Latin American consensus on the quality indicators for comprehensive care clinics for patients with inflammatory bowel disease: PANCCO-GETECCU

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic and incurable entity. The aim of the Pan American Crohn's and Colitis Organisation (PANCCO) is to create awareness of IBD, with special emphasis on Latin America, and the primary objective of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU, the Spanish acronym) is to obtain the accreditation of the clinical and therapeutic criteria for the diagnosis and treatment of IBD.

AIM

To carry out a consensus for evaluating the approval criteria that a Comprehensive Care Clinic for Latin American IBD patients must meet, to be considered a center of excellence.

MATERIALS AND METHODS

Fourteen clinical experts participated in the consensus. They were made up of specialists in gastroenterology, with broad clinical experience, spanning several years, in managing the care of a large number of patients with IBD, as well as advanced specialists in IBD. Thirteen of the participants came from 11 Latin American countries (Argentina, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Mexico, Peru, Puerto Rico, Uruguay, and Venezuela) that have IBD clinics. An expert from Spain, representing the GETECCU, provided the methodologic support. The consensus consisted of 52 statements divided into three sections: 1) Structure indicators, 2) Process indicators, and 3) Result indicators. The Delphi panel method was applied.

RESULTS

The present Latin American consensus describes the quality indicators that a Comprehensive Care Clinic for IBD patients must meet, to be considered a center of excellence, taking into account the needs of our region.

CONCLUSIONS

This is the first Latin American consensus, jointly carried out by the PANCCO and GETECCU, to present accreditation standards for centers of excellence in the care of patients with IBD.

Progression of Inflammatory Bowel Diseases Throughout Latin America and the Caribbean: A Systematic Review

BACKGROUND & AIMS

The incidence of inflammatory bowel diseases (IBD) is increasing in Latin America. We performed a systematic review to identify clinical and epidemiologic features of IBD in Latin America (including Mexico, Central America, and South America) and the Caribbean.

METHODS

We searched MEDLINE, EMBASE, and SciELO databases for clinical or epidemiologic studies of Crohn's disease (CD) or ulcerative colitis (UC) from Latin American and Caribbean countries and territories that reported incidence, prevalence, ratio of UC:CD, IBD phenotype, and treatment, through September 12, 2018. Data were extracted from 61 articles for analysis.

RESULTS

The incidence and prevalence of IBD have been steadily increasing in Latin America and the Caribbean. The incidence of CD in Brazil increased from 0.08 per 100,000 person-years in 1988 to 0.68 per 100,000 person-years in 1991-1995 to 5.5 per 100,000 person-years in 2015. The highest reported prevalence of IBD was in Argentina, in 2007, at 15 and 82 per 100,000 person-years for CD and UC, respectively. The ratio of UC:CD exceeded 1 in all regions throughout Latin America and the Caribbean with the exception of Brazil. Treatment with tumor necrosis factor antagonists increased steadily for patients with CD (43.4% of all patients in Brazil were treated in 2014) but less so for patients with UC (4.5% of all patients were treated in 2014). Surgery for IBD decreased with time. In Chile, surgeries were performed on 57.0% of patients with CD and 18.0% of patients with UC during the period of 1990-2002; these values decreased to 38.0% and 5.0%, respectively, during the period of 2012-2015. In Peru, 6.9% of patients with UC received colectomies in the period of 2001-2003 and 6.2% in 2004-2014.

CONCLUSIONS

In a systematic review, we found the incidence of IBD to be increasing throughout Latin America and the Caribbean. Population-based epidemiology studies are needed to evaluate the increase in IBD in these regions, which differ from other global regions in climate, culture, demographics, diet, healthcare delivery and infrastructure, and socioeconomic status.

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.

Incidence of inflammatory bowel disease in five geographical areas of Uruguay in the biennial 2007-2008

INTRODUCTION

The incidence of inflammatory bowel disease (IBD) is different according to the geographical areas. No data on the incidence of IBD in Uruguay are available.

OBJECTIVE

To determine the incidence of IBD, ulcerative colitis (UC) and Crohn's disease (CD), in five areas of Uruguay and to compare the results with those from other geographical regions.

MATERIAL AND METHOD

A prospective study was performed in five areas of Uruguay during 2007-2008. The study population included 645,695 inhabitants. Multiple independent sources were used for the uptake of cases. Patients older than 14 years and living in the selected areas were included only after reviewing their medical history. Confirmed IBD was defined by a standard protocol after one year of follow up.

RESULTS

A total of 34 cases were diagnosed in the study period, 29 UC and 5 CD. Crude incidence rate for IBD was 2.63 per 100,000 inhabitants/year, 2.25 and 0.39 for UC and CD, respectively. Adjusted rates were 4.26 per 100,000 inhabitants/year for UC and 0.74 per 100,000 inhabitants/year for CD. The UC/CD ratio was 5.8. The average age for IBD was 40.7 years. No statistically significant differences were found between UC and CD by age (P = 0.267) or gender (P = 0.489).

CONCLUSIONS

Incidence rates of IBD place Uruguay in the regions of low incidence. As it has been described in low-incidence countries, UC is more common than CD. This study establishes a precedent to follow the evolution of IBD epidemiology in Uruguay.

[Clinical characteristics of patients with inflammatory bowel disease and thromboembolic events]

OBJECTIVE

To determine the clinical characteristics of patients with thromboembolic events (TEE) included in the National Register of Inflammatory Bowel Diseases of Uruguay (RNEII).

MATERIAL AND METHODS

From the RNEII database of 515 patients, an analysis of case series was made. Medical records of 23 patients with diagnosis of ETE were reviewed Image studies were required for diagnosis of deep thrombosis, while superficial thromboflebitis diagnosis was clinical.

RESULTS

Eight patients who did not meet the inclusion criteria were excluded. Of the remaining fifteen patients (2.9%), 11 had ulcerative colitis (CUC) and 4 Crohn's disease (CD). The mean age was 42.1 years (range 12 to 64 years). 40% presented this complication before the 40 years old and the mortality caused by TEE was 6.7%. 53.3 of cases had active disease when the TEE presented. 63.6% of CUC patients developed an extensive colitis, while 100% of patients with CD had colonic involvement. Another extraintestinal manifestation was seen in 46.7% of patients, specially in the CUC group. Deep vein thrombosis was the most frequent TEE (66.7%). 40% of patients repeated more than one TEE episode.

CONCLUSIONS

TEE in inflammatory bowel disease are an important morbimortality factor because they can occur in young people, be recurrent and affect unusual vascular sites. TEE may be observed in both active and quiescent disease. They have been more frequently found in patients with extensive disease, colonic involvement and other extraintestinal manifestations.

[The Latin-American Consensus on Chronic Constipation]

The Latin-American Consensus on Chronic Constipation aimed to establish guidelines to improve the identification, diagnosis and treatment of this disorder in the region. Two coordinators and an honorary coordinator established the process and the topics to be discussed, based on a systematic review of the literature published in the previous 10 years, since 1995. Seventeen members participated with the support of their local gastroenterology societies. The members reviewed the different subjects based on the levels of evidence and grades of recommendation; the topics were then discussed in a plenary session. A written report was drafted and the coordinators prepared the final declarations to be submitted to a vote by all the members in October 2006. The consensus concluded that chronic constipation has an estimated prevalence of 5-21% in the region, with a female-to-male ratio of 3:1. Among individuals with constipation, 75% use some type of medication, with more than 50% using home remedies. A diagnosis based on Rome Criteria was recommended and diagnostic testing only in persons older than 50 years or with alarm symptoms. The use of barium enema as an initial investigation was recommended only in countries with a high prevalence of idiopathic megacolon or Chagas' disease. Recommendations on treatment included an increase in dietary fiber of up to 25-30 g/day (grade C). No evidence was found to recommend measures such as exercise, increased water intake, or frequent visits to the toilet. Fiber supplements such as Psyllium received a grade B and pharmacological treatments such as tegaserod and polyethylene glycol, both grade A. There was insufficient evidence to recommend lactulose, but the consensus did not disadvise its use when necessary. Complementary investigations such as colonic transit followed by anorectal manometry and defecography were only recommended to rule out colonic inertia and/or obstructive defecation in patients not responding to treatment. Biofeedback was recommended (grade B) for those with pelvic dyssynergia.