eHealth: individualisation of infliximab treatment and disease course via a self-managed web-based solution in Crohn’s disease

BACKGROUND

Infliximab (IFX) maintenance therapy for Crohn's disease (CD) is administered every 8 weeks, but inter-patient variation in optimal treatment intervals may exist.

AIM

To assess, in a prospective pilot study, the efficacy, safety and quality of life (QoL) of IFX maintenance treatment scheduled through web-based self-monitoring of disease activity.

METHODS

Twenty-seven CD patients in IFX maintenance therapy were enrolled and received a standardised disease education and web-training. Using the http://www.cd.constant-care.dk concept, patients recorded their disease activity and faecal calprotectin weekly. From this, the inflammatory burden (IB) score was calculated, placing patients in the green, yellow or red zones of a ‘traffic light’ system. If placed in the yellow or red zones, the computer directed these patients to consult their physician for IFX infusion.

RESULTS

Seventeen patients (63%) completed 52 weeks of follow-up, 6 (22%) completed 26 weeks and 4 (15%) were excluded due to loss of response, patient decision or non-adherence. In total, 121 IFX infusions were given with a median interval of 9 (range: 4–18) weeks. Only 10% of infusions were given at 8-week intervals, whereas 39% were administered with shorter and 50% with longer intervals respectively. The mean IB and the QoL remained stable during the web-treatment. One mild infusion reaction and one case of folliculitis were observed, while three patients underwent surgery.

CONCLUSIONS

The program http://www.cd.constant-care.dk appears to be a practical and safe concept for the individualised scheduling of maintenance treatment with IFX in patients with Crohn's disease. Larger studies are awaited to confirm this preliminary outcome.

E-health: Web-guided therapy and disease self-management in ulcerative colitis. Impact on disease outcome, quality of life and compliance

Ulcerative Colitis (UC) together with Crohn's disease (CD) belongs to inflammatory bowel diseases (IBD). IBD is to date as frequent as Insulin Dependent Diabetes (IDDM) and is second to Rheumatoid Arthritis (RA) in its chronicity. The majority (91%) of patients with UC have a mild to moderate disease course eligible for 5-ASA treatment. Poor adherence in UC is a well known phenomenon, which is associated with a 5-fold increased risk of relapse and increased health care costs. Web-based treatment solution with self-initiated 5-ASA treatment in UC based on the patient's pattern recognition of the disease course had not been published previously. The aims of the thesis were: 1) In a European evidence based consensus to assess the IBD patients' need for Quality of Health Care (QoHC); 2) To validate the influence of a Patient Educational Center (PEC) and a web-based treatment solution program, www.constant-care.dk, on patients' disease self-management, adherence, Quality of Life, and disease course after 1 year of self-initiated 5-ASA treatment. UC patients in a conventional out-patient setting were used as controls; 3) To validate two new quantitative rapid tests (RT scanning and HT photo) for Faecal Calprotectin (FC) measurement, and to assess whether HT photo can be useful as a home test to help the patients deciding on self-initiated treatment. The ECCO Consensus found evidence for optimising QoHC by "information"; "education", "benchmarking", and "psychological analysis", which could help to improve patient compliance, QoL, and to decrease depression and anxiety. UC patients, educated in the PEC, significantly improved the level of disease specific knowledge. Patient education and training on www.constant-care.dk, being validated on first 21 Danish patients and subsequently on 233 Danish and 100 Irish patients, showed that the new web guided approach was feasible, safe, and cost effective for the selected group of the patients included in the trial. Use of the web concept increased patients adherence to acute 5-ASA treatment, (p = 0.005) and community effectiveness up to 33%, improved Quality of Life, (p = 0.004), increased patients' ability to sufficient self-initiated treatment and reduce out-patient visits, (p < 0.0001). Patients' morbidity and depression remained unchanged. Median duration of relapse in the web-group was 59 days shorter than in the control-group possibly due to high dose of systemic 5-ASA treatment, (p < 0.0001). We found that the new rapid home test (HT photo) was accurate and comparable with the Enzyme-Linked Immunosorbent Assay (ELISA) with a 90% specificity and a 96% sensitivity. The rapid test can be useful in clinical settings concerning disease self-monitoring at home, which would decrease the use of endoscopy in some cases. The findings corresponded well with action plan for a European e-Health Area and could be a helpful tool to provide more efficient health care for UC patients. Widespread implementation of the "Constant-Care" is possible, but it may require a reshaping of the current health care for IBD patients both legally and economically. It may also empower patients in disease self-management and reduce dependency on doctors. Future long-term studies are needed to investigate, if this concept could possibly change the natural disease course.

Environmental factors in inflammatory bowel disease: a case-control study based on a Danish inception cohort

BACKGROUND

The role of environmental factors in development of inflammatory bowel disease (IBD) remains uncertain. The aim of the present study was to assess a number of formerly suggested environmental factors in a case-control study of an unselected and recently diagnosed group of patients with IBD and a control group of orthopaedic patients.

METHODS

A total of 123 patients diagnosed with Crohn's disease (CD) and 144 with ulcerative colitis (UC) in Copenhagen (2003-2004) were matched 1:1 on age and gender to 267 orthopaedic controls. Participants received a questionnaire with 87 questions concerning environmental factors prior to IBD/orthopaedic admission. Odds ratios (OR) were calculated by logistic regression.

RESULTS

Being breastfed >6 months (OR, 0.50; 95% CI, 0.23-1.11) and undergoing tonsillectomy (OR, 0.49; 95% CI, 0.31-0.78) decreased the odds for IBD, whereas appendectomy decreased the odds for UC only (OR, 0.29; 95% CI, 0.12-0.71). Vaccination against pertussis (OR, 2.08; 95% CI, 1.07-4.03) and polio (OR, 2.38; 95% CI, 1.04-5.43) increased the odds for IBD, whereas measles infection increased the odds for UC (OR, 3.50; 95% CI, 1.15-10.6). Low consumption of fibres and high consumption of sugar were significantly associated with development of CD and UC. Smoking increased the risk for CD and protected against UC.

CONCLUSION

Among Danish patients with CD and UC belonging to an unselected cohort, disease occurrence was found to be associated both with well-known factors such as smoking and appendectomy, and with more debated factors including breastfeeding, tonsillectomy, childhood vaccinations, childhood infections, and dietary intake of fibres and sugar.

Construction and validation of a web-based epidemiological database for inflammatory bowel diseases in Europe An EpiCom study

BACKGROUND

The EpiCom-study investigates a possible East-West-gradient in Europe in the incidence of IBD and the association with environmental factors. A secured web-based database is used to facilitate and centralize data registration.

AIM

To construct and validate a web-based inception cohort database available in both English and Russian language.

METHOD

The EpiCom database has been constructed in collaboration with all 34 participating centers. The database was translated into Russian using forward translation, patient questionnaires were translated by simplified forward-backward translation. Data insertion implies fulfillment of international diagnostic criteria, disease activity, medical therapy, quality of life, work productivity and activity impairment, outcome of pregnancy, surgery, cancer and death. Data is secured by the WinLog3 System, developed in cooperation with the Danish Data Protection Agency. Validation of the database has been performed in two consecutive rounds, each followed by corrections in accordance with comments.

RESULTS

The EpiCom database fulfills the requirements of the participating countries' local data security agencies by being stored at a single location. The database was found overall to be "good" or "very good" by 81% of the participants after the second validation round and the general applicability of the database was evaluated as "good" or "very good" by 77%. In the inclusion period January 1st -December 31st 2010 1336 IBD patients have been included in the database.

CONCLUSION

A user-friendly, tailor-made and secure web-based inception cohort database has been successfully constructed, facilitating remote data input. The incidence of IBD in 23 European countries can be found at www.epicom-ecco.eu.

E-health empowers patients with ulcerative colitis: a randomised controlled trial of the web-guided 'Constant-care' approach

BACKGROUND

The natural history of ulcerative colitis requires continuous monitoring of medical treatment via frequent outpatient visits. The European health authorities' focus on e-health is increasing. Lack of easy access to inflammatory bowel disease (IBD) clinics, patients' education and understanding of the importance of early treatment at relapse is leading to poor compliance. To overcome these limitations a randomised control trial 'Constant-care' was undertaken in Denmark and Ireland.

METHODS

333 patients with mild/moderate ulcerative colitis and 5-aminosalicylate acid treatment were randomised to either a web-group receiving disease specific education and self-treatment via http://www.constant-care.dk or a control group continuing the usual care for 12 months. A historical control group was included to test the comparability with the control group. We investigated: feasibility of the approach, its influence on patients' compliance, knowledge, quality of life (QoL), disease outcomes, safety and health care costs.

RESULTS

88% of the web patients preferred using the new approach. Adherence to 4 weeks of acute treatment was increased by 31% in Denmark and 44% in Ireland compared to the control groups. In Denmark IBD knowledge and QoL were significantly improved in web patients. Median relapse duration was 18 days (95% CI 10 to 21) in the web versus 77 days (95% CI 46 to 108) in the control group. The number of acute and routine visits to the outpatient clinic was lower in the web than in the control group, resulting in a saving of 189 euro/patient/year. No difference in the relapse frequency, hospitalisation, surgery or adverse events was observed. The historical control group was comparable with the control group.

CONCLUSION

The new web-guided approach on http://www.constant-care.dk is feasible, safe and cost effective. It empowers patients with ulcerative colitis without increasing their morbidity and depression. It has yet to be shown whether this strategy can change the natural disease course of ulcerative colitis in the long term.

Risk of extra-intestinal cancer in inflammatory bowel disease: meta-analysis of population-based cohort studies

OBJECTIVES

Extra-intestinal manifestations of inflammatory bowel disease (IBD) are relatively common, whereas the risk of extra-intestinal cancer (EIC) remains uncertain. The aim of this study was to obtain a reliable estimate of the risk of EIC in Crohn's disease (CD) and ulcerative colitis (UC) by performing a meta-analysis of population-based cohort studies.

METHODS

A systematic literature review was performed using MEDLINE (1966-2009) and abstracts from recent international conferences. Eight population-based cohort studies comprising a total of 17,052 patients with IBD were available. Standardized incidence ratios (SIRs) of EICs were pooled in a meta-analysis approach using STATA software.

RESULTS

Overall, IBD patients were not at increased risk of EIC (SIR, 1.10; 95% confidence interval (CI) 0.96-1.27). However, site-specific analyses revealed that CD patients had an increased risk of cancer of the upper gastrointestinal tract (SIR 2.87, 95% CI 1.66-4.96), lung (SIR 1.82, 95% CI 1.18-2.81), urinary bladder (SIR 2.03, 95% CI 1.14-3.63), and skin (SIR 2.35, 95% CI 1.43-3.86). Patients with UC had a significantly increased risk of liver-biliary cancer (SIR 2.58, 95% CI 1.58-4.22) and leukemia (SIR 2.00, 95% CI 1.31-3.06) but a decreased risk of pulmonary cancer (SIR 0.39, 95% CI 0.20-0.74).

CONCLUSIONS

Although the overall risk of EIC was not significantly increased among patients with IBD, the risk of individual cancer types differed from that of the background population as well as between CD and UC patients. These findings may primarily be explained by smoking habits, extra-intestinal manifestations of IBD, and involvement of the upper gastrointestinal tract in CD.

Clinical and economic outcomes in a population-based European cohort of 948 ulcerative colitis and Crohn's disease patients by Markov analysis

BACKGROUND

Forecasting clinical and economic outcomes in ulcerative colitis (UC) and Crohn's disease (CD) patients is complex, but necessary.

AIMS

To determine: the frequency of treatment-classified clinical states; the probability of transition between states; and the economic outcomes.

METHODS

Newly diagnosed UC and CD patients, allocated into seven clinical states by medical and surgical treatments recorded in serial 3-month cycles, underwent Markov analysis.

RESULTS

Over 10 years, 630 UC and 318 CD patients had 22,823 and 11,871 cycles. The most frequent clinical outcomes were medical/surgical remission (medication-free) and mild disease (on 5-aminosalicylates, antibiotics, topical corticosteroids), comprising 28% and 62% of UC cycles and 24% and 51% of CD cycles respectively. The probability of drug-response in patients receiving systemic corticosteroids/immunomodulators was 0.74 in UC, 0.66 in CD. Both diseases had similar likelihood of persistent drug-dependency or drug-refractoriness. Surgery was more probable in CD, 0.20, than UC, 0.08. In terms of economic outcomes, surgery was costlier in UC per cycle, but the outlay over 10 years was greater in CD. Drug-refractory UC and CD cases engendered high costs in the cohort.

CONCLUSIONS

Most patients on 5-aminosalicylates, corticosteroids and immunomodulators had favourable clinical and economic outcomes over 10 years. Drug-refractory and surgical patients exhibited greater long-term expenses.

Overall and cause-specific mortality in Crohn's disease: a meta-analysis of population-based studies

BACKGROUND

An overview of mortality risk among unselected patients with Crohn's disease (CD) is lacking. We therefore performed a systematic review and meta-analysis of population-based studies on overall and cause-specific mortality in CD.

METHODS

MEDLINE (January 1965 to February 2008), abstracts from international conferences and reference lists of selected articles were searched systematically. All articles fulfilling the predefined inclusion criteria were scrutinized for data on population size, time of follow-up, gender, age, and observed to expected deaths. STATA meta-analysis software was used to calculate overall and cause-specific pooled standardized mortality ratios (SMR, observed/expected).

RESULTS

Nine studies were included with overall SMRs ranging from 0.72-3.2, resulting in a significantly increased pooled SMR of 1.39 (95% confidence interval [CI]: 1.30-1.49). Regarding cause-specific mortality, a significantly increased risk of death from cancer (SMR 1.50, 95% CI: 1.18-1.92), in particular of pulmonary cancer (SMR 2.72, 95% CI: 1.35-5.45), as well as chronic obstructive pulmonary disease (SMR 2.55, 95% CI: 1.19-5.47), gastrointestinal diseases (SMR 6.76, 95% CI: 4.37-10.45), and genitourinary diseases (SMR 3.28, 95% CI: 1.69-6.35) was observed.

CONCLUSIONS

Among unselected patients with CD, overall mortality was slightly but significantly higher than in the general population-primarily explained by deaths from gastrointestinal, respiratory, and genitourinary diseases. Notably, mortality from colorectal cancer was not increased.

A new rapid home test for faecal calprotectin in ulcerative colitis

BACKGROUND

Enzyme-linked immunosorbent assay (ELISA) is a time-consuming method for the measurement of faecal calprotectin. Two new quantitative rapid tests have been developed.

AIM

To compare the new rapid tests with ELISA as 'Gold Standard'.

METHODS

Quantitative analysis involved the application of a sample onto the 'Lateral Flow Device'. The colour intensity of a test line was read using a laptop computer linked to a scanner (rapid test scanning). A picture taken with a mobile phone (HT photo) of the same 'Lateral Flow Device' was sent to a server via Mobile Internet and the result appeared on the phone screen after 15 s.

RESULTS

A total of 404 faecal samples were analysed. Mean differences of 1.7 mg/kg (range -23.4-20.1) ELISA vs. rapid test scanning, 6.8 mg/kg (-28-14.5) ELISA vs. HT photo and 2.9 mg/kg (-10.3-4.5) rapid test scanning vs. HT photo were found with good agreement calculated using kappa statistic (86%, 87% and 95% respectively). The Coefficients of Variation for HT photo was <10%, with a sensitivity of 96.2% and a specificity of 90.1%.

CONCLUSIONS

The new rapid tests are accurate and useful in clinical settings. Feasibility of the home test as part of disease control and self-management is currently being investigated.

Does glyceryl nitrate prevent post-ERCP pancreatitis? A prospective, randomized, double-blind, placebo-controlled multicenter trial

OBJECTIVE

Acute pancreatitis is the most dreaded complication of ERCP. Two studies have shown a significant effect of glyceryl nitrate (GN) in preventing post-ERCP pancreatitis (PEP). We wanted to evaluate this promising effect in a larger study with a realistically precalculated incidence of PEP.

DESIGN/PATIENTS

A randomized, double-blind, placebo-controlled multicenter study including patients from 14 European centers was performed. A total of 820 patients were entered; 806 were randomized.

INTERVENTION

The active drug was transdermal GN (Discotrine/Minitran, 3M Pharma) 15 mg/24 hours; placebo (PL) was an identical-looking patch applied before ERCP. A total of 401 patients received GN; 405 received PL.

RESULTS

Forty-seven patients had PEP (5.8%), 18 (4.5%) in the GN group and 29 (7.1%) in the PL group. The relative risk reduction of PEP in the GN group of 36% (95% CI, 11%-65%) compared with the PL group was not statistically significant (P = .11). Thirteen had mild pancreatitis (4 in the GN group, 9 in the PL group), 26 had moderate pancreatitis (9 in the GN group, 17 in the PL group), and 8 had severe pancreatitis (5 in the GN group, 3 in the PL group). Headache (P < .001) and hypotension (P = .006) were more common in the GN group. Significant variables predictive of PEP were not having biliary stones extracted; hypotension after ERCP; morphine, propofol, glucagon, and general anesthesia during the procedure; or no sufentanil during the procedure.

CONCLUSIONS

The trial showed no statistically significant preventive effect of GN on PEP. Because of a considerable risk of a type II error, an effect of GN may have been overlooked. (ClinicalTrials.gov ID: NCT00121901.).

Infliximab dependency in children with Crohn's disease

BACKGROUND

Recently, infliximab dependency has been described.

AIM

To assess frequency of ID in 82 consecutive Crohn's disease children treated with infliximab 2000-2006 and to describe clinical and genetic predictors of long-term infliximab response.

METHODS

A phenotype model of infliximab dependency was used to assess treatment response: 'immediate outcome' (30 days after infliximab start)--complete/partial/no response. 'Long-term outcome': (i) prolonged response: maintenance of complete/partial response; (ii) infliximab dependency: relapse < or = 90 days after intended infliximab cessation requiring repeated infusions to regain complete/partial response or need of infliximab >12 months to sustain response. Polymorphisms TNF-308 A>G, TNF-857 C>T, Casp9 93 C>T, FasL-844 C>T, LTA 252 C>T and CARD15 (R702W, G908R, 1007fs) were analysed.

RESULTS

Ninety-four per cent of children obtained complete/partial response. In long-term outcome, 22% maintained prolonged response, 12% had no response, while 66% became infliximab dependent. Perianal disease and no previous surgery were associated with infliximab dependency (OR 5.34, 95% CI: 1.24-22.55; OR 6.7, 95% CI: 1.67-26.61). No association was found with studied polymorphisms. The cumulative probability of surgery 50 months after starting infliximab was 10% in infliximab dependency, 30% in prolonged responders and 70% in nonresponders (P = 0.0002).

CONCLUSIONS

Sixty-six per cent of children became infliximab dependent. Perianal disease and no surgery prior to infliximab were associated with infliximab dependency phenotype.

Infliximab for inflammatory bowel disease in Denmark 1999-2005: clinical outcome and follow-up evaluation of malignancy and mortality

BACKGROUND & AIMS

Data on safety and long-term follow-up evaluation of population-based cohorts of inflammatory bowel disease (IBD) patients treated with infliximab are sparse. The aim of this article is to describe the use of infliximab in a national Danish population-based IBD cohort during 1999-2005.

METHODS

Medical records of all infliximab-treated IBD patients were scrutinized to abstract information on patient demographics, treatment efficacy, and adverse events.

RESULTS

A total of 651 patients (619 with Crohn's disease, 15 with ulcerative colitis, and 17 with colonic IBD type unclassified) received infliximab during 1999-2005. A total of 3351 infusions were administered, with a median of 3 infusions per patient. A positive clinical response was observed in 82.7% (95% confidence interval, 79.9-85.5) of patients. Infusion reactions were observed after 146 of 3351 infusions (4.4%). Significantly fewer infusion reactions were seen in patients also receiving azathioprine or methotrexate (63 of 2079; 3.0%), compared with patients not receiving azathioprine or methotrexate (83 of 1272; 6.5%) (P < .0001). Severe adverse events were observed after 112 of 3351 infusions (3.3%) in a total of 95 patients (14.6%). Four patients developed cancer versus 5.9 expected (standardized incidence ratio, 0.7; 95 confidence interval, 0.2-1.7) and 13 patients died versus 6.9 expected (standardized mortality ratio, 1.9; 95% confidence interval, 1.0-3.2). Two deaths caused by infections were possibly related to infliximab.

CONCLUSIONS

Infliximab seemed effective in IBD and generally was well tolerated. However, rare but severe adverse events occurred, and patients receiving infliximab therefore should be selected carefully and monitored closely. No lymphomas and no increased risk of cancer were observed.

Efficacy of Infliximab treatment in patients with severe Fistulizing Hidradenitis Suppurativa

BACKGROUND

The association of Crohn's disease with Fistulizing Hidradenitis Suppurativa (FHS) was established in the 90s. FHS is a chronic disease, characterized by the formation of multiple abscesses and sinus tracts in apocrine gland-bearing areas. The aetiology and pathogenesis is unknown. The disease is painful and often socially disabling implying a poor Quality of Life. Treatment of FHS with Infliximab - a chimeric antibody to TNFα - has recently been proposed as alternative to surgery.

AIM

To describe efficacy of Infliximab treatment in the first 2 Danish patients with resistant severe FHS.

METHODS

Two patients with severe FHS previously unsuccessfully treated with conventional therapies. Infliximab 5 mg/kg was given as induction treatment. Clinical response was measured by MRI and modified Quality of Life scoring before and after the Infliximab.

RESULTS

The first patient obtained partial remission after the first infusion, with 2 active sinus tracts of 20 detected by MRI. The patient became INF dependent and continued on maintenance treatment every 8th week. In total 8 infusions. The second patient obtained partial remission after 3 infusions and did not experience relapse after withdrawal of Infliximab. The clinical findings of remission were underscored by showing improvement on MRI. The Quality of Life has been increased in both patients.

CONCLUSION

Infliximab treatment seems to be efficacious in patients with severe FHS. Maintenance treatment may be necessary. Infliximab can lead to improvement in Quality of Life, partial remission of disease verified by closure of fistula in MRI and keeping the patients from mutilating surgery.

IBD patients need in health quality of care ECCO consensus

INTRODUCTION

: Inflammatory bowel diseases (IBD) is a lifelong disorder with increasing incidence and prevalence. IBD primarily affects young people's productivity in addition to direct and indirect costs. The chronic nature of the disease and the patients' requirement of frequent and easy access to the Health Care providers regarding lifelong medication, social and psychological support and regular follow-up in out-patient clinics are important considerations to address.

AIM AND METHODS

: To define IBD patient needs in Quality of Health Care (QoHC) in Europe based on up- to date available evidence. The working group consisted of doctors, nurses and patient organizations from 12 European countries and Israel. Pub Med searching was performed as defined in the Delta Method. Each recommendation was graded (RG) in accordance with level of evidence (EL) based on Evidence Based Medicine, Oxford Centre. During UEGW 2007 the group reconvened to agree on the final version for each chapter of guideline statement

RESULTS

: Pub Med search led to 6 RCT, 7 reviews, 63 original articles, but no meta-analysis regarding "Information"; "Education"; "Primary Care", "Quality of life", "Psychological help" and "Benchmarking of Health Care systems" in IBD. Seven ECCO statements have been worked out.

CONCLUSION

: Evidence-based medicine in QoHC is limited. It is concluded that optimizing QoHC by "information"; "education", "benchmarking" and "psychological analysis" helps the patient to understand the disease and comply with its therapy, increasing QoL, reducing depression and anxiety. Future aspects regarding more evidence-based science and optimization of QoHC in IBD throughout Europe have been proposed.

Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database

OBJECTIVES

A continuous increase in the incidence of inflammatory bowel disease (IBD), Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC) has been suggested. Since Denmark provides excellent conditions for epidemiological research, we aimed to describe contemporary IBD incidence rates and patient characteristics in Copenhagen County and City.

METHODS

All patients diagnosed with IBD during 2003-2005 were followed prospectively. Demographic and clinical characteristics, such as disease extent, extraintestinal manifestations, smoking habits, medical treatment, surgical interventions, cancer, and death, were registered.

RESULTS

Five-hundred sixty-two patients were diagnosed with IBD, resulting in mean annual incidences of 8.6/10(5) for CD, 13.4/10(5) for UC, and 1.1/10(5) for IC. Time from onset to diagnosis was 8.3 months in CD and 4.5 months in UC patients. A family history of IBD, smoking, and extraintestinal manifestations was significantly more common in CD than in UC patients. Only 0.6% of UC patients had primary sclerosing cholangitis. In CD, old age at diagnosis was related to pure colonic disease, whereas children significantly more often had proximal and extensive involvement. Twelve percent of CD patients and 6% of UC patients underwent surgery during the year of diagnosis, significantly less than earlier reported.

CONCLUSIONS

The incidence of IBD in Copenhagen increased noticeably during the last decades. Time from onset of symptoms until diagnosis decreased markedly, extent of CD was related to age at diagnosis, and the risk of surgery was low in UC.

Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database

OBJECTIVES

A continuous increase in the incidence of inflammatory bowel disease (IBD), Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC) has been suggested. Since Denmark provides excellent conditions for epidemiological research, we aimed to describe contemporary IBD incidence rates and patient characteristics in Copenhagen County and City.

METHODS

All patients diagnosed with IBD during 2003-2005 were followed prospectively. Demographic and clinical characteristics, such as disease extent, extraintestinal manifestations, smoking habits, medical treatment, surgical interventions, cancer, and death, were registered.

RESULTS

Five-hundred sixty-two patients were diagnosed with IBD, resulting in mean annual incidences of 8.6/10(5) for CD, 13.4/10(5) for UC, and 1.1/10(5) for IC. Time from onset to diagnosis was 8.3 months in CD and 4.5 months in UC patients. A family history of IBD, smoking, and extraintestinal manifestations was significantly more common in CD than in UC patients. Only 0.6% of UC patients had primary sclerosing cholangitis. In CD, old age at diagnosis was related to pure colonic disease, whereas children significantly more often had proximal and extensive involvement. Twelve percent of CD patients and 6% of UC patients underwent surgery during the year of diagnosis, significantly less than earlier reported.

CONCLUSIONS

The incidence of IBD in Copenhagen increased noticeably during the last decades. Time from onset of symptoms until diagnosis decreased markedly, extent of CD was related to age at diagnosis, and the risk of surgery was low in UC.

Localization of aquaporin-7 in rat and mouse kidney using RT-PCR, immunoblotting, and immunocytochemistry

To establish the segmental, cellular, and subcellular localization of AQP7 in rat and mouse kidney, we used RT-PCR, immunocytochemical, and immunoblotting approaches. RT-PCR of rat and mouse kidney zones revealed AQP7 mRNA in cortex and outer stripe of the outer medulla. RT-PCR on microdissected nephron segments revealed AQP7 mRNA in proximal convoluted and straight tubules. Immunoblotting using peptide-derived rabbit antibodies to either rat or mouse AQP7 revealed a 28-kDa band in kidney and testes from rat and mouse, respectively. Immunocytochemistry revealed strong AQP7 labeling of segment 3 proximal tubules and weaker labeling of proximal convoluted tubules in both rat and mouse kidneys. The labeling was almost exclusively confined to the brush border with no basolateral labeling. No labeling was observed of thin descending limbs or collecting duct. Immunolabeling controls were negative. The presence of AQP7 in the proximal tubule brush border indicates a role of AQP7 in proximal tubule water reabsorption.

Immunolocalization of AQP9 in liver, epididymis, testis, spleen, and brain

The aims of this study were to determine the cellular and subcellular localization of aquaporin-9 (AQP9) in different rat organs by immunoblotting, immunohistochemistry and immunoelectron microscopy. To analyze this, we used rabbit antibodies to rat AQP9 raised against three different AQP9 peptides (amino acids 267-287, 274-295, and 278-295). In Cos7 cells transfected with rat AQP9, the affinity-purified antibodies exhibited marked labeling, whereas nontransfected cells and cells transfected with aquaporin-8 (AQP8) exhibited no labeling, indicating the specificity of the AQP9 antibodies. Immunoblotting revealed a predominant band of 28 kDa in membranes of total rat liver, epididymis, testes, spleen, and brain. Preabsorption with the immunizing peptides eliminated the labeling. Immunohistochemistry showed strong anti-AQP9 labeling in liver hepatocytes. The labeling was strongest at the sinusoidal surface, and there was little intracellular labeling. Immunoelectron microscopy revealed that the labeling was associated with the plasma membrane of the hepatocytes. In testes Leydig cells exhibited anti-AQP9 labeling, and in epididymis, the stereocilia of the ciliated cells (principal cells) exhibited significant labeling, whereas there was no labeling of the nonciliated cells (basal cells). This was confirmed by immunoelectron microscopy. In spleen strong labeling of cells was observed of leukocytes in the red pulp, whereas there was no labeling of cells in the white pulp. In rat brain, AQP9 immunolabeling was confined to ependymal cells lining the ventricles and to the tanycytes of the mediobasal hypothalamus. Antibody preabsorbed with the immunizing peptide revealed no labeling. In conclusion, AQP9 proteins is strongly expressed in rat liver, testes, epididymis, spleen, and brain.