disease Flare in a 6-Month Period

BACKGROUND & AIMS

Chronic inflammatory bowel diseases (IBDs) have been associated with an abnormal mucosal response to the gastrointestinal microbiota. Although dietary fiber affects the gastrointestinal microbiota, there is limited information on the role of fiber on IBD activity. We investigated factors associated with fiber consumption and whether it was associated with flares in patients with IBD.

METHODS

We collected a completed 26-item dietary survey from 1619 participants in the Crohn's and Colitis Foundation of America Partners Internet cohort (Crohn's disease, 1130; ulcerative colitis/indeterminate colitis, 489). Eligible individuals were in remission based on disease activity index at baseline and completed a follow-up survey 6 months later. Fiber and whole grain consumption were categorized into quartiles and deciles. Disease flare at 6 months was defined as a disease activity index score exceeding remission cutoff values, and/or an IBD-related surgical procedure or hospitalization since baseline.

RESULTS

Participants with longer duration of disease, past history of surgery, and past IBD hospitalization ate less fiber. The risks for disease flare differed by disease type. Compared with those in the lowest quartile of fiber consumption, participants with Crohn's disease in the highest quartile were less likely to have a flare (adjusted odds ratios [OR], 0.58; 95% confidence interval [CI], 0.37-0.90). Participants with Crohn's disease who reported that they did not avoid high-fiber foods were ∼40% less likely to have a disease flare than those who avoided high-fiber foods (adjusted OR, 0.59; 95% CI, 0.43-0.81). There was no association between fiber intake and flares in patients with ulcerative colitis (adjusted OR, 1.82; 95% CI, 0.92-3.60).

CONCLUSIONS

Intake of dietary fiber is associated with reduced disease flares in patients with Crohn's disease, but not UC. Recommendations to limit dietary fiber should be re-evaluated.

Patients With Inflammatory Bowel Disease Are Unaware of the Impact of Smoking on Their Disease

BACKGOUND

Tobacco is one of the most significant risk factors for inflammatory bowel disease (IBD).

GOALS

The main objective was to assess the knowledge of patients with IBD regarding the effects of tobacco on their disease. Secondary objectives were to determine the source of their knowledge, the influence of their knowledge on their intent to quit smoking, and the association between patients' characteristics and their knowledge.

STUDY

Patients with IBD completed a self-administered questionnaire on demographic data, severity of disease, and effects of tobacco on their disease.

RESULTS

In total 259 patients [182 with Crohn's disease, 77 with ulcerative colitis (UC)] participated. The prevalence of current smokers, exsmokers, and nonsmokers was 19.6%, 40.2%, and 40.2%, respectively. Patients with Crohn's disease were more aware of the effects of tobacco on their disease compared with those with UC (57.7% vs. 13.0%, P<0.0001). In informed patients, the main source of information was the gastroenterologist (56.9%). The intent to quit smoking was superior in informed patients compared with those uninformed (78.6% vs. 47.8%, P=0.046). Older patients (odds ratio=0.97, P=0.01) and patients with UC (odds ratio=0.11, P<0.0001) were less likely to be informed.

CONCLUSIONS

Only half of patients with IBD are aware of the risks of smoking associated with their disease, whereas their intent to quit smoking is directly related to their awareness. In the scope of IBD's treatment, management of smoking cessation should be undertaken in all smokers.

A mechanistic review on plant-derived natural compounds as dietary supplements for prevention of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a recurrent idiopathic inflammatory condition, characterized by disruption of the gut mucosal barrier. This mechanistic review aims to highlight the significance of plant-derived natural compounds as dietary supplements, which can be used in addition to restricted conventional options for the prevention of IBD and induction of remission. Various clinical trials confirmed the effectiveness and tolerability of natural supplements in patients with IBD. Mounting evidence suggests that these natural compounds perform their protective and therapeutic effect on IBD through numerous molecular mechanisms, including anti-inflammatory and immunoregulatory, anti-oxidative stress, modulation of intracellular signaling transduction pathways, as well as improving gut microbiota. In conclusion, natural products can be considered as dietary supplements with therapeutic potential for IBD, provided that their safety and efficacy is confirmed in future well-designed clinical trials with adequate sample size.

Incidence of Crohn's Disease and Ulcerative Colitis in Rhode Island: Report from the Ocean State Crohn's and Colitis Area Registry

BACKGROUND

Studies describing the incidence of Crohn's disease (CD) and ulcerative colitis (UC) are uncommon in the United States. We sought to determine the incidence of CD and UC in the state of Rhode Island.

METHODS

The Ocean State Crohn's and Colitis Area Registry is a state-based inception cohort of patients newly diagnosed with inflammatory bowel disease (IBD) in Rhode Island. To confirm a diagnosis of CD, UC, or IBD unclassified (IBDU), the National Institute of Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium criteria were applied in a review of medical records from gastroenterology practices located in the state of Rhode Island and adjacent to the Rhode Island border in Massachusetts and Connecticut. Using population-based data, we determined the statewide incidence of IBD in Rhode Island from 2008 to 2010.

RESULTS

A total of 971 Rhode Island residents were diagnosed with IBD, including 444 with CD, 486 with UC, and 41 with IBD unclassified from 2008 to 2010. The overall age- and sex-adjusted IBD incidence was 30.2 (95% confidence interval, 28.3-32.1) per 100,000 persons in this time frame with 13.9, 15.1, and 1.3 per 100,000 diagnosed with CD, UC, and IBD unclassified, respectively. Of the total incident cases in Rhode Island, 30% (n = 291) were enrolled in Ocean State Crohn's and Colitis Area Registry for follow-up.

CONCLUSIONS

The incidence of IBD in Rhode Island is higher than that previously reported by other population-based cohorts in the United States. Prospective follow-up of individuals enrolled in the community-based Ocean State Crohn's and Colitis Area Registry cohort is ongoing.

Circadian rhythm abnormalities - Association with the course of inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) are the main representatives of inflammatory bowel diseases (IBD), a group of chronic, immune system-mediated inflammatory diseases of the gastrointestinal (GI) tract. The pathogenesis of the intestinal lesions in IBD is not entirely identified and understood: excessive activation of the immune system may come as a result of the interaction of various environmental and infectious factors, genetic predisposition, and the mediation of abnormal intestinal flora. The main objective of the current study is to further identify the risk factors for the development of IBD. Currently, there is very little knowledge about circadian rhythm and IBD and there are only a few studies on the relationship between sleep disturbances and the course of the disease, as well as pro- and anti-inflammatory cytokine profile and general immune system functioning. Furthermore, the relationship between the expression of circadian rhythm genes and severe course of IBD is still unknown. The aim of this review is to show the current state of knowledge about the relationship between circadian rhythm disorders, sleep disturbance and inflammation in the GI tract and to analyze the possibility of employing this knowledge in diagnosis and treatment of IBD.

Role of Nonsteroidal Anti-Inflammatory Drugs in Exacerbations of Inflammatory Bowel Disease

GOALS

To determine the role of nonsteroidal anti-inflammatory drugs (NSAIDs) in activation of inflammatory bowel disease (IBD).

BACKGROUND

NSAIDs may activate inflammatory pathways in IBD.

STUDY

Crohn's and Colitis Foundation of American Partners is an ongoing cohort study of patients living with IBD. All data are self-reported using the internet. We identified a subcohort of participants whose disease activity, based on short Crohn's Disease Activity Index and simple clinical colitis activity index, indicated remission. Pattern of use of NSAIDs was measured at baseline, and disease activity assessment was performed 6 months later. We used multivariate binomial regression to determine effects of NSAIDs on disease activity.

RESULTS

A total of 791 individuals in remission had baseline and follow-up data available for analysis. Of these, 247 Crohn's disease (CD) patients (43.2%) and 89 ulcerative colitis (UC) patients (40.6%) reported NSAID use. CD patients with NSAID use ≥5 times/month had greater risk of active disease at follow-up (23% vs. 15%, P=0.04); [adjusted risk ratio (RR), 1.65; 95% confidence interval (CI), 1.12-2.44). No effect was observed in patients with UC (22% vs. 21%, P=0.98; adjusted RR, 1.25; 95% CI, 0.81-1.92). Acetaminophen use was associated with active disease at follow-up in CD (adjusted RR, 1.72; 95% CI, 1.11-2.68).

CONCLUSIONS

Regular (≥5 times/mo) NSAID and acetaminophen use were associated with active CD, but not UC. Less frequent NSAID use was not associated with active CD or UC. These findings indicate that regular NSAID use may increase CD activity, or that NSAID use may be a marker of a less robust remission; thus reflecting subclinical disease activity.