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Bajaj A, Markandey M, Singh M, Sahu P, Vuyyuru SK, Kante B, Kumar P, Verma M, Makharia G, Kedia S, Travis SPL, Ahuja V. Exclusive Enteral Nutrition Mediates Beneficial Gut Microbiome Enrichment in Acute Severe Colitis. Inflamm Bowel Dis 2024; 30:641-650. [PMID: 37950921 DOI: 10.1093/ibd/izad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) supplementation of the standard of care (SOC) augments steroid responsiveness in patients with acute severe ulcerative colitis (ASUC). EEN is known to alter gut microbial composition. The present study investigates EEN-driven gut microbial alterations in patients with ASUC and examines their correlations with clinical parameters. METHODS Stool samples from patients with ASUC (n = 44) who received either EEN-supplemented SOC (EEN group; n = 20) or SOC alone (SOC group; n = 24) for 7 days were collected at baseline (day 0) and postintervention (day 7). Microbiome analysis was carried out using 16S ribosomal RNA gene sequencing followed by data processing using QIIME2 and R packages. RESULTS Seven-day EEN-conjugated corticosteroid therapy in patients with ASUC enhanced the abundances of beneficial bacterial genera Faecalibacterium and Veillonella and reduced the abundance of Sphingomonas (generalized linear model fitted with Lasso regularization with robustness of 100%), while no such improvements in gut microbiota were observed in the SOC group. The EEN-associated taxa correlated with the patient's clinical parameters (serum albumin and C-reactive protein levels). Unlike the SOC group, which retained its preintervention core microbiota, EEN contributed Faecalibacterium prausnitzii, a beneficial gut bacterial taxon, to the gut microbial core. EEN responders showed enhancement of Ligilactobacillus and Veillonella and reduction in Prevotella and Granulicatella. Analysis of baseline gut microbiota showed relative enhancement of certain microbial genera being associated with corticosteroid response and baseline clinical parameters and that this signature could conceivably be used as a predictive tool. CONCLUSIONS Augmentation of clinical response by EEN-conjugated corticosteroid therapy is accompanied by beneficial gut microbial changes in patients with ASUC.
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Affiliation(s)
- Aditya Bajaj
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Manasvini Markandey
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Mukesh Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pabitra Sahu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer K Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Kante
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peeyush Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Mahak Verma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, University of Oxford and Oxford Biomedical Research Centre, Oxford, United Kingdom
- Kennedy Institute of Rheumatology, University of Oxford and Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Nigam GB, Murphy MF, Travis SPL, Stanley AJ. Machine learning in the assessment and management of acute gastrointestinal bleeding. BMJ Med 2024; 3:e000699. [PMID: 38389720 PMCID: PMC10882311 DOI: 10.1136/bmjmed-2023-000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/05/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Gaurav Bhaskar Nigam
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Michael F Murphy
- Transfusion Medicine, NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon P L Travis
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and, Biomedical Research Centre, Oxford University, Oxford, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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Matini L, Chapman TP, Kantschuster R, Wilson J, Tarafdar A, Hussain M, Song K, Simadibrata DM, Seeva P, White L, Slater J, Kormilitzin A, Collins G, Travis SPL, Walsh A. Development of the Escalation of Therapy or Intervention (ETI) Calculator for Patients with Ulcerative Colitis Using ePROMs. J Crohns Colitis 2023; 17:1744-1751. [PMID: 37306285 DOI: 10.1093/ecco-jcc/jjad099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/17/2023] [Accepted: 06/11/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND AIMS Digital collection of patient-reported outcome measures [PROMs] is largely unexplored as a basis for follow-up for patients with ulcerative colitis [UC]. Our aim was to develop a model to predict the likelihood of escalation of therapy or intervention at an outpatient appointment that may be used to rationalize follow-up. METHODS TrueColours-IBD is a web-based, real-time, remote monitoring software that allows longitudinal collection of ePROMs. Data for prediction modelling were derived from a Development Cohort, guided by the TRIPOD statement. Logistic regression modelling used ten candidate items to predict escalation of therapy or intervention. An Escalation of Therapy or Intervention [ETI] calculator was developed, and applied in a Validation Cohort at the same centre. RESULTS The Development Cohort [n = 66] was recruited in 2016 and followed for 6 months [208 appointments]. From ten items, four significant predictors of ETI were identified: SCCAI, IBD Control-8, faecal calprotectin, and platelets. For practicality, a model with only SCCAI and IBD Control-8, both entered remotely by the patient, without the need for faecal calprotectin or blood tests was selected. Between 2018 and 2020, a Validation Cohort of 538 patients [1188 appointments] was examined. A 5% threshold on the ETI calculator correctly identified 343/388 [88%] escalations and 274/484 [57%] non-escalations. CONCLUSIONS A calculator based on digital, patient-entered data on symptoms and quality of life can predict whether a patient with UC requires escalation of therapy or intervention at an outpatient appointment. This may be used to streamline outpatient appointments for patients with UC.
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Affiliation(s)
- Lawrence Matini
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Thomas P Chapman
- Department of Gastroenterology, St Richard's and Worthing Hospitals, University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
| | - Ramona Kantschuster
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Jean Wilson
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Adib Tarafdar
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Moheez Hussain
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Kaiyang Song
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | | | - Pavetha Seeva
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Lydia White
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Jessica Slater
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | | | - Gary Collins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Simon P L Travis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
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Paridaens K, Fullarton JR, Travis SPL. Efficacy of oral prolonged-release mesalazine in moderately active ulcerative colitis. JGH Open 2023; 7:516-519. [PMID: 37496812 PMCID: PMC10366489 DOI: 10.1002/jgh3.12935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/05/2023] [Accepted: 06/17/2023] [Indexed: 07/28/2023]
Abstract
New meta-analyses are presented that provide further evidence supporting the effectiveness of oral prolonged-release mesalazine compared to other oral mesalazines as induction therapy in patients with moderately active ulcerative colitis.
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Affiliation(s)
| | | | - Simon P L Travis
- NIHR Oxford Biomedical Research CentreOxford University Hospitals NHS Foundation Trust, John Radcliffe HospitalOxfordUK
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Bryant RV, Travis SPL. APOLLO Has Landed: PROMS and Histology in UC. J Crohns Colitis 2023:7085876. [PMID: 36964690 DOI: 10.1093/ecco-jcc/jjad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Robert V Bryant
- IBD Service, Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Simon P L Travis
- Kennedy Institute of Rheumatology, Translational Gastroenterology Unit, and Biomedical Research Centre, University of Oxford, Oxford, UK
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Adams A, Gupta V, Mohsen W, Chapman TP, Subhaharan D, Kakkadasam Ramaswamy P, Kumar S, Kedia S, McGregor CG, Ambrose T, George BD, Palmer R, Brain O, Walsh A, Ahuja V, Travis SPL, Satsangi J. Early management of acute severe UC in the biologics era: development and international validation of a prognostic clinical index to predict steroid response. Gut 2023; 72:433-442. [PMID: 36171080 DOI: 10.1136/gutjnl-2022-327533] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/27/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVES We aimed to determine whether changes in acute severe colitis (ASC) management have translated to improved outcomes and to develop a simple model predicting steroid non-response on admission. DESIGN Outcomes of 131 adult ASC admissions (117 patients) in Oxford, UK between 2015 and 2019 were compared with data from 1992 to 1993. All patients received standard treatment with intravenous corticosteroids and endoscopic disease activity scoring (Ulcerative Colitis Endoscopic Index of Severity (UCEIS)). Steroid non-response was defined as receiving medical rescue therapy or surgery. A predictive model developed in the Oxford cohort was validated in Australia and India (Gold Coast University Hospital 2015-2020, n=110; All India Institute of Medical Sciences, New Delhi 2018-2020, n=62). RESULTS In the 2015-2019 Oxford cohort, 15% required colectomy during admission vs 29% in 1992-1993 (p=0.033), while 71 (54%) patients received medical rescue therapy (27% ciclosporin, 27% anti-tumour necrosis factor, compared with 27% ciclosporin in 1992-1993 (p=0.0015). Admission C reactive protein (CRP) (false discovery rate, p=0.00066), albumin (0.0066) and UCEIS scores (0.015) predicted steroid non-response. A four-point model was developed involving CRP of ≥100 mg/L (one point), albumin of ≤25 g/L (one point), and UCEIS score of ≥4 (1 point) or ≥7 (2 points). Patients scoring 0, 1, 2, 3 and 4 in the validation cohorts had steroid response rates of 100, 75.0%, 54.9%, 18.2% and 0%, respectively. Scoring of ≥3 was 84% (95% CI 0.70 to 0.98) predictive of steroid failure (OR 11.9, 95% CI 10.8 to 13.0). Colectomy rates in the validation cohorts were were 8%-11%. CONCLUSIONS Emergency colectomy rates for ASC have halved in 25 years to 8%-15% worldwide. Patients who will not respond to corticosteroids are readily identified on admission and may be prioritised for early intensification of therapy.
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Affiliation(s)
- Alex Adams
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
| | - Waled Mohsen
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Digestive Diseases Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Thomas P Chapman
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Department of Gastroenterology, St Richard's and Worthing Hospitals, University Hospitals Sussex NHS Foundation Trust, West Sussex, UK
| | - Deloshaan Subhaharan
- Digestive Diseases Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Sudheer Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Tim Ambrose
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Bruce D George
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
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Dubinsky MC, Clemow DB, Hunter Gibble T, Li X, Vermeire S, Hisamatsu T, Travis SPL. Clinical Effect of Mirikizumab Treatment on Bowel Urgency in Patients with Moderately to Severely Active Ulcerative Colitis and the Clinical Relevance of Bowel Urgency Improvement for Disease Remission. Crohns Colitis 360 2022; 5:otac044. [PMID: 36777368 PMCID: PMC9802448 DOI: 10.1093/crocol/otac044] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 12/15/2022] Open
Abstract
Background Bowel urgency reduces ulcerative colitis patients' quality of life. Mirikizumab, a p19-directed anti-IL-23 antibody, demonstrates ulcerative colitis efficacy. Mirikizumab efficacy to reduce bowel urgency and bowel urgency association with other endpoints were analyzed in 2 Phase 3 trials. Methods LUCENT-1 (Induction): 1162 patients randomized 3:1 to intravenous 300 mg mirikizumab or placebo every 4 weeks for 12 weeks. LUCENT-2 (Maintenance): 544 mirikizumab responders during induction were re-randomized 2:1 to subcutaneous mirikizumab 200 mg or placebo every 4 weeks for 40 weeks (52 weeks of continuous treatment). Bowel urgency was measured using the Urgency Numeric Rating Scale (0-10); for patients with LUCENT-1 baseline score ≥3, bowel urgency clinically meaningful improvement (≥3-point decrease) and remission (score ≤1) rates in mirikizumab versus placebo groups were compared at Weeks 12 and 52. Associations between bowel urgency and other efficacy endpoints were assessed at Weeks 12 and 52. Results A significantly higher proportion of mirikizumab patients versus placebo achieved clinically meaningful improvement in bowel urgency and remission at Weeks 12 and 52. Significantly higher percentages of patients achieving bowel urgency clinically meaningful improvement or remission, compared with those who did not, also achieved endpoints for clinical, corticosteroid-free, endoscopic, and symptomatic remission; clinical response; normalized fecal calprotectin and C-reactive protein; and improved quality of life. Conclusions In patients with ulcerative colitis, bowel urgency improvement was associated with better clinical outcomes than in patients without improvement during induction and maintenance. A greater proportion of mirikizumab patients achieved sustainable bowel urgency improvement and remission compared to placebo patients.
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Affiliation(s)
- Marla C Dubinsky
- Mount Sinai Kravis Children’s Hospital, Mount Sinai, New York, USA
| | - David B Clemow
- Address correspondence to: Dr David Clemow, PhD, Eli Lilly and Company, Indianapolis, Indiana 46285, UA ()
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Wong D, Matini L, Kormilitzin A, Kantschuster R, Simadibrata DM, Lyden S, Wilson J, Brain OA, Palmer R, Ambrose T, Satsangi J, South M, Geddes J, Bodger K, Travis SPL, Walsh A. Patient-reported Outcomes: the ICHOM Standard Set for Inflammatory Bowel Disease in Real-life Practice Helps Quantify Deficits in Current Care. J Crohns Colitis 2022; 16:1874-1881. [PMID: 35868223 PMCID: PMC9721458 DOI: 10.1093/ecco-jcc/jjac099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-reported outcome measures [PROMs] are key to documenting outcomes that matter most to patients and are increasingly important to commissioners of health care seeking value. We report the first series of the ICHOM Standard Set for Inflammatory Bowel Disease [IBD]. METHODS Patients treated for ulcerative colitis [UC] or Crohn's disease [CD] in our centre were offered enrolment into the web-based TrueColours-IBD programme. Through this programme, e-mail prompts linking to validated questionnaires were sent for symptoms, quality of life, and ICHOM IBD outcomes. RESULTS The first 1299 consecutive patients enrolled [779 UC, 520 CD] were studied with median 270 days of follow-up (interquartile range [IQR] 116, 504). 671 [52%] were female, mean age 42 years (standard deviation [sd] 16), mean body mass index [BMI] 26 [sd 5.3]. At registration, 483 [37%] were using advanced therapies. Median adherence to fortnightly quality of life reporting and quarterly outcomes was 100% [IQR 48, 100%] and 100% [IQR 75, 100%], respectively. In the previous 12 months, prednisolone use was reported by 229 [29%] patients with UC vs 81 [16%] with CD, p <0.001; 202 [16%] for <3 months; and 108 [8%] for >3 months. An IBD-related intervention was reported by 174 [13%] patients, and 80 [6%] reported an unplanned hospital admission. There were high rates of fatigue [50%] and mood disturbance [23%]. CONCLUSIONS Outcomes reported by patients illustrate the scale of the therapeutic deficit in current care. Proof of principle is demonstrated that PROM data can be collected continuously with little burden on health care professionals. This may become a metric for quality improvement programmes or to compare outcomes.
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Affiliation(s)
- Darren Wong
- Corresponding author: Dr Alissa Walsh, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK. E-mail:
| | - Lawrence Matini
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | | | - Ramona Kantschuster
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Daniel Martin Simadibrata
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sara Lyden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jean Wilson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Oliver A Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Matthew South
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
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Banerjee R, Pal P, Hilmi I, Ghoshal UC, Desai DC, Rahman MM, Dutta U, Mohiuddin SA, Al Mohannadi M, Philip M, Ramesh GN, Niriella MA, De Silva AP, de Silva HJ, Pisespongsa P, Limsrivilai J, Aniwan S, Nawarathne M, Fernandopulle N, Aye TT, Ni N, Al Awadhi S, Joshi N, Ngoc PTV, Kieu TV, Nguyen AD, Abdullah M, Ali E, Zeid A, Sollano JD, Saberi B, Omar M, Mohsin MN, Aftab H, Wai TM, Shastri YM, Chaudhuri S, Ahmed F, Bhatia SJ, Travis SPL. Emerging inflammatory bowel disease demographics, phenotype, and treatment in South Asia, South-East Asia, and Middle East: Preliminary findings from the Inflammatory Bowel Disease-Emerging Nations' Consortium. J Gastroenterol Hepatol 2022; 37:1004-1015. [PMID: 35178742 DOI: 10.1111/jgh.15801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/04/2022] [Accepted: 01/23/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Inflammatory bowel disease (IBD) is emerging in the newly industrialized countries of South Asia, South-East Asia, and the Middle East, yet epidemiological data are scarce. METHODS We performed a cross-sectional study of IBD demographics, disease phenotype, and treatment across 38 centers in 15 countries of South Asia, South-East Asia, and Middle East. Intergroup comparisons included gross national income (GNI) per capita. RESULTS Among 10 400 patients, ulcerative colitis (UC) was twice as common as Crohn's disease (CD), with a male predominance (UC 6678, CD 3495, IBD unclassified 227, and 58% male). Peak age of onset was in the third decade, with a low proportion of elderly-onset IBD (5% age > 60). Familial IBD was rare (5%). The extent of UC was predominantly distal (proctitis/left sided 67%), with most being treated with mesalamine (94%), steroids (54%), or immunomodulators (31%). Ileocolic CD (43%) was the commonest, with low rates of perianal disease (8%) and only 6% smokers. Diagnostic delay for CD was common (median 12 months; interquartile range 5-30). Treatment of CD included mesalamine, steroids, and immunomodulators (61%, 51%, and 56%, respectively), but a fifth received empirical antitubercular therapy. Treatment with biologics was uncommon (4% UC and 13% CD), which increased in countries with higher GNI per capita. Surgery rates were 0.1 (UC) and 2 (CD) per 100 patients per year. CONCLUSIONS The IBD-ENC cohort provides insight into IBD in South-East Asia and the Middle East, but is not yet population based. UC is twice as common as CD, familial disease is uncommon, and rates of surgery are low. Biologic use correlates with per capita GNI.
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Affiliation(s)
- Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Partha Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ida Hilmi
- University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Devendra C Desai
- Department of Gastroenterology, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | | | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Syed A Mohiuddin
- Division of Gastroenterology, Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Munnera Al Mohannadi
- Division of Gastroenterology, Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Mathew Philip
- Lisie Institute of Gastroenterology, Lisie Hospital, Kochi, India
| | | | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Arjuna P De Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | | | - Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | - Than Than Aye
- Department of Gastroenterology, Thingangyun General Hospital, University of Medicine 2, Yangon, Myanmar
| | - Nwe Ni
- Department of Gastroenterology, Mandalay General Hospital and University of Medicine, Mandalay, Myanmar
| | - Sameer Al Awadhi
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | | | | | | | | | - Murdani Abdullah
- Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Ezzat Ali
- Department of Internal Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ahmed Zeid
- Department of Internal Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | | | | | - Mostafa Noor Mohsin
- Department of Gastroenterology, Chittagong Medical College, Chittagong, Bangladesh
| | - Hafeza Aftab
- Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh
| | - Tin Moe Wai
- Department of Gastroenterology, Yangon General Hospital, University of Medicine (1), Yangon, Myanmar
| | - Yogesh M Shastri
- Department of Gastroenterology, NMC Specialty Hospital, Abu Dhabi, United Arab Emirates
| | | | - Faruque Ahmed
- Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh
| | | | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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10
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Dignass AU, Paridaens K, Al Awadhi S, Begun J, Cheon JH, Fullarton JR, Louis E, Magro F, Marquez JR, Moschen AR, Narula N, Rydzewska G, Travis SPL. Multinational evaluation of clinical decision-making in the treatment and management of mild-to-moderate ulcerative colitis. Scand J Gastroenterol 2022; 57:424-431. [PMID: 34932423 DOI: 10.1080/00365521.2021.2015801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To understand current thinking and clinical decision-making in the treatment and management of patients with mild-to-moderate ulcerative colitis (UC). METHODS This multinational, survey-based study was conducted in 2021. Two meetings were held, involving 11 IBD specialists, that used a series of questions and discussion to identify all factors possibly related to the management of UC. The importance of identified factors was assessed using an online questionnaire covering three scenarios - active disease, remission and patient empowerment. Each factor was scored on a scale of 0 (very-unimportant) to 100 (very-important) within each scenario, by a separate group of healthcare professionals working in IBD. RESULTS A total of 157 individual factors were identified by the 11 IBD specialists and scored in the three scenarios by 56 respondents (52; 93% specialist gastroenterologists) from Europe and North America (25; 45%), South America (19; 34%) and the Middle East, Asia and Australia (12; 21%). For all scenarios, factors related to educating patients regarding UC and its treatment and understanding of patient goals ranked highest, ahead of clinical considerations regarding disease activity and treatment history. Setting realistic short-term treatment targets was a key consideration. 5-ASA optimisation and use of faecal calprotectin monitoring were core strategies across the three scenarios tested. Support for patients during longer-term management of their disease, starting from initial flare, was an important recurring theme. CONCLUSION The current management approach for mild-to-moderate UC was found to be guided primarily by the patient's perspectives and goals, alongside assessment of their medical and disease history.
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Affiliation(s)
- Axel U Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt am Main, Germany
| | | | - Sameer Al Awadhi
- Department of Gastroenterology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Australia
| | - Jae Hee Cheon
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | | | - Edouard Louis
- Hepato-Gastroenterology and Digestive Oncology Department, University and Centre Hospitalaire Univestitaire (CHU) Liège, Liège, Belgium
| | - Fernando Magro
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, University of Porto, Porto, Portugal.,Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | | | - Alexander R Moschen
- Department of Internal Medicine, Gastroenterology and Hepatology, Kepler University Hospital, Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Grazyna Rydzewska
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subdivision, The Central Clinical Hospital of the Ministry of the Interior Affairs and Administration, Warsaw, Poland.,Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Simon P L Travis
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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11
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Affiliation(s)
- Darren Wong
- Department of Gastroenterology, Austin Health, Heidelberg, VIC,Australia
| | - Simon P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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12
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Bolton C, Smillie CS, Pandey S, Elmentaite R, Wei G, Argmann C, Aschenbrenner D, James KR, McGovern DPB, Macchi M, Cho J, Shouval DS, Kammermeier J, Koletzko S, Bagalopal K, Capitani M, Cavounidis A, Pires E, Weidinger C, McCullagh J, Arkwright PD, Haller W, Siegmund B, Peters L, Jostins L, Travis SPL, Anderson CA, Snapper S, Klein C, Schadt E, Zilbauer M, Xavier R, Teichmann S, Muise AM, Regev A, Uhlig HH. An Integrated Taxonomy for Monogenic Inflammatory Bowel Disease. Gastroenterology 2022; 162:859-876. [PMID: 34780721 DOI: 10.1053/j.gastro.2021.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Monogenic forms of inflammatory bowel disease (IBD) illustrate the essential roles of individual genes in pathways and networks safeguarding immune tolerance and gut homeostasis. METHODS To build a taxonomy model, we assessed 165 disorders. Genes were prioritized based on penetrance of IBD and disease phenotypes were integrated with multi-omics datasets. Monogenic IBD genes were classified by (1) overlapping syndromic features, (2) response to hematopoietic stem cell transplantation, (3) bulk RNA-sequencing of 32 tissues, (4) single-cell RNA-sequencing of >50 cell subsets from the intestine of healthy individuals and patients with IBD (pediatric and adult), and (5) proteomes of 43 immune subsets. The model was validated by addition of newly identified monogenic IBD defects. As a proof-of-concept, we explore the intersection between immunometabolism and antimicrobial activity for a group of disorders (G6PC3/SLC37A4). RESULTS Our quantitative integrated taxonomy defines the cellular landscape of monogenic IBD gene expression across 102 genes with high and moderate penetrance (81 in the model set and 21 genes in the validation set). We illustrate distinct cellular networks, highlight expression profiles across understudied cell types (e.g., CD8+ T cells, neutrophils, epithelial subsets, and endothelial cells) and define genotype-phenotype associations (perianal disease and defective antimicrobial activity). We illustrate processes and pathways shared across cellular compartments and phenotypic groups and highlight cellular immunometabolism with mammalian target of rapamycin activation as one of the converging pathways. There is an overlap of genes and enriched cell-specific expression between monogenic and polygenic IBD. CONCLUSION Our taxonomy integrates genetic, clinical and multi-omic data; providing a basis for genomic diagnostics and testable hypotheses for disease functions and treatment responses.
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Affiliation(s)
- Chrissy Bolton
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK; Institute of Child Health, University College London, London, UK
| | - Christopher S Smillie
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sumeet Pandey
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Rasa Elmentaite
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Gabrielle Wei
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carmen Argmann
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Kylie R James
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK; Garvan Institute of Medical Research, The Kinghorn Cancer Centre, Darlinghurst, Australia
| | - Dermot P B McGovern
- F. Widjaja Foundation, Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marina Macchi
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Judy Cho
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jochen Kammermeier
- Gastroenterology Department, Evelina London Children's Hospital, London, UK
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | | | - Melania Capitani
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Athena Cavounidis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Elisabete Pires
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Mansfield Road, Oxford, UK
| | - Carl Weidinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health Department of Gastroenterology, Rheumatology and Infectious Disease, Campus Benjamin Franklin, Berlin, Germany
| | - James McCullagh
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Mansfield Road, Oxford, UK
| | - Peter D Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Wolfram Haller
- Department of Gastroenterology and Nutrition, Birmingham Children's Hospital, Birmingham, UK
| | - Britta Siegmund
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health Department of Gastroenterology, Rheumatology and Infectious Disease, Campus Benjamin Franklin, Berlin, Germany
| | - Lauren Peters
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Jostins
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK; Biomedical Research Center, University of Oxford, Oxford, UK
| | - Carl A Anderson
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Scott Snapper
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christoph Klein
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - Eric Schadt
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthias Zilbauer
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Addenbrooke's Hospital, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Ramnik Xavier
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Sarah Teichmann
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK; Theory of Condensed Matter, Cavendish Laboratory, Department of Physics, University of Cambridge, Cambridge, UK; European Molecular Biology Laboratory, European Bioinformatics Institute (EBI), Wellcome Genome Campus, Hinxton UK
| | - Aleixo M Muise
- Gastroenterology Division, The Hospital for Sick Children, Toronto, Ontario, Canada; SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aviv Regev
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA; Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Holm H Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK; The Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK; Department of Paediatrics, University of Oxford, Oxford, United Kingdom.
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13
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Ryzhakov G, Almuttaqi H, Corbin AL, Berthold DL, Khoyratty T, Eames HL, Bullers S, Pearson C, Ai Z, Zec K, Bonham S, Fischer R, Jostins-Dean L, Travis SPL, Kessler BM, Udalova IA. Defactinib inhibits PYK2 phosphorylation of IRF5 and reduces intestinal inflammation. Nat Commun 2021; 12:6702. [PMID: 34795257 PMCID: PMC8602323 DOI: 10.1038/s41467-021-27038-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Interferon regulating factor 5 (IRF5) is a multifunctional regulator of immune responses, and has a key pathogenic function in gut inflammation, but how IRF5 is modulated is still unclear. Having performed a kinase inhibitor library screening in macrophages, here we identify protein-tyrosine kinase 2-beta (PTK2B/PYK2) as a putative IRF5 kinase. PYK2-deficient macrophages display impaired endogenous IRF5 activation, leading to reduction of inflammatory gene expression. Meanwhile, a PYK2 inhibitor, defactinib, has a similar effect on IRF5 activation in vitro, and induces a transcriptomic signature in macrophages similar to that caused by IRF5 deficiency. Finally, defactinib reduces pro-inflammatory cytokines in human colon biopsies from patients with ulcerative colitis, as well as in a mouse colitis model. Our results thus implicate a function of PYK2 in regulating the inflammatory response in the gut via the IRF5 innate sensing pathway, thereby opening opportunities for related therapeutic interventions for inflammatory bowel diseases and other inflammatory conditions.
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Affiliation(s)
- Grigory Ryzhakov
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Novartis Campus, Basel, Switzerland
| | - Hannah Almuttaqi
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Alastair L Corbin
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Dorothée L Berthold
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Tariq Khoyratty
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Hayley L Eames
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Samuel Bullers
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Claire Pearson
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Zhichao Ai
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Kristina Zec
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Sarah Bonham
- Target Discovery Institute, Nuffield Department of Medicine, Centre for Medicines Discovery, Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Roman Fischer
- Target Discovery Institute, Nuffield Department of Medicine, Centre for Medicines Discovery, Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Luke Jostins-Dean
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom
| | - Simon P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Benedikt M Kessler
- Target Discovery Institute, Nuffield Department of Medicine, Centre for Medicines Discovery, Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Irina A Udalova
- University of Oxford, Kennedy Institute of Rheumatology, Oxford, United Kingdom.
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14
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Paridaens K, Fullarton JR, Travis SPL. Efficacy and safety of oral Pentasa (prolonged-release mesalazine) in mild-to-moderate ulcerative colitis: a systematic review and meta-analysis. Curr Med Res Opin 2021; 37:1891-1900. [PMID: 34404286 DOI: 10.1080/03007995.2021.1968813] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pentasa (prolonged-release mesalazine [5-ASA]) has been available for >30 years as an effective treatment for mild-to-moderate ulcerative colitis (UC). A systematic literature review and meta-analysis was undertaken to provide an up-to-date evaluation of oral Pentasa efficacy and safety for induction and maintenance of remission. METHODS Literature searches were conducted in PubMed, Embase and Cochrane databases, from inception to 02 December 2020. Unpublished studies were also sourced. Meta-analyses using a random-effects model and Bayesian inference compared Pentasa (tablets, granules, capsules) against placebo and other 5-ASAs. RESULTS Twelve studies involving 3674 patients treated with Pentasa were identified. Pentasa 2-4 g/day was superior to placebo at inducing (absolute risk difference [ARD] at 8 weeks 0.14, 95% CI 0.07‒0.21; p < .001) and maintaining (ARD 6-12 months 0.18, 95% CI 0.04‒0.33; p < .05) remission (clinical/endoscopic). Against other 5-ASAs, Pentasa had similar efficacy for induction (ARD <0.001, 95% CI -0.05‒0.05) and maintenance (ARD 0.01, 95% CI -0.07‒0.08) treatment using randomized controlled trial data. Upon inclusion of real-world study data, Pentasa was significantly better at maintaining remission compared both to Eudragit-S mesalazine and sulfasalazine (ARD 0.04, 95% CI 0.02‒0.06; p < .001). Pentasa (1-4 g/day) had similar treatment-related adverse event rates to placebo (ARD 0.02, 95% CI -0.03‒0.06) and Eudragit-L/S mesalazines (2.25-3 vs 2.4-3 g/day, respectively; ARD -0.03, 95% CI -0.12‒0.05), but was better tolerated than sulfasalazine (3 g/day) (ARD 0.07, 95% CI 0.003‒0.14; p < .05). CONCLUSION This study confirms oral Pentasa is efficacious and well-tolerated in treating active UC and maintaining remission. The availability of multiple forms of Pentasa supports physicians' ability to individualize treatment and optimize dosing to improve outcomes.
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Affiliation(s)
| | | | - Simon P L Travis
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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15
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Kedia S, Ghosh TS, Jain S, Desigamani A, Kumar A, Gupta V, Bopanna S, Yadav DP, Goyal S, Makharia G, Travis SPL, Das B, Ahuja V. Gut microbiome diversity in acute severe colitis is distinct from mild to moderate ulcerative colitis. J Gastroenterol Hepatol 2021; 36:731-739. [PMID: 32870508 DOI: 10.1111/jgh.15232] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 08/04/2020] [Accepted: 08/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Although the gut microbiome of patients with ulcerative colitis (UC) has been characterized, no study has characterized the gut microbiome in acute severe colitis (ASC). We compared the gut microbiome of patients with UC, ASC, and healthy controls (HCs). METHODS Patients with mild to moderate UC (n = 24), ASC (n = 19 with 21 episodes) and HCs (n = 50) were recruited prospectively. A 16SrDNA amplicon approach was used to explore gut microbial diversity and taxonomic repertoires. UC was diagnosed using European Crohn's and Colitis Organization guidelines, and ASC was diagnosed using Truelove and Witts' criteria. RESULTS The normalized alpha diversity was significantly lower in ASC than mild-moderately active UC (P < 0.05) or HC (P < 0.001). The gut microbiome in ASC was highly unstable, as characterized by high intracohort variation (analyzed using J-divergence measure), which was significantly greater than in UC or HC. On principal coordinate analysis, the microbiome of HC and UC were similar, with the ASC cohort being distinct from both. Comparison of ranked abundances identified four distinct clusters of genera (G1, G2, G3, and G4), with specific trends in their abundance across three groups: G1/G2A clusters had the least, whereas G3 had the highest abundance in the ASC cohort. CONCLUSIONS Gut microbial diversity is lower in ASC than mild-moderate UC or HCs. Gut microbiome composition is increasingly unstable in ASC, with a distinct abundance of specific genera varying between HCs and ASC. Mild-moderate UC lies within the spectrum.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Tarini Shankar Ghosh
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India
| | - Saransh Jain
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anbumani Desigamani
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India
| | - Ashok Kumar
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India.,School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Vipin Gupta
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Goyal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Bhabatosh Das
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, Faridabad, India.,School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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16
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Sahu P, Kedia S, Vuyyuru SK, Bajaj A, Markandey M, Singh N, Singh M, Kante B, Kumar P, Ranjan M, Sahni P, Panwar R, Sharma R, Das P, Makharia G, Travis SPL, Ahuja V. Randomised clinical trial: exclusive enteral nutrition versus standard of care for acute severe ulcerative colitis. Aliment Pharmacol Ther 2021; 53:568-576. [PMID: 33440046 DOI: 10.1111/apt.16249] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/28/2020] [Accepted: 12/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intravenous corticosteroids are the mainstay of therapy for acute severe ulcerative colitis (ASUC), but 30%-40% of patients fail to respond. AIM To investigate the effectiveness of exclusive enteral nutrition (EEN) as adjunctive therapy to intravenous corticosteroids in patients with ASUC. METHODS This was an open-label randomised controlled trial, in which patients who were admitted with ASUC between August 2018 and May 2020 were randomised 1:1 to EEN or standard of care (SOC). Patients on EEN received a semi-elemental formula for 7 days along with SOC. The primary outcome was corticosteroid failure, defined by the need for salvage medical therapy or colectomy. Faecal microbial analysis was performed on day 1 and day 7 by 16s ribosomal RNA sequencing in some patients. RESULTS Of 62 patients (mean age 35.3 ± 12.1 years, 40% male), 32 were randomised to EEN and 30 to SOC. Corticosteroid failure was lower on EEN compared to SOC (intention-to-treat analysis 25% vs 43%, P = 0.051; per protocol analysis 19% vs 43%, P = 0.04), without any difference in colectomy rate (9% vs 13%; P = 0.41). Patients on EEN had a shorter hospital stay [median (range) 10 (8-17) vs 13 (8-24) days; P = 0.04], higher day 7 albumin level (34 ± 4 vs 29 ± 3 g/L, P < 0.01), greater reduction in serum C-reactive protein and faecal calprotectin levels (both P = 0.04) and a lower composite outcome of colectomy/hospitalisation at 6 months (16% vs 39%; P = 0.045) compared to SOC. Patients on EEN showed increased abundance of Erysipelotrichaceae on day 7, with reduced Bifidobacterium and Veillonellaceae compared to SOC. CONCLUSIONS EEN for 7 days may augment corticosteroid responsiveness in patients with ASUC. (REF/2018/05/019844; CTRI/2020/06/025989).
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Affiliation(s)
- Pabitra Sahu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer K Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Bajaj
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Manasvini Markandey
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Mukesh Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Kante
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peeyush Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Mukesh Ranjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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17
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Ye L, Chapman TP, Wen Z, Lin L, Qiu Y, Liu Z, Ran Z, Qian J, Wu K, Gao X, Hu P, Chen M, Travis SPL, Cao Q. Targeted versus universal tuberculosis chemoprophylaxis in 1968 patients with inflammatory bowel disease receiving anti-TNF therapy in a tuberculosis endemic region. Aliment Pharmacol Ther 2021; 53:390-399. [PMID: 33314259 PMCID: PMC7839545 DOI: 10.1111/apt.16130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor (anti-TNF) therapy increases the risk of tuberculosis (TB). Given limitations of screening techniques, it remains uncertain if patients receiving anti-TNF in TB endemic regions should be screened for latent infection with chemoprophylaxis restricted to those with proven infection, or if all patients should receive chemoprophylaxis. AIMS To compare the incidence of active TB with infliximab (IFX) following targeted and universal TB chemoprophylaxis, and to determine the rates of adverse events (AE) related to TB chemoprophylaxis METHODS: A multi-centre retrospective cohort study was performed at 18 hospitals in China of 1968 adult patients with IBD receiving IFX from 2009 to 2017. TB screening prior to IFX was performed with chest X-ray and/or computed tomography [CT] and immune reactivity testing (interferon-γ release assay and/or tuberculin skin test). Patients were followed-up for a minimum of 3 months after IFX discontinuation, or until last hospital visit if IFX therapy was ongoing. Targeted strategy was defined as TB chemoprophylaxis only for patients with a positive latent TB screen, with universal strategy defined as TB chemoprophylaxis for all patients. RESULTS Mean follow-up was 1.07 ± 0.87 years with a total follow-up of 2102 patient-years. There were 1433 patients in the targeted and 483 patients in the universal TB chemoprophylaxis groups, with no significant difference in the incidence rates of active TB between groups (673.3 per 100 000 population per year vs 891.5 per 100 000 population per year, P = 0.60). In the targeted group, 55/1433 patients received TB chemoprophylaxis compared with 483/483 in the universal group, with significantly fewer AEs related to TB chemoprophylaxis in the targeted compared to the universal group (0.35% (5/1433) vs 6.8% (33/483), P < 0.05). CONCLUSIONS In this study of patients receiving IFX in a TB endemic area, universal chemoprophylaxis was not associated with a reduced risk of active TB when compared to a targeted chemoprophylaxis strategy, and AEs were more common. This supports the use of targeted TB chemoprophylaxis when anti-TNF therapy is initiated in TB endemic regions.
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Affiliation(s)
- Lingna Ye
- Department of GastroenterologyXiasha Branch of Sir Run Run Shaw HospitalCollege of Medicine Zhejiang UniversityHangzhouChina
| | - Thomas P. Chapman
- Translational Gastroenterology UnitNIHR Oxford Biomedical Research CentreOxford University Hospitals NHS Foundation TrustJohn Radcliffe HospitalOxfordUK
| | - Zhenzhen Wen
- Department of GastroenterologySir Run Run Shaw HospitalCollege of Medicine Zhejiang UniversityHangzhouChina
| | - Lang Lin
- Department of GastroenterologyThe Sixth Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yun Qiu
- Department of GastroenterologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Zhanju Liu
- Department of GastroenterologyThe Shanghai Tenth People's HospitalTongji UniversityShanghaiChina
| | - Zhihua Ran
- Division of Gastroenterology and HepatologyKey Laboratory of Gastroenterology and HepatologyMinistry of HealthShanghai Inflammatory Bowel Disease Research CenterRenji HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Jiaming Qian
- Department of GastroenterologyPeking Union Medical College HospitalChinese Academy Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Kaichun Wu
- State Key Laboratory of Cancer BiologyNational Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive DiseasesFourth Military Medical UniversityXi'anChina
| | - Xiang Gao
- Department of GastroenterologyThe Sixth Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Pinjin Hu
- Department of GastroenterologyThe Sixth Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Minhu Chen
- Department of GastroenterologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Simon P. L. Travis
- Translational Gastroenterology UnitNIHR Oxford Biomedical Research CentreOxford University Hospitals NHS Foundation TrustJohn Radcliffe HospitalOxfordUK
| | - Qian Cao
- Department of GastroenterologySir Run Run Shaw HospitalCollege of Medicine Zhejiang UniversityHangzhouChina
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18
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Ambrose T, Travis SPL, Allan PJ. Letter to the editor-Reply-Intestinal transplantation and quality of life. Clin Nutr 2020; 40:332-333. [PMID: 33248873 DOI: 10.1016/j.clnu.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Tim Ambrose
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
| | - Simon P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Philip J Allan
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom; Oxford Transplant Centre, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, OX3 7LE, United Kingdom
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19
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Culver EL, Bungay HK, Betts M, Forde C, Buchel O, Manganis C, Warren BF, Cummings FR, Keshav S, Travis SPL, Chapman RW. Prevalence and long-term outcome of sub-clinical primary sclerosing cholangitis in patients with ulcerative colitis. Liver Int 2020; 40:2744-2757. [PMID: 32841490 DOI: 10.1111/liv.14645] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is closely associated with inflammatory bowel disease, particularly ulcerative colitis (UC), with an increased risk of biliary and colorectal malignancy. We sought to clarify the prevalence, characteristics and long-term outcome of sub-clinical PSC diagnosed by magnetic resonance cholangiogram (MRC) in patients with UC and normal liver biochemistry, with or without colorectal dysplasia (CRD). METHODS In this prospective case-control study, 70 patients with UC and normal liver function (51 extensive UC, 19 CRD), 28 healthy volunteers (negative controls) and 28 patients with PSC and cholestasis (positive controls) underwent MRC and blood evaluation. MRC scans were interpreted blindly by two radiologists who graded individually, the scans as definitive for PSC, possible for PSC or normal. Clinical outcome was assessed by blood monitoring, abdominal imaging and endoscopic surveillance. RESULTS 7/51 (14%) with extensive UC and 4/19 (21%) with CRD had biliary abnormalities on MRC consistent with PSC. 7/11 (64%) with sub-clinical PSC had isolated intrahepatic duct involvement. Sub-clinical PSC was associated with advanced age (P = .04), non-smoking (P = .03), pANCA (P = .04), quiescent colitis (P = .02), absence of azathioprine (P = .04) and high-grade CRD (P = .03). Inter-observer (kappa = 0.88) and intra-observer (kappa = 0.96) agreement for MRC interpretation was high. No negative controls were assessed as definite PSC, 4/28 were considered on blinding as possible PSC. During follow-up of sub-clinical PSC (median 10.1(3.1-11.9) years), four patients developed abnormal liver biochemistry, two had radiological progression of PSC and seven developed malignancy, including two biliary and one colorectal carcinoma. CONCLUSIONS Prevalence of sub-clinical PSC appears high in patients with extensive UC and normal liver biochemistry, with or without CRD. Disease progression and malignancy were identified on long-term follow-up. MRC should be considered for all patients with extensive UC or CRD to stratify surveillance.
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Affiliation(s)
- Emma L Culver
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Helen K Bungay
- Radiology Department, John Radcliffe Hospital and Churchill Hospital, Oxford, UK
| | - Margaret Betts
- Radiology Department, John Radcliffe Hospital and Churchill Hospital, Oxford, UK
| | - Colm Forde
- Radiology Department, John Radcliffe Hospital and Churchill Hospital, Oxford, UK.,Radiology Department, Queen Elizabeth Hospital, Birmingham, UK
| | - Otto Buchel
- Rondebosch Medical Centre, Cape Town, South Africa
| | - Charis Manganis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bryan F Warren
- Histopathology Department, John Radcliffe Hospital, Oxford, UK
| | - Fraser R Cummings
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Gastroenterology Department, Southampton General Hospital, Southampton, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Roger W Chapman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
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20
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Landerholm K, Reali C, Mortensen NJ, Travis SPL, Guy RJ, George BD. Short- and long-term outcomes of strictureplasty for obstructive Crohn's disease. Colorectal Dis 2020; 22:1159-1168. [PMID: 32053253 DOI: 10.1111/codi.15013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the frequency and outcome of strictureplasty in the era of biologicals and to compare patients operated on by strictureplasty alone, resection alone or a combination of both. METHOD A retrospective review of all patients undergoing strictureplasty for obstructing jejunoileal Crohn's disease (CD) in Oxford between 2004 and 2016 was conducted. For comparison, a cohort of CD patients with resection only during 2009 and 2010 was included. RESULTS In all, 225 strictureplasties were performed during 85 operations, 37 of them in isolation and 48 with simultaneous resection. Another 82 procedures involved resection only; these patients had shorter disease duration, fewer previous operations and longer bowel preoperatively. The frequency of strictureplasty procedures did not alter during the study period and was similar to that in the preceding 25 years. There was no postoperative mortality. One patient required re-laparotomy for a leak after strictureplasty. None developed cancer. The 5-year reoperation rate for recurrent obstruction was 22% (95% CI 12-39) for resection alone, 30% (17-52) for strictureplasty alone and 42% (27-61) for strictureplasty and resection (log rank P = 0.038). Young age was a risk factor for surgical recurrence (log rank P = 0.006). CONCLUSION The use of strictureplasty in CD has not changed significantly since the widespread introduction of biologicals. Surgical morbidity remains low. The risk of recurrent strictures is high and young age is a risk factor. In this study, strictureplasty alone was associated with a lower rate of reoperation compared with strictureplasty with resection.
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Affiliation(s)
- K Landerholm
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Surgery, Ryhov County Hospital, Jönköping and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - C Reali
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S P L Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Nuffield Department of Experimental Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - R J Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B D George
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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21
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Panaccione R, Colombel JF, Travis SPL, Bossuyt P, Baert F, Vaňásek T, Danalıoğlu A, Novacek G, Armuzzi A, Reinisch W, Johnson S, Buessing M, Neimark E, Petersson J, Lee WJ, D’Haens GR. Tight control for Crohn's disease with adalimumab-based treatment is cost-effective: an economic assessment of the CALM trial. Gut 2020; 69:658-664. [PMID: 31285357 PMCID: PMC7063396 DOI: 10.1136/gutjnl-2019-318256] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of an inflammatory biomarker and clinical symptom directed tight control strategy (TC) compared with symptom-based clinical management (CM) in patients with Crohn's disease (CD) naïve to immunosuppressants and biologics using a UK public payer perspective. DESIGN A regression model estimated weekly CD Activity Index (CDAI)-based transition matrices (remission: CDAI <150, moderate: CDAI ≥150 to <300, severe: CDAI ≥300 to <450, very severe: CDAI ≥450) based on the Effect of Tight Control Management on Crohn's Disease (CALM) trial. A regression predicted hospitalisations. Health utilities and costs were applied to health states. Work productivity was monetised and included in sensitivity analyses. Remission rate, CD-related hospitalisations, adalimumab injections, other direct medical costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were calculated. RESULTS Over 48 weeks, TC was associated with a higher clinical remission (CDAI <150) rate (58.2% vs 46.8%), fewer CD-related hospitalisations (0.124 vs 0.297 events per patient) and more injections of adalimumab (40 mg sc) (mean 31.0 vs 24.7) than CM. TC was associated with 0.032 higher QALYs and £593 higher total medical costs. The ICER was £18 656 per QALY. The ICER was cost-effective in 57.9% of simulations. TC became dominant, meaning less costly but more effective, when work productivity was included. CONCLUSION A TC strategy as used in the CALM trial is cost-effective compared with CM. Incorporating costs related to work productivity increases the economic value of TC. Cross-national inferences from this analysis should be made with caution given differences in healthcare systems. TRIAL REGISTRATION NUMBER NCT01235689; Results.
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Affiliation(s)
- Remo Panaccione
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine Vanasek, Division of Gastroenterology and Hepatology, New York, New York, USA
| | | | - Peter Bossuyt
- Gastroenterology, Imelda General Hospital, Bonheiden, Belgium
| | - Filip Baert
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Tomáš Vaňásek
- Division of Gastroenterology and Hepatology, Hepato-Gastroenterologie HK, sro, Hradec Králové, Czech Republic
| | - Ahmet Danalıoğlu
- Gastroenterology Department, Bezmialem Vakıf University, Istanbul, Turkey
| | - Gottfried Novacek
- Department of Internal Medicine IV, Medical University of Vienna, Vienna, Austria
| | - Alessandro Armuzzi
- Internal Medicine and Gastroenterology, Catholic University, Rome, Italy
| | - Walter Reinisch
- Department of Medicine IV, Medical University Vienna, Vienna, Austria
| | | | | | | | | | - Wan-Ju Lee
- AbbVie Inc., North Chicago, Illinois, USA
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22
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Vleugels JLA, Rutter MD, Ragunath K, Rees CJ, Ponsioen CY, Lahiff C, Ket SN, Wanders LK, Samuel S, Butt F, Kuiper T, Travis SPL, D'Haens G, Wang LM, van Eeden S, East JE, Dekker E. Diagnostic Accuracy of Endoscopic Trimodal Imaging and Chromoendoscopy for Lesion Characterization in Ulcerative Colitis. J Crohns Colitis 2019; 13:1586. [PMID: 31125049 DOI: 10.1093/ecco-jcc/jjz074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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Bryant RV, Schultz CG, Ooi S, Goess C, Costello SP, Vincent AD, Schoeman S, Lim A, Bartholomeusz FD, Travis SPL, Andrews JM. Authors' reply: The Association Between Visceral Adipose Tissue and Stricturing Crohn's Disease Behavior, Fecal Calprotectin and Quality of Life. Inflamm Bowel Dis 2019; 25:e62-e63. [PMID: 30380064 DOI: 10.1093/ibd/izy338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Robert Venning Bryant
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher G Schultz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Soong Ooi
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Charlotte Goess
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Samuel Paul Costello
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew D Vincent
- Freemasons Foundation Centre for Men's Health, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Scott Schoeman
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Amanda Lim
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Francis Dylan Bartholomeusz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, Oxfordshire, United Kingdom
| | - Jane Mary Andrews
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.,IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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24
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Bryant RV, Schultz CG, Ooi S, Goess C, Costello SP, Vincent AD, Schoeman S, Lim A, Bartholomeusz FD, Travis SPL, Andrews JM. Visceral Adipose Tissue Is Associated With Stricturing Crohn's Disease Behavior, Fecal Calprotectin, and Quality of Life. Inflamm Bowel Dis 2019; 25:592-600. [PMID: 30215805 DOI: 10.1093/ibd/izy278] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Visceral adipose tissue (VAT) has been proposed to play a pathogenic role in Crohn's disease (CD); however, prospective clinical data are lacking. The aim was to evaluate whether VAT, beyond body mass index (BMI), is associated with CD behavior, disease activity, quality of life (QoL), or outcomes. METHODS Body composition data and clinical, anthropometric, disease activity (fecal calprotectin [FC]), and QoL scores were gathered prospectively on adults with CD at 0, 12, and 24 months. BMI and, VAT metrics (visceral adipose tissue volume [cm3]/height [m2] index and VAT:subcutaneous adipose tissue [SAT] ratio) were calculated. Inflammatory bowel disease-related surgery and hospitalization were recorded over extended follow-up (median, 51 months). Multivariable linear mixed effects and logistic regression analyses were performed. RESULTS Ninety-seven participants were assessed at baseline (55% male; median age, 31 years), 84 at 12 months, and 72 at 24 months. VAT:SAT was positively associated with stricturing disease behavior (log odds ratio [OR], 1.7; 95% confidence interval [CI], 0.32 to 3; P = 0.01) and elevated FC in patients with ileocolonic disease (β, 1.3; 95% CI, 0.32 to 2.3; P = 0.01). VAT:SAT was associated with lower QoL, particularly in those with ileal disease (β, -12; 95% CI, -19 to -4.5; P = 0.05). However, no prospective associations were observed between serial VAT measurements and time to surgery or hospitalization. No correlations were found between BMI and disease behavior, activity, or QoL. CONCLUSIONS VAT:SAT, rather than BMI, is associated with stricturing CD behavior, elevated FC, and reduced QoL in a disease distribution-dependent manner. Further studies are required to substantiate the role of VAT as a useful biomarker in CD.
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Affiliation(s)
- Robert Venning Bryant
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia
| | - Christopher G Schultz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia
| | - Soong Ooi
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia
| | - Charlotte Goess
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia
| | - Samuel Paul Costello
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia
| | - Andrew D Vincent
- Freemasons Foundation Centre for Men's Health, School of Medicine, University of Adelaide, Adelaide, South Australia
| | - Scott Schoeman
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia
| | - Amanda Lim
- IBD Service, Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, South Australia
| | - Francis Dylan Bartholomeusz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Jane Mary Andrews
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia.,IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia
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25
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Vleugels JLA, Rutter MD, Ragunath K, Rees CJ, Ponsioen CY, Lahiff C, Ket SN, Wanders LK, Samuel S, Butt F, Kuiper T, Travis SPL, D'Haens G, Wang LM, van Eeden S, East JE, Dekker E. Diagnostic Accuracy of Endoscopic Trimodal Imaging and Chromoendoscopy for Lesion Characterization in Ulcerative Colitis. J Crohns Colitis 2018; 12:1438-1447. [PMID: 30202856 DOI: 10.1093/ecco-jcc/jjy129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND During surveillance colonoscopy of patients with long-standing ulcerative colitis [UC], a variety of dysplastic and non-dysplastic lesions are detected. The aim of this study was to address the diagnostic accuracy of endoscopic characterization of endoscopic trimodal imaging [ETMI] and chromoendoscopy [CE]. ETMI includes the combination of autofluorescence imaging [AFI], narrow band imaging [NBI] and white light endoscopy [WLE]. METHODS This is a pre-specified additional analysis of a multi-centre, randomized controlled trial that compared AFI with CE for dysplasia detection in 210 patients with long-standing UC [FIND-UC trial]. In the AFI arm, endoscopists used the ETMI system to record AFI colour, Kudo pit pattern using NBI and WLE for lesion characterization. For AFI, purple colour and ambiguous colour combined with pit pattern type III-V on NBI was considered dysplastic. Kudo pit pattern was described in the CE arm. For pit pattern description using NBI and CE, type III-V was considered dysplastic. Histology was the reference standard. RESULTS In total, 52 dysplastic and 255 non-dysplastic lesions were detected. Overall sensitivity for real-time prediction of dysplasia was 76.9% (95% confidence interval [CI] 46.2-95.0) for ETMI, and 81.6% [95% CI 65.7-92.3] for CE. Overall negative predictive value [NPV] for ETMI was 96.9% [95% CI 92.0-98.8] and 94.7% [90.2-97.2] for CE. CONCLUSIONS Sensitivity for endoscopic differentiation of dysplastic lesions detected during surveillance of patients with long-standing UC seems limited using ETMI and CE. Future research is warranted as the high NPV indicates that these techniques are valuable for the exclusion of dysplastic lesions [NTR4062].
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Affiliation(s)
- Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Mathew D Rutter
- Tees Bowel Cancer Screening Centre, University Hospital of North Tees, Stockton-on-Tees Cleveland, UK.,Newcastle University, Newcastle-upon-Tyne, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Colin J Rees
- Newcastle University, Newcastle-upon-Tyne, UK.,Department of Gastroenterology, South Tyneside District Hospital, Tyne and Wear, UK
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Conor Lahiff
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, UK
| | - Shara N Ket
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, UK
| | - Linda K Wanders
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Sunil Samuel
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Faheem Butt
- Department of Gastroenterology, South Tyneside District Hospital, Tyne and Wear, UK
| | - Taeco Kuiper
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Simon P L Travis
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, UK
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lai Mun Wang
- Departmernt of Cellular Pathology, John Radcliffe Hospital, University of Oxford, UK
| | - Susanne van Eeden
- Department of Pathology, Academic Medical Centre, Amsterdam, the Netherlands
| | - James E East
- Department of Gastroenterology, South Tyneside District Hospital, Tyne and Wear, UK
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
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26
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Irani NR, Wang LM, Collins GS, Keshav S, Travis SPL. Correlation Between Endoscopic and Histological Activity in Ulcerative Colitis Using Validated Indices. J Crohns Colitis 2018; 12:1151-1157. [PMID: 29893824 DOI: 10.1093/ecco-jcc/jjy081] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopy and histopathology are pivotal for evaluating disease activity in ulcerative colitis [UC]; correlation between validated endoscopic and histological indices has not been examined. We aim to correlate the Ulcerative Colitis Endoscopic Index of Severity [UCEIS] with two new validated histological indices in patients with established UC. METHODS This was a single-centre cohort of patients with established UC, who underwent flexible sigmoidoscopy or colonoscopy by a single endoscopist. The UCEIS was scored at the worst affected area in the distal colon, which was biopsied; histological disease activity using Nancy [NI] and Robarts' Histological [RHI] indices was scored by a pathologist blinded to the endoscopy. Spearman correlation between the UCEIS, NI, and RHI, and between NI and RHI, was performed. RESULTS A total of 125 patients, median age 37 years [range 16-81 years], with UCEIS scores [scale 0-8]: 0, n = 21; 1-3, n = 48; 4-6, n = 51; and 7-8, n = 5, were included. Correlation coefficients between UCEIS and NI [scale 0-4] were r = 0.84 (95% confidence interval [CI] 0.76-0.89, p < 0.001) and between UCEIS and RHI [scale 0-33] r = 0.86 [95% CI 0.80-0.90, p < 0.001]. The difference in correlation was not significant [p = 0.57]. There was excellent correlation between the two histological indices [r = 0.92, 95% CI 0.87-0.95, p < 0.001]. Quiescent disease activity defined as the absence of neutrophils [Nancy 0-1, Robarts 0-3] was most closely correlated with UCEIS = 0. CONCLUSIONS The UCEIS strongly correlates with both NI and RHI. Complete mucosal healing is best defined as a UCEIS = 0/8, since this correlates with the absence of microscopic disease activity.
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Affiliation(s)
- Nazneen R Irani
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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Kedia S, Jain S, Goyal S, Bopanna S, Yadav DP, Sachdev V, Sahni P, Pal S, Dash NR, Makharia G, Travis SPL, Ahuja V. Potential of Fecal Calprotectin as an Objective Marker to Discriminate Hospitalized Patients with Acute Severe Colitis from Outpatients with Less Severe Disease. Dig Dis Sci 2018; 63:2747-2753. [PMID: 29948556 DOI: 10.1007/s10620-018-5157-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 05/30/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute severe colitis (ASC) is conventionally diagnosed by Truelove and Witts' criteria which are non-specific and can be affected by other pathologic conditions. Fecal calprotectin (FCP) is a gut-specific marker of inflammation which can predict short-term outcomes in patients with ASC. We aimed to define the role of FCP in the diagnosis of ASC. METHODS This prospective observational cohort study included adult patients (> 18 years) with ulcerative colitis (UC) for whom FCP was measured and was under follow-up from April 2015 to December 2016. Patients were divided into two cohorts: (1) all consecutive hospitalized patients with ASC as defined by Truelove and Witts' criteria; (2) outpatients with active UC (defined by Mayo score) who did not fulfill Truelove and Witts' criteria. FCP levels were compared between the two cohorts, and a cutoff for FCP to diagnose ASC was determined. RESULTS Of 97 patients, 49 were diagnosed with ASC (mean age: 36.1 ± 11.9 years, 36 males) and 48 with active UC (mean age: 37.9 ± 12.4 years, 25 males). Median FCP levels were significantly higher in patients with ASC [1776(952-3123) vs 282(43-568) µg/g, p < 0.001] than mild to moderately active UC (n = 48) or moderately active UC [n = 35, 1776(952-3123) vs 332(106-700) µg/g, p < 0.001]. A FCP cutoff of 782 μg/g of stool had excellent diagnostic accuracy, with an area under the curve of 0.92(95% CI 0.87-0.97), sensitivity of 84% and specificity of 88% to differentiate ASC from active UC. CONCLUSION FCP could differentiate ASC from mild to moderate patients with UC, but requires validation before clinical use.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Goyal
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Sachdev
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of GI Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- John Radcliffe Hospital, Translational Gastroenterology Unit, Headley Way, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Lahiff C, Wang LM, Travis SPL, East JE. Polyp-adjacent biopsies no longer required in inflammatory bowel disease. Gastrointest Endosc 2018; 88:782-783. [PMID: 30217249 DOI: 10.1016/j.gie.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/06/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Conor Lahiff
- Translational Gastroenterology Unit, Nuffield Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom; Milton Keynes University Hospital, Buckinghamshire, United Kingdom
| | - Lai Mun Wang
- Translational Gastroenterology Unit, Nuffield Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom; Department of Histopathology, Changi General Hospital, Singapore
| | - Simon P L Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Brierley CK, Castilla-Llorente C, Labopin M, Badoglio M, Rovira M, Ricart E, Dierickx D, Vermeire S, Hasselblatt P, Finke J, Onida F, Cassinotti A, Satsangi J, Kazmi M, López-Sanromán A, Schmidt C, Farge D, Travis SPL, Hawkey CJ, Snowden JA. Autologous Haematopoietic Stem Cell Transplantation for Crohn's Disease: A Retrospective Survey of Long-term Outcomes From the European Society for Blood and Marrow Transplantation. J Crohns Colitis 2018; 12:1097-1103. [PMID: 29788233 PMCID: PMC6113702 DOI: 10.1093/ecco-jcc/jjy069] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/05/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Autologous haematopoietic stem cell transplantation [AHSCT] is a therapeutic option for patients with severe, treatment-refractory Crohn's disease [CD]. The evidence base for AHSCT for CD is limited, with one randomised trial [ASTIC] suggesting benefit. The aim of this study was to evaluate safety and efficacy for patients undergoing AHSCT for CD in Europe, outside the ASTIC trial. METHODS We identified 99 patients in the European Society for Blood and Marrow Transplantation [EBMT] registry, who were eligible for inclusion. Transplant and clinical outcomes were obtained for 82 patients from 19 centres in seven countries. RESULTS Median patient age was 30 years [range 20-65]. Patients had failed or been intolerant to a median of six lines of drug therapy; 61/82 [74%] had had surgery. Following AHSCT, 53/78 [68%] experienced complete remission or significant improvement in symptoms at a median follow-up of 41 months [range 6-174]; 22/82 [27%] required no medical therapy at any point post-AHSCT. In patients who had re-started medical therapy at latest follow-up, 57% [24/42] achieved remission or significant symptomatic improvement with therapies to which they had previously lost response or been non-responsive. Treatment-free survival at 1 year was 54%. On multivariate analysis, perianal disease was associated with adverse treatment-free survival (hazard ratio 2.34, 95% confidence interval [CI] 1.14-4.83, p = 0.02). One patient died due to infectious complications [cytomegalovirus disease] at Day +56. CONCLUSIONS In this multicentre retrospective analysis of European centres, AHSCT was relatively safe and appeared to be effective in controlling otherwise treatment-resistant Crohn's disease. Further prospective randomised controlled trials against standard of care are warranted.
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Affiliation(s)
- Charlotte K Brierley
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK,Corresponding author: Dr Charlotte Brierley, MA, MRCP, Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LE, UK.
| | - Cristina Castilla-Llorente
- Unité de transplantation des cellules souches, Département d’Hématologie Gustave Roussy, Villejuif, France
| | - Myriam Labopin
- EBMT Paris Study Office, Department of Haematology, Université Pierre et Marie Curie, Saint Antoine Hospital, Paris, France
| | - Manuela Badoglio
- EBMT Paris Study Office, Department of Haematology, Université Pierre et Marie Curie, Saint Antoine Hospital, Paris, France
| | - Montserrat Rovira
- BMT Unit, Haematology Department, Hospital Clínic of Barcelona, IDIBAPS, Institut Josep Carreras, Barcelona, Spain
| | - Elena Ricart
- Gastroenterology Department, Hospital Clínic of Barcelona, CIBER-EHD, IDIBAPS, Barcelona, Spain
| | - Daan Dierickx
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Severine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Peter Hasselblatt
- Department of Medicine II, Medical Faculty and University Hospital Freiburg, Freiburg, Germany
| | - Juergen Finke
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Faculty and University Hospital Freiburg, Freiburg, Germany
| | - Francesco Onida
- Haematology - BMT Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | - Jack Satsangi
- Gastro-intestinal Unit, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Majid Kazmi
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College Hospital, London, UK
| | | | - Carsten Schmidt
- Department of Gastroenterology, Medizinische Klinik II, Klinikum Fulda AG, Universitätsmedizin Marburg-Campus, Fulda, Germany
| | - Dominique Farge
- Internal Medicine, Autoimmune and Vascular Diseases Unit, UF 04, AP-HP Hôpital Saint-Louis, Centre de Référence des Maladies auto-immunes systémiques Rares d’Ile-de-France [site constitutif], Filière FAI2R Paris 7 University, France
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Chris J Hawkey
- Nottingham Digestive Diseases Centre, School of Clinical Sciences, Queen’s Medical Centre, Nottingham, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Das B, Ghosh TS, Kedia S, Rampal R, Saxena S, Bag S, Mitra R, Dayal M, Mehta O, Surendranath A, Travis SPL, Tripathi P, Nair GB, Ahuja V. Analysis of the Gut Microbiome of Rural and Urban Healthy Indians Living in Sea Level and High Altitude Areas. Sci Rep 2018; 8:10104. [PMID: 29973712 PMCID: PMC6031670 DOI: 10.1038/s41598-018-28550-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/26/2018] [Indexed: 12/18/2022] Open
Abstract
The diversity and basic functional attributes of the gut microbiome of healthy Indians is not well understood. This study investigated the gut microbiome of three Indian communities: individuals residing in rural and urban (n = 49) sea level Ballabhgarh areas and in rural high altitude areas of Leh, Ladakh in North India (n = 35). Our study revealed that the gut microbiome of Indian communities is dominated by Firmicutes followed by Bacteroidetes, Actinobateria and Proteobacteria. Although, 54 core bacterial genera were detected across the three distinct communities, the gut bacterial composition displayed specific signatures and was observed to be influenced by the topographical location and dietary intake of the individuals. The gut microbiome of individuals living in Leh was observed to be significantly similar with a high representation of Bacteroidetes and low abundance of Proteobacteria. In contrast, the gut microbiome of individuals living in Ballabhgarh areas harbored higher number of Firmicutes and Proteobacteria and is enriched with microbial xenobiotic degradation pathways. The rural community residing in sea level Ballabhgarh areas has unique microbiome characterized not only by a higher diversity, but also a higher degree of interindividual homogeneity.
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Affiliation(s)
- Bhabatosh Das
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India.
| | - Tarini Shankar Ghosh
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ritika Rampal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Shruti Saxena
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - Satyabrata Bag
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - Ridhima Mitra
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - Mayanka Dayal
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - Ojasvi Mehta
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - A Surendranath
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Prabhanshu Tripathi
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India
| | - G Balakrish Nair
- Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, 121001, India.,Research Policy and Cooperation Unit, Communicable Diseases Department, World Health Organization (WHO), Mahatma Gandhi Marg, Indraprastha Estate, New Delhi, 110 002, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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Feagan BG, Bhayat F, Khalid M, Blake A, Travis SPL. Respiratory Tract Infections in Patients With Inflammatory Bowel Disease: Safety Analyses From Vedolizumab Clinical Trials. J Crohns Colitis 2018; 12:905-919. [PMID: 29788248 PMCID: PMC6065483 DOI: 10.1093/ecco-jcc/jjy047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Vedolizumab, a humanised monoclonal antibody for the treatment of inflammatory bowel disease, selectively blocks gut lymphocyte trafficking. This may reduce the risk of respiratory tract infections [RTIs] compared with systemic immunosuppressive therapies. To assess this possibility, we evaluated the rates of RTIs in clinical trials of vedolizumab. METHODS Patient-level data from Phase 3 randomised controlled trials [RCTs] of vedolizumab in ulcerative colitis [UC; GEMINI 1] and Crohn's disease [CD; GEMINI 2], and a long-term safety study [UC and CD] were pooled. Cox proportional hazards models were used to estimate the incidence of upper RTIs [URTIs] and lower RTIs [LRTIs] with adjustment for significant covariates. RESULTS In the RCTs [n = 1731 patients], the incidence of URTIs was numerically higher in patients receiving vedolizumab compared with those receiving placebo, although this difference was not statistically significant (38.7 vs 33.0 patients per 100 patient-years; hazard ratio [HR] 1.12; 95% confidence interval [CI]: 0.83-1.51; p = 0.463). The rate of LRTIs, including pneumonia, was numerically lower in the vedolizumab versus the placebo group: this difference was not statistically significant (7.7 vs 8.5 per 100 patient-years [HR 0.85; 95% CI: 0.48-1.52; p = 0.585]). Both URTIs and LRTIs were more frequent in patients with CD compared with UC. Most RTIs in patients receiving vedolizumab were not serious and did not require treatment discontinuation. CONCLUSIONS Vedolizumab therapy was not associated with an increased incidence of respiratory tract infection compared with placebo.
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Affiliation(s)
- Brian G Feagan
- Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, London, ON, Canada,Corresponding author: Brian G. Feagan, MD, FRCPC, Robarts Clinical Trials, Robarts Research Institute, University of Western Ontario, 1151 Richmond St N., London, ON, N6A 5B7, Canada. Tel.: 1 [519] 931–5289 or 858–5087; fax: 1 [519] 931–5278;
| | - Fatima Bhayat
- Global Patient Safety, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Mona Khalid
- Evidence and Value generation, Takeda International – UK Branch, London, UK
| | - Aimee Blake
- Evidence and Value generation, Takeda International – UK Branch, London, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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Quaranta M, Wilson R, Gonçalves Serra E, Pandey S, Schwerd T, Gilmour K, Klenerman P, Powrie F, Keshav S, Travis SPL, Anderson CA, Uhlig HH. Consequences of Identifying XIAP Deficiency in an Adult Patient With Inflammatory Bowel Disease. Gastroenterology 2018; 155:231-234. [PMID: 29894681 DOI: 10.1053/j.gastro.2018.03.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/26/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Maria Quaranta
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Rachel Wilson
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Sumeet Pandey
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Tobias Schwerd
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Paul Klenerman
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Fiona Powrie
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital and Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Holm H Uhlig
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Lahiff C, Mun Wang L, Travis SPL, East JE. Diagnostic Yield of Dysplasia in Polyp-adjacent Biopsies for Patients with Inflammatory Bowel Disease: A Cross-sectional Study. J Crohns Colitis 2018; 12:670-676. [PMID: 29385427 DOI: 10.1093/ecco-jcc/jjy007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 01/18/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Patients with inflammatory bowel disease (IBD) undergoing polypectomy are recommended by current guidelines to have biopsies taken from adjacent mucosa to determine whether there is dysplasia present. With improvements in endoscopic imaging, it is now possible to characterize colonic lesions with higher levels of confidence than previously. We have reviewed the diagnostic yield of polyp-adjacent biopsies in IBD. MATERIALS AND METHODS A systematic search of our histopathology database revealed cases in which polyps had been endoscopically resected or biopsied in patients with IBD. Endoscopy reports and medical records were reviewed, and patient demographic and disease-specific details were recorded, along with details of polyp characteristics and histopathology outcomes. RESULTS Three hundred and two polyps were biopsied or resected in 131 patients undergoing 178 colonoscopies. The median polyp size was 4 mm (range 1-45), and the predominant morphology was Paris 0-Is (n = 98, 32%). The histology was tubular adenoma in 76 (25%), tubulovillous adenoma in 14 (5%), hyperplastic in 112 (37%), post-inflammatory in 32 (11%), sessile serrated polyp in 31 (10%), traditional serrated adenoma in 2 (0.7%), flat high-grade dysplasia or cancer in 2 (0.7%) and other in 33 (11%). Dysplasia in adjacent biopsies was detected in 2 patients (0.7%), and was endoscopically visible in both cases. The proportion of endoscopically unsuspected dysplasia was 0/300 (0%, 95% CI 0-1.6%). CONCLUSION The diagnostic yield for polyp-adjacent biopsies in patients with IBD is negligible. With high-definition technology and chromoendoscopy, it may no longer be necessary to biopsy endoscopically normal adjacent tissue to detect invisible dysplasia.
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Affiliation(s)
- Conor Lahiff
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Laboratory Medicine, Changi General Hospital, Singapore.,Ludwig Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Williams JG, Alam MF, Alrubaiy L, Arnott I, Clement C, Cohen D, Gordon JN, Hawthorne AB, Hilton M, Hutchings HA, Jawhari AU, Longo M, Mansfield J, Morgan JM, Rapport F, Seagrove AC, Sebastian S, Shaw I, Travis SPL, Watkins A. Infliximab versus ciclosporin for steroid-resistant acute severe ulcerative colitis (CONSTRUCT): a mixed methods, open-label, pragmatic randomised trial. Lancet Gastroenterol Hepatol 2018; 1:15-24. [PMID: 27595142 PMCID: PMC4994668 DOI: 10.1016/s2468-1253(16)30003-6] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Infliximab and ciclosporin are of similar efficacy in treating acute severe ulcerative colitis, but there has been no comparative evaluation of their relative clinical effectiveness and cost-effectiveness. Methods In this mixed methods, open-label, pragmatic randomised trial, we recruited consenting patients aged 18 years or older at 52 district general and teaching hospitals in England, Scotland, and Wales who had been admitted, unscheduled, with severe ulcerative colitis and failed to respond to intravenous hydrocortisone within about 5 days. Patients were randomly allocated (1:1) to receive either infliximab (5 mg/kg intravenous infusion given over 2 h at baseline, and again at 2 weeks and 6 weeks after the first infusion) or ciclosporin (2 mg/kg per day by continuous infusion for up to 7 days, followed by twice-daily tablets delivering 5·5 mg/kg per day for 12 weeks). Randomisation used a web-based password-protected site, with a dynamic algorithm to generate allocations on request, thus protecting against investigator preference or other subversion, while ensuring that each trial group was balanced by centre, which was the only stratification used. Local investigators and participants were aware of the treatment allocated, but the chief investigator and analysts were masked. Analysis was by treatment allocated. The primary outcome was quality-adjusted survival—ie, the area under the curve (AUC) of scores from the Crohn's and Ulcerative Colitis Questionnaire (CUCQ) completed by participants at baseline, 3 months, and 6 months, then every 6 months from 1 year to 3 years. This trial is registered with the ISRCTN Registry, number ISRCTN22663589. Findings Between June 17, 2010, and Feb 26, 2013, 270 patients were recruited. 135 patients were allocated to the infliximab group and 135 to the ciclosporin group. 121 (90%) patients in each group were included in the analysis of the primary outcome. There was no significant difference between groups in quality-adjusted survival (mean AUC 564·0 [SD 241·9] in the infliximab group vs 587·0 [226·2] in the ciclosporin group; mean adjusted difference 7·9 [95% CI −22·0 to 37·8]; p=0·603). Likewise, there were no significant differences between groups in the secondary outcomes of CUCQ scores, EQ-5D, or SF-6D scores; frequency of colectomy (55 [41%] of 135 patients in the infliximab group vs 65 [48%] of 135 patients in the ciclosporin group; p=0·223); or mean time to colectomy (811 [95% CI 707–912] days in the infliximab group vs 744 [638–850] days in the ciclosporin group; p=0·251). There were no differences in serious adverse reactions (16 reactions in 14 participants receiving infliximab vs ten in nine patients receiving ciclosporin); serious adverse events (21 in 16 patients vs 25 in 17 patients); or deaths (three in the infliximab group vs none in the ciclosporin group). Interpretation There was no significant difference between ciclosporin and infliximab in clinical effectiveness. Funding NIHR Health Technology Assessment programme.
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Affiliation(s)
| | - M Fasih Alam
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | | | - Ian Arnott
- NHS Lothian, Western General Hospital, Edinburgh, UK
| | | | | | - John N Gordon
- Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester, UK
| | - A Barney Hawthorne
- Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Mike Hilton
- Swansea University Medical School, Swansea, UK
| | | | - Aida U Jawhari
- National Institute for Health Research (NIHR), Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Mirella Longo
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - John Mansfield
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | | | | | | | - Ian Shaw
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Trust, Oxford, UK
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Vleugels JLA, Rutter MD, Ragunath K, Rees CJ, Ponsioen CY, Lahiff C, Ket SN, Wanders LK, Samuel S, Butt F, Kuiper T, Travis SPL, D'Haens G, Wang LM, van Eeden S, East JE, Dekker E. Chromoendoscopy versus autofluorescence imaging for neoplasia detection in patients with longstanding ulcerative colitis (FIND-UC): an international, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 3:305-316. [PMID: 29567006 DOI: 10.1016/s2468-1253(18)30055-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with longstanding ulcerative colitis undergo regular dysplasia surveillance because they have an increased colorectal cancer risk. Autofluorescence imaging and chromoendoscopy improve dysplasia detection. The aim of this study was to determine whether autofluorescence imaging should be further studied as an alternative method for dysplasia surveillance in patients with longstanding ulcerative colitis. METHODS This prospective, international, randomised controlled trial included patients from an ulcerative colitis-dysplasia surveillance cohort from five centres in the Netherlands and the UK. Eligible patients were aged 18 years or older who were undergoing dysplasia surveillance after being diagnosed with extensive colitis (Montreal E3) at least 8 years before study start or with left-sided colitis (Montreal E2) at least 15 years before study start. Randomisation (1:1) was minimised for a previous personal history of histologically proven dysplasia and concomitant primary sclerosing cholangitis. The coprimary outcomes were the proportion of patients in whom at least one dysplastic lesion was detected and the mean number of dysplastic lesions per patient. The relative dysplasia detection rate, calculated as the ratio of the detection rates by autofluorescence imaging and chromoendoscopy, needed to be more than 0·67 (using an 80% CI) for both primary outcomes to support a subsequent large non-inferiority trial. Outcomes were analysed on a per-protocol basis. The trial is registered at the Netherlands Trial Register, number NTR4062. FINDINGS Between Aug 1, 2013, and March 10, 2017, 210 patients undergoing colonoscopy surveillance for longstanding ulcerative colitis were randomised for inspection with either autofluorescence imaging (n=105) or chromoendoscopy (n=105). Dysplasia was detected in 13 (12%) patients by autofluorescence imaging and in 20 patients (19%) by chromoendoscopy. The relative dysplasia detection rate of autofluorescence imaging versus chromoendoscopy for the proportion of patients with ulcerative colitis with at least one dysplastic lesion was 0·65 (80% CI 0·43-0·99). The mean number of detected dysplastic lesions per patient was 0·13 (SD 0·37) for autofluorescence imaging and 0·37 (1·02) for chromoendoscopy (relative dysplasia detection rate 0·36, 80% CI 0·21-0·61). Adverse events were reported for two patients in the autofluorescence imaging group (one patient had intraprocedural mild bleeding, and one patient had abdominal pain) and for three patients in the chromoendoscopy group (two patients had intraprocedural mild bleeding, and one patient had perforation). INTERPRETATION Autofluorescence imaging did not meet criteria for proceeding to a large non-inferiority trial. Therefore, existing autofluorescence imaging technology should not be further investigated as an alternative dysplasia surveillance method. FUNDING Olympus Europe and Olympus Keymed.
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Affiliation(s)
- Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Matt D Rutter
- Tees Bowel Cancer Screening Centre, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK; Newcastle University, Newcastle-upon-Tyne, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK; NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Colin J Rees
- Newcastle University, Newcastle-upon-Tyne, UK; Department of Gastroenterology, South Tyneside District Hospital, Tyne and Wear, UK
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Conor Lahiff
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Shara N Ket
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Linda K Wanders
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Sunil Samuel
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK; NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Faheem Butt
- Department of Gastroenterology, South Tyneside District Hospital, Tyne and Wear, UK
| | - Teaco Kuiper
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Lai M Wang
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Susanne van Eeden
- Department of Pathology, Academic Medical Centre, Amsterdam, Netherlands
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands.
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Fairhurst NG, Travis SPL. Why is it so difficult to evaluate faecal microbiota transplantation as a treatment for ulcerative colitis? Intest Res 2018; 16:209-215. [PMID: 29743833 PMCID: PMC5934593 DOI: 10.5217/ir.2018.16.2.209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 09/06/2017] [Accepted: 09/06/2017] [Indexed: 12/16/2022] Open
Abstract
Faecal microbiota transplantation (FMT) has recently re-emerged as a viable therapeutic option for colonic disorders. Its efficacy has been proved in the treatment of Clostridium difficile infection which has encouraged research into the use of FMT for other disorders involving gut dysbiosis, such as ulcerative colitis (UC), a chronic inflammatory disease characterized by relapsing and remitting colonic inflammation. Although the FMT protocol for C. difficile treatment is well established, there are numerous additional factors to consider when applying FMT to treat inflammatory diseases. Various studies have attempted to address these factors but technical inconsistency between reports has resulted in a failure to achieve clinically significant findings. Case reports of FMT in UC have shown favorable outcomes yet demonstrating these effects on a larger scale has proved difficult. The following review aims to explore these issues and to analyze why they may be hindering the progression of FMT therapy in UC.
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Affiliation(s)
| | - Simon P L Travis
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, John Radcliffe Hospital, Oxford, UK
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37
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Jain S, Kedia S, Sethi T, Bopanna S, Yadav DP, Goyal S, Padhan R, Venigalla PM, Sahni P, Dash NR, Pal S, Makharia G, Travis SPL, Ahuja V. Predictors of long-term outcomes in patients with acute severe colitis: A northern Indian cohort study. J Gastroenterol Hepatol 2018; 33:615-622. [PMID: 28801987 DOI: 10.1111/jgh.13921] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/04/2017] [Accepted: 08/09/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Knowledge of long-term outcomes following an index episode of acute severe colitis (ASC) can help informed decision making at a time of acute exacerbation especially when colectomy is an option. We aimed to identify long-term outcomes and their predictors after a first episode of ASC in a large North Indian cohort. METHODS Hospitalized patients satisfying Truelove and Witts' criteria under follow-up at a single center from January 2003 to December 2013 were included. Patients avoiding colectomy at index admission were categorized as complete (≤ 3 non bloody stool per day) or incomplete responders, based upon response to corticosteroids at day 7. Random Forest-based machine learning models were constructed to predict the long-term risk of colectomy or steroid dependence following an index episode of ASC. RESULTS Of 1731 patients with ulcerative colitis, 179 (10%) had an index episode of ASC. Nineteen (11%) patients underwent colectomy at index admission and 42 (26%) over a median follow-up of 56 (1-159) months. Hazard ratio for colectomy for incomplete responder was 3.6 (1.7-7.5, P = 0.001) compared with complete responder. Modeling based on four variables, response at day 7 of hospitalization, steroid use during the first year of diagnosis, longer disease duration before ASC, and number of extra-intestinal manifestations, was able to predict colectomy with an accuracy of 77%. CONCLUSIONS Disease behavior of ASC in India is similar to the West, with a third undergoing colectomy at 10 years. Clinical features, especially response at day 7 hospitalization for index ASC, can predict both colectomy and steroid dependence with reasonable accuracy.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Tavpritesh Sethi
- Indraprastha Institute of Information Technology, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh Prakash Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Goyal
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Padhan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pratap Mouli Venigalla
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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38
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Bryant RV, Costello SP, Schoeman S, Sathananthan D, Knight E, Lau SY, Schoeman MN, Mountifield R, Tee D, Travis SPL, Andrews JM. Limited uptake of ulcerative colitis "treat-to-target" recommendations in real-world practice. J Gastroenterol Hepatol 2018; 33:599-607. [PMID: 28806471 DOI: 10.1111/jgh.13923] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/22/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS A "treat-to-target" approach has been proposed for ulcerative colitis (UC), with a target of combined clinical and endoscopic remission. The aim of the study was to evaluate the extent to which proposed targets are achieved in real-world care, along with clinician perceptions and potential challenges. METHODS A multicentre, retrospective, cross-sectional review of patients with UC attending outpatient services in South Australia was conducted. Clinical and objective assessment of disease activity (endoscopy, histology, and/or biomarkers) was recorded. A survey evaluated gastroenterologists' perceptions of treat to target in UC. Statistical analysis included logistic regression and Fisher's exact tests. RESULTS Of 246 patients with UC, 61% were in clinical remission (normal bowel habit and no rectal bleeding), 35% in clinical and endoscopic remission (Mayo endoscopic sub-score ≤ 1), and 16% in concordant clinical, endoscopic, and histological (Truelove and Richards' Index) remission. Rather than disease-related factors (extent/activity), clinician-related factors dominated outcome. Hospital location and the choice of therapy predicted combined clinical and endoscopic remission (OR 3.6, 95% CI 1.6-8.7, P < 0.001; OR 3.3, 95% CI 1.1-12.5, P = 0.04, respectively). Clinicians used C-reactive protein more often than endoscopy as a biomarker for disease activity (75% vs 47%, P < 0.001). In the survey, 45/61 gastroenterologists responded, with significant disparity between clinician estimates of targets achieved in practice and real-world data (P < 0.001 for clinical and endoscopic remission). CONCLUSIONS Most patients with UC do not achieve composite clinical and endoscopic remission in "real-world" practice. Clinician uptake of proposed treat-to-target guidelines is a challenge to their implementation.
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Affiliation(s)
- Robert V Bryant
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Samuel P Costello
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Scott Schoeman
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dharshan Sathananthan
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Emma Knight
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Su-Yin Lau
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Mark N Schoeman
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Reme Mountifield
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Derrick Tee
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Jane M Andrews
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia.,IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Jain S, Kedia S, Bopanna S, Yadav DP, Goyal S, Sahni P, Pal S, Dash NR, Makharia G, Travis SPL, Ahuja V. Are Truelove and Witts criteria for diagnosing acute severe colitis relevant for the Indian population? A prospective study. Intest Res 2018; 16:69-74. [PMID: 29422800 PMCID: PMC5797274 DOI: 10.5217/ir.2018.16.1.69] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/26/2017] [Accepted: 08/29/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS Truelove and Witts criteria have been used to define acute severe colitis since the 1950s. However, hemoglobin (an additional criterion of the definition) levels in the general population in developing countries are lower than in the population of developed countries. We aimed to determine the relevance of Truelove and Witts criteria in the Indian population. METHODS Consecutive patients with acute severe colitis satisfying the Truelove and Witts criteria, hospitalized at a single center between April 2015 and December 2016 were included. All patients received intravenous corticosteroids and 16 required colectomy. The hemoglobin levels at admission were subsequently excluded from the classification criteria, and the effect this had on the criteria for diagnosis was determined. RESULTS Out of 61 patients of acute severe colitis diagnosed according to the original Truelove and Witts criteria, 12 patients (20%) had 1 additional criterion, 33 (54%) had 2 additional criteria and 16 (26%) had 3 or more additional criteria in addition to 6 or more blood stained stools on admission. On excluding hemoglobin as an additional criterion from the Truelove and Witts definition, all patients still met the criteria for acute severe colitis. CONCLUSIONS Truelove and Witts criteria can be used to define acute severe colitis in India, despite lower mean hemoglobin in the native population.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Goyal
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon P. L. Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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40
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Jain S, Kedia S, Bopanna S, Sachdev V, Sahni P, Dash NR, Pal S, Vishnubhatla S, Makharia G, Travis SPL, Ahuja V. Faecal Calprotectin and UCEIS Predict Short-term Outcomes in Acute Severe Colitis: Prospective Cohort Study. J Crohns Colitis 2017; 11:1309-1316. [PMID: 29088461 DOI: 10.1093/ecco-jcc/jjx084] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Early objective markers for failure of intravenous[iv] corticosteroid for acute severe colitis [ASC] can avoid delay in rescue therapy or colectomy. We investigated faecal calprotectin [FC], C-reactive protein [CRP], and endoscopy using the ulcerative colitis endoscopic index of severity [UCEIS] as predictors of steroid failure following intensive therapy of ASC. METHODS Consecutive patients with ASC satisfying Truelove and Witts' criteria, hospitalised at a single centre from May 2015 to November 2016, were included; all received iv corticosteroids. The primary outcome measure was steroid failure defined as colectomy and/or rescue therapy with ciclosporin or infliximab during admission. FC levels were measured at admission and on Day 3 of intensive therapy. UCEIS was scored at admission, and CRP on Day 3 of intensive therapy. RESULTS Of 49 patients, 21 [43%] failed iv corticosteroids and 15 [31%] underwent surgery. FC levels were significantly higher in steroid failures (2522 [590-9654] µg/g) compared with steroid responders (1530 [352-10278] µg/g) at admission [p = 0.04], as well as on Day 3 of iv corticosteroid therapy (2718 [222-9175] µg/g vs 727 [218-4062] µg/g, p = 0.001). Steroid failures had a higher median [range] UCEIS score than responders (6 [4-8] vs 5 [4-7] [p = 0.001]). CRP level did not differ significantly between steroid failures and responders. A UCEIS > 6 at admission and FC > 1000 µg/g on Day 3 were independent predictors of steroid failure and need for rescue therapy/colectomy. CONCLUSIONS All patients with UCEIS > 6 and Day 3 FC > 1000 µg/g failed iv corticosteroids. The UCEIS score on admission and Day 3 FC are early predictors of failure of ivcorticosteroid therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
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41
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Bye WA, Jairath V, Travis SPL. Editorial: gut selective immunosuppression-is it a double edged sword? Authors' reply. Aliment Pharmacol Ther 2017; 46:374. [PMID: 28677283 DOI: 10.1111/apt.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- W A Bye
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - V Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - S P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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42
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Bye WA, Jairath V, Travis SPL. Systematic review: the safety of vedolizumab for the treatment of inflammatory bowel disease. Aliment Pharmacol Ther 2017; 46:3-15. [PMID: 28449273 DOI: 10.1111/apt.14075] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 02/15/2017] [Accepted: 03/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vedolizumab specifically recognises the α4β7 integrin and selectively blocks gut lymphocyte trafficking: potentially, it offers gut-specific immunosuppression. AIM To review the safety of vedolizumab and summarise post-marketing data to assess if any safety concerns that differ from registration trials have emerged. METHOD A systematic bibliographic search identified six registration trials and nine cohort studies. RESULTS Integrated data from registration trials included 2830 vedolizumab-exposed patients (4811 person-years exposure [PYs]) and 513 placebo patients. This reported lower exposure-adjusted incidence rates of infection (63.5/100 PYs; 95% CI: 59.6-67.3) and serious adverse events (20.0/100 PYs; 95% CI: 18.5-21.5) compared to placebo (82.9/100 PYs; 95% CI: 68.3-97.5) and (28.3/100 PYs 95% CI: 20.6-35.9) respectively. Higher, but statistically insignificant rates of enteric infections occurred in vedolizumab-exposed patients (7.4/100 PYs; 95% CI: 6.6-8.3) compared to placebo (6.7 PYs; 95% CI: 3.2-10.1). Six post-marketing cohort studies (1049 patients, 403 PYs) demonstrated rates of infection of 8% (82/1049); enteric infection of 2% (21/1049) and adverse events of 16% (166/1049). Multivariate analysis in one cohort study suggested increased risk of surgical site infection with perioperative VDZ. Human experience in pregnancy is limited. CONCLUSIONS Post-marketing data confirm the excellent safety of vedolizumab observed in registration trials. The signal of post-operative complications should be interpreted with caution, but warrants further study. Although comparative studies are needed, Vedolizumab may be a safe alternative in patients who best avoid systematic immunosuppression, including those pre-disposed to infection, malignancy or the elderly.
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Affiliation(s)
- W A Bye
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - V Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - S P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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West NR, Hegazy AN, Owens BMJ, Bullers SJ, Linggi B, Buonocore S, Coccia M, Görtz D, This S, Stockenhuber K, Pott J, Friedrich M, Ryzhakov G, Baribaud F, Brodmerkel C, Cieluch C, Rahman N, Müller-Newen G, Owens RJ, Kühl AA, Maloy KJ, Plevy SE, Keshav S, Travis SPL, Powrie F. Oncostatin M drives intestinal inflammation and predicts response to tumor necrosis factor-neutralizing therapy in patients with inflammatory bowel disease. Nat Med 2017; 23:579-589. [PMID: 28368383 PMCID: PMC5420447 DOI: 10.1038/nm.4307] [Citation(s) in RCA: 475] [Impact Index Per Article: 67.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/17/2017] [Indexed: 02/08/2023]
Abstract
Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are complex chronic inflammatory conditions of the gastrointestinal tract that are driven by perturbed cytokine pathways. Anti-tumor necrosis factor-α (TNF) antibodies are mainstay therapies for IBD. However, up to 40% of patients are nonresponsive to anti-TNF agents, which makes the identification of alternative therapeutic targets a priority. Here we show that, relative to healthy controls, inflamed intestinal tissues from patients with IBD express high amounts of the cytokine oncostatin M (OSM) and its receptor (OSMR), which correlate closely with histopathological disease severity. The OSMR is expressed in nonhematopoietic, nonepithelial intestinal stromal cells, which respond to OSM by producing various proinflammatory molecules, including interleukin (IL)-6, the leukocyte adhesion factor ICAM1, and chemokines that attract neutrophils, monocytes, and T cells. In an animal model of anti-TNF-resistant intestinal inflammation, genetic deletion or pharmacological blockade of OSM significantly attenuates colitis. Furthermore, according to an analysis of more than 200 patients with IBD, including two cohorts from phase 3 clinical trials of infliximab and golimumab, high pretreatment expression of OSM is strongly associated with failure of anti-TNF therapy. OSM is thus a potential biomarker and therapeutic target for IBD, and has particular relevance for anti-TNF-resistant patients.
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Affiliation(s)
- Nathaniel R. West
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ahmed N. Hegazy
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Bryan Linggi
- Janssen Research and Development LLC, Raritan, NJ, USA
| | - Sofia Buonocore
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Margherita Coccia
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Dieter Görtz
- Institute of Biochemistry and Molecular Biology, RWTH Aachen University, Aachen, Germany
| | - Sébastien This
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Krista Stockenhuber
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Johanna Pott
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | | | - Grigory Ryzhakov
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | | | | | - Constanze Cieluch
- Medical Department, Division of Gastroenterology, Infectiology and Rheumatology, Charité–Universitätsmedizin Berlin, Germany
| | - Nahid Rahman
- OPPF-UK, The Research Complex at Harwell, Rutherford Appleton Laboratory, Harwell, Oxford, UK
| | - Gerhard Müller-Newen
- Institute of Biochemistry and Molecular Biology, RWTH Aachen University, Aachen, Germany
| | - Raymond J. Owens
- OPPF-UK, The Research Complex at Harwell, Rutherford Appleton Laboratory, Harwell, Oxford, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Anja A. Kühl
- Medical Department, Division of Gastroenterology, Infectiology and Rheumatology, Charité–Universitätsmedizin Berlin, Germany
| | - Kevin J. Maloy
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | | | | | - Satish Keshav
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Simon P. L. Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Powrie
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Guirgis M, Wendt E, Wang LM, Walsh A, Burger D, Bryant RV, Kent A, Adamson R, Brain O, Travis SPL, Keshav S. Beyond Histological Remission: Intramucosal Calprotectin as a Potential Predictor of Outcomes in Ulcerative Colitis. J Crohns Colitis 2017; 11:460-467. [PMID: 27856523 DOI: 10.1093/ecco-jcc/jjw174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 11/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Histological remission and low faecal calprotectin are positive prognostic factors in ulcerative colitis [UC]. Intramucosal calprotectin [iMC], which can be readily determined by immunohistochemistry, has not so far been evaluated as a predictor of outcome in UC. We aimed to investigate the relationship between iMC and clinical, endoscopic, and histological measures of remission in UC, and the independent prognostic value of iMC. METHODS Ambulant patients with UC were recruited for a study comparing clinical activity indices. Sigmoidoscopy and biopsy were performed at the index visit. Clinical, endoscopic, and histological activity were scored and iMC semi-quantitatively measured using immunohistochemistry for the S100A8/9 heterodimer on colonic biopsies, scored as the mean number of positive cells in five high-power fields [HPF]. At the end of follow-up [6 years], data on steroid use, hospitalisation, and colectomy ['adverse outcomes'] were collected. RESULTS iMC was determined in 83 patients and 20 controls, and correlated with clinical, endoscopic, and histological activity [r = 0.51, 0.65, 0.53, p > 0.001, respectively]. iMC was lowest (median 2.4, interquartile range [IQR]: 5.2-5, p < 0.001) in patients with concordance between clinical, endoscopic, and histological remission. Median iMC > 5/HPF was associated with adverse outcome (hazard ratio [HR] 3.36, confidence interval [CI] 1.58, 7.15, p < 0.001). Only 53%, 33%, and 25% of patients in histological remission with iMC > 5 cells/HPF avoided an adverse outcome after 1, 3, and 6 years, respectively. CONCLUSIONS iMC was lowest in patients with concordant clinical, endoscopic, and histological remission. Median iMC > 5/HPF was associated with adverse outcomes despite histological remission. Therefore iMC is a potentially useful independent marker of activity.
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Affiliation(s)
- Marianne Guirgis
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Emily Wendt
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospital, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Daniel Burger
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Robert V Bryant
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Alex Kent
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Rebecca Adamson
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Oxford University Hospital, Oxford, UK
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Martí-Gallostra M, Myrelid P, Mortensen N, Keshav S, Travis SPL, George B. The role of a defunctioning stoma for colonic and perianal Crohn's disease in the biological era. Scand J Gastroenterol 2017; 52:251-256. [PMID: 27855530 DOI: 10.1080/00365521.2016.1205127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A defunctioning stoma is a therapeutic option for colonic or perianal Crohn's disease. In the pre-biologic era the response rate to defunctioning in our unit was high (86%), but intestinal continuity was only restored in 11-20%. Few data exist on the outcome of defunctioning since the widespread introduction of biologicals. MATERIAL AND METHODS All patients undergoing a defunctioning stoma for colonic/perianal Crohn's disease since 2003-2011 were identified from a prospective database. Indications for surgery, medical therapy, response to defunctioning and long-term clinical outcome were recorded. Successful restoration of continuity was defined as no stoma at last follow up. RESULTS Seventy-six patients were defunctioned (57 with biologicals) and at last follow up, 20 (27%) had continuity restored. Early clinical response rate (<3 months) was 15/76 (20%) and overall response 31/76 (41%). Complex anal fistulae/stenosis were associated with a very low chance of restoring continuity (10% and 0%, respectively), while colitis was associated with a higher chance of restoring continuity (48%). Endoscopic or histological improvement in colitis after defunctioning was associated with a higher rate of restoring continuity (10/16, 63%) compared to no such improvement (4/15, 27%, p = 0.05). Those failing biologics had similar chance of restoration as those not receiving biologics, 15/57 (26%) and 5/19 (26%), respectively. CONCLUSION Overall response to colonic defunctioning was 41%. Successful restoration of continuity occurred in 27%, but 48% in the absence of perianal disease. Response is appreciably less in the pre-biologic era, so patient and physician expectations need to be managed appropriately.
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Affiliation(s)
- M Martí-Gallostra
- a Unit of Colorectal Surgery, Department of General Surgery , Hospital Universitari Vall Hebrón , Barcelona , Spain.,b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
| | - P Myrelid
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK.,c Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences , Linköping University , Linköping , Sweden.,d Department of Surgery , County Council of Östergötland , Linköping , Sweden
| | - N Mortensen
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
| | - S Keshav
- e Translational Gastroenterology Unit , Oxford University Hospitals , Oxford , UK
| | - S P L Travis
- e Translational Gastroenterology Unit , Oxford University Hospitals , Oxford , UK
| | - B George
- b Unit of Colorectal Surgery, Department of Surgery , Oxford University Hospitals , Oxford , UK
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Cesarini M, Collins GS, Rönnblom A, Santos A, Wang LM, Sjöberg D, Parkes M, Keshav S, Travis SPL. Predicting the Individual Risk of Acute Severe Colitis at Diagnosis. J Crohns Colitis 2017; 11:335-341. [PMID: 27647858 PMCID: PMC5881607 DOI: 10.1093/ecco-jcc/jjw159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 09/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Acute severe colitis [ASC] is associated with major morbidity. We aimed to develop and externally validate an index that predicted ASC within 3 years of diagnosis. METHODS The development cohort included patients aged 16-89 years, diagnosed with ulcerative colitis [UC] in Oxford and followed for 3 years. Primary outcome was hospitalization for ASC, excluding patients admitted within 1 month of diagnosis. Multivariable logistic regression examined the adjusted association of seven risk factors with ASC. Backwards elimination produced a parsimonious model that was simplified to create an easy-to-use index. External validation occurred in separate cohorts from Cambridge, UK, and Uppsala, Sweden. RESULTS The development cohort [Oxford] included 34/111 patients who developed ASC within a median 14 months [range 1-29]. The final model applied the sum of 1 point each for extensive disease, C-reactive protein [CRP] > 10mg/l, or haemoglobin < 12g/dl F or < 14g/dl M at diagnosis, to give a score from 0/3 to 3/3. This predicted a 70% risk of developing ASC within 3 years [score 3/3]. Validation cohorts included different proportions with ASC [Cambridge = 25/96; Uppsala = 18/298]. Of those scoring 3/3 at diagnosis, 18/18 [Cambridge] and 12/13 [Uppsala] subsequently developed ASC. Discriminant ability [c-index, where 1.0 = perfect discrimination] was 0.81 [Oxford], 0.95 [Cambridge], 0.97 [Uppsala]. Internal validation using bootstrapping showed good calibration, with similar predicted risk across all cohorts. A nomogram predicted individual risk. CONCLUSIONS An index applied at diagnosis reliably predicts the risk of ASC within 3 years in different populations. Patients with a score 3/3 at diagnosis may merit early immunomodulator therapy.
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Affiliation(s)
- Monica Cesarini
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK,Dipartimento di Medicina Interna e Specialità Mediche, ‘Sapienza’, University of Rome, Rome, Italy
| | - Gary S. Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Anders Rönnblom
- Department of Medical Sciences, Gastroenterology, Uppsala University, Uppsala, Sweden
| | - Antonieta Santos
- Gastroenterology Unit, Cambridge University Hospitals, Cambridge, UK,Gastroenterology Unit, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospitals, Oxford, UK
| | - Daniel Sjöberg
- Department of Medical Sciences, Gastroenterology, Uppsala University, Uppsala, Sweden
| | - Miles Parkes
- Gastroenterology Unit, Cambridge University Hospitals, Cambridge, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Simon P. L. Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
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Vuitton L, Peyrin-Biroulet L, Colombel JF, Pariente B, Pineton de Chambrun G, Walsh AJ, Panes J, Travis SPL, Mary JY, Marteau P. Defining endoscopic response and remission in ulcerative colitis clinical trials: an international consensus. Aliment Pharmacol Ther 2017; 45:801-813. [PMID: 28112419 DOI: 10.1111/apt.13948] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/07/2016] [Accepted: 12/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently, endpoints for clinical trials have been changing from measuring clinical response to mucosal healing in ulcerative colitis. Endoscopic evaluation is the current gold standard to assess mucosal lesions and has become a major measure of therapeutic efficacy in addition to patients reported outcomes. AIM To achieve consensus on endoscopic definitions of remission and response for clinical trials in patients with ulcerative colitis. METHODS In reaching the current international recommendations on an International Organization For the Study of Inflammatory Bowel Disease (IOIBD) initiative, we first performed a systematic review of technical aspects of endoscopic scoring systems. Then, to achieve consensus on endoscopic definitions of remission and response for clinical trials, we conducted a two-round vote using a Delphi-style process among fifteen specialists in the field of inflammatory bowel diseases. RESULTS The literature review showed that many endoscopic indices have been proposed to evaluate disease activity in ulcerative colitis; most are unvalidated and arbitrary definitions have been used in clinical trials for defining endoscopic response or remission. At the end of the voting process, the investigators ranked initially the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) 0 for the definition of endoscopic remission, and a decrease in Mayo endoscopic score ≥1 grade or a decrease in UCEIS ≥2 points for the definition of endoscopic response in ulcerative colitis. CONCLUSIONS These international recommendations represent the first consensus on measurement indices for endoscopic outcomes in ulcerative colitis. They should be subject to prospective testing in clinical trials of ulcerative colitis.
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Bryant RV, Burger DC, Delo J, Walsh AJ, Thomas S, von Herbay A, Buchel OC, White L, Brain O, Keshav S, Warren BF, Travis SPL. Beyond endoscopic mucosal healing in UC: histological remission better predicts corticosteroid use and hospitalisation over 6 years of follow-up. Gut 2016; 65:408-14. [PMID: 25986946 DOI: 10.1136/gutjnl-2015-309598] [Citation(s) in RCA: 270] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/29/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic mucosal healing is an established treatment target for UC, yet the value of achieving histological remission remains unclear. AIMS To evaluate histological remission compared to endoscopic mucosal healing for predicting patient outcomes in UC. METHODS Blinded assessment of endoscopic and histological measures of disease activity was performed on patients with established UC at baseline. Concordance and prognostic values of endoscopic mucosal healing (defined by Baron score ≤1) and histological remission (defined by Truelove and Richards' index) for predicting outcomes of corticosteroid use, hospitalisation and colectomy were determined over a median 6 years follow-up, including κ statistics and Cox regression multivariate analysis. RESULTS 91 patients with UC were followed up for a median 72 months (IQR 54-75 months). Overall, concordance between endoscopic and histological remission was moderate (κ=0.56, 95% CI 0.36 to 0.77); 24% patients had persistent inflammation despite endoscopic remission. Histological remission predicted corticosteroid use and acute severe colitis requiring hospitalisation over the follow-up period (HR 0.42 (0.2 to 0.9), p=0.02; HR 0.21 (0.1 to 0.7), p=0.02; respectively), whereas endoscopic mucosal healing did not (HR 0.86, 95% CI 0.5 to 1.7, p0.65; HR 0.83 95% CI 0.3 to 2.4, p0.74; respectively). CONCLUSIONS Histological remission is a target distinct from endoscopic mucosal healing in UC and better predicts lower rates of corticosteroid use and acute severe colitis requiring hospitalisation, over a median of 6 years of follow-up. Our findings support the inclusion of histological indices in both UC clinical trials and practice, towards a target of 'complete remission'.
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Affiliation(s)
- Robert V Bryant
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Daniel C Burger
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Joseph Delo
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Alissa J Walsh
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Sally Thomas
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Axel von Herbay
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Otto C Buchel
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Lydia White
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Oliver Brain
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Satish Keshav
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Bryan F Warren
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit and Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
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Travis SPL, Schnell D, Feagan BG, Abreu MT, Altman DG, Hanauer SB, Krzeski P, Lichtenstein GR, Marteau PR, Mary JY, Reinisch W, Sands BE, Schnell P, Yacyshyn BR, Colombel JF, Bernhardt CA, Sandborn WJ. The Impact of Clinical Information on the Assessment of Endoscopic Activity: Characteristics of the Ulcerative Colitis Endoscopic Index Of Severity [UCEIS]. J Crohns Colitis 2015; 9:607-16. [PMID: 25956538 PMCID: PMC4584567 DOI: 10.1093/ecco-jcc/jjv077] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/07/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS To determine whether clinical information influences endoscopic scoring by central readers using the Ulcerative Colitis Endoscopic Index of Severity [UCEIS; comprising 'vascular pattern', 'bleeding', 'erosions and ulcers']. METHODS Forty central readers performed 28 evaluations, including 2 repeats, from a library of 44 video sigmoidoscopies stratified by Mayo Clinic Score. Following training, readers were randomised to scoring with ['unblinded', n = 20, including 4 control videos with misleading information] or without ['blinded', n 20] clinical information. A total of 21 virtual Central Reader Groups [CRGs], of three blinded readers, were created. Agreement criteria were pre-specified. Kappa [κ] statistics quantified intra- and inter-reader variability. RESULTS Mean UCEIS scores did not differ between blinded and unblinded readers for any of the 40 main videos. UCEIS standard deviations [SD] were similar [median blinded 0.94, unblinded 0.93; p = 0.97]. Correlation between UCEIS and visual analogue scale [VAS] assessment of overall severity was high [r blinded = 0.90, unblinded = 0.93; p = 0.02]. Scores for control videos were similar [UCEIS: p ≥ 0.55; VAS: p ≥ 0.07]. Intra- [κ 0.47-0.74] and inter-reader [κ 0.40-0.53] variability for items and full UCEIS was 'moderate'-to-'substantial', with no significant differences except for intra-reader variability for erosions and ulcers [κ blinded: 0.47 vs unblinded: 0.74; p 0.047]. The SD of CRGs was lower than for individual central readers [0.54 vs 0.95; p < 0.001]. Correlation between blinded UCEIS and patient-reported symptoms was high [stool frequency: 0.76; rectal bleeding: 0.82; both: 0.81]. CONCLUSIONS The UCEIS is minimally affected by knowledge of clinical details, strongly correlates with patient-reported symptoms, and is a suitable instrument for trials. CRGs performed better than individuals.
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Affiliation(s)
- Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | | | - Brian G Feagan
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Maria T Abreu
- Division of Gastroenterology, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Stephen B Hanauer
- Digestive Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gary R Lichtenstein
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philippe R Marteau
- AP-HP, Hôpital Lariboisière Medicosurgical Department of Digestive Diseases and University Denis Diderot, Paris, France
| | - Jean-Yves Mary
- INSERM U717 Biostatistics and Clinical Epidemiology, Université Paris Diderot, Paris, France
| | - Walter Reinisch
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Bruce R Yacyshyn
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | | | | | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
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