Highlights • Systematic review shows effect of oral nutritional supplements (ONS) on (re)admissions. • 9 RCT (N 1190) in this systematic review and meta-analyses, most in older people. • Significant ...reduction in hospital (re)admissions with ONS ( P = 0.001). • ONS reduced (re)admissions from 33.8% to 23.9% with a number needed to treat of 10. • (Re)admissions significantly lower with ONS in community and hospital-community RCT.
To determine the role of colonic barrier defects and low-grade inflammation in irritable bowel syndrome (IBS)-like symptoms in quiescent inflammatory bowel disease (IBD).
Caecal biopsies were ...collected from 51 IBS, 49 quiescent IBD (31 Crohn's disease (CD) and 18 ulcerative colitis (UC)) patients and 27 controls. IBS was assessed using the Rome III criteria and the IBS severity score. Epithelial barrier integrity was evaluated by determining the paracellular permeability of biopsies mounted in Ussing chambers and the mRNA expression of tight junction proteins (ZO-1, α-catenin and occludin). Low-grade inflammation was evaluated by counting cells, including intraepithelial lymphocytes (IELs), eosinophils and mast cells, and by determining the mRNA and protein expression of tumour necrosis factor (TNF)-α in biopsies and culture supernatants.
IBS-like symptoms were present in 35.4 and 38% of CD and UC patients, respectively. Paracellular permeability was significantly increased in both quiescent IBD with IBS-like symptoms and IBS compared with quiescent IBD without IBS-like symptoms (p<0.01, respectively) or controls (p<0.01, respectively). Significantly lower expression of ZO-1 and α-catenin was detected in IBS and quiescent IBD with IBS-like symptoms. IELs and TNF-α were significantly increased in quiescent IBD with IBS-like symptoms, but not in IBS.
In quiescent IBD, IBS-like symptoms related to persistent subclinical inflammation associated with increased colonic paracellular permeability. A persistent increase in TNF-α in colonic mucosa may contribute to the epithelial barrier defects associated with abdominal pain in quiescent IBD, but not in IBS. Optimisation of anti-inflammatory therapy may be considered in quiescent IBD with IBS-like symptoms.
Summary
Background
Mucosal healing can be achieved with infliximab (IFX).
Aim
To assess the impact of mucosal healing on long‐term outcomes in patients with ulcerative colitis (UC) when treated with ...infliximab (IFX) beyond 1 year.
Methods
All consecutive adult patients with refractory UC receiving maintenance treatment with IFX in five French referral centres were analysed retrospectively. Only patients who had endoscopic evaluation between 6 and 52 weeks following IFX initiation were included. According to their Mayo endoscopic sub‐score, patients were categorised into mucosal healing (sub‐score: 0–1) and no mucosal healing (2–3). Outcome measures were colectomy and IFX failure defined by drug withdrawal due to secondary failure among primary responders.
Results
Of the 63 patients (30 women; median age: 38 years), 30 (48%) achieved mucosal healing. The median follow‐up duration was 27 (3–79) months. Colectomy‐free survival rates at 12, 24 and 36 months were, respectively, 100%, 96% and 96% in patients with mucosal healing. The corresponding figures were, respectively, 80%, 65% and 65% in patients without mucosal healing (P = 0.004). By multivariate analysis, mucosal healing was the only factor associated with colectomy‐free survival, with an odds ratio of 18.01 (95%CI: 1.58–204.92). IFX failure‐free survival rates at 12, 24 and 36 months were, respectively, 76%, 69% and 64% in patients with mucosal healing, and 44%, 25% and 21% in those without mucosal healing (P = 0.003).
Conclusion
Patients with refractory UC who achieved mucosal healing after IFX initiation had better long‐term outcomes, with significantly less colectomy and less IFX failure.
Summary
Background Adalimumab (ADA) and certolizumab pegol (CZP) have demonstrated efficacy in Crohn’s disease (CD) patients previously treated with infliximab (IFX).
Aim To assess the efficacy and ...tolerability of a third anti‐TNF in CD after failure of and/or intolerance to two different anti‐TNF antibodies.
Methods Crohn’s disease patients who received ADA or CZP after loss of response and/or intolerance to two anti‐TNF agent were included in this retrospective study. Data were collected using a standardized questionnaire. Clinical response, duration, safety and reasons for discontinuation were assessed.
Results Sixty‐seven patients treated with CZP (n = 40) or ADA (n = 27) were included. A clinical response was observed in 41 (61%) at week 6 and 34 patients (51%) at week 20. The probability of remaining under treatment at 3 months, 6 months and 9 months was 68%, 60% and 45%, respectively. At the end of follow‐up, the third anti‐TNF had been stopped in 36 patients for intolerance (n = 13), or failure (n = 23). Two deaths were observed.
Conclusions The treatment with a third anti‐TNF (CZP or ADA) agent of CD patients, who have experienced loss of response and/or intolerance to two anti‐TNF antibodies, has favourable short‐term and long‐term efficacy. It is an option to be considered in patients with no other therapeutic options.
Recent evidence suggests a role for increased colonic permeability and mucosal mast cell (MC) mediators on symptoms related to the irritable bowel syndrome (IBS). Whether allergic factors (AFs) are ...involved in the pathophysiology of IBS is unclear. We addressed the question of the possible influence of an allergic background on IBS symptoms.
We assessed paracellular permeability, mucosal MCs counts, and spontaneous release of tryptase of colonic biopsy specimens in 34 IBS patients and 15 healthy subjects. The severity of IBS was assessed through self-reported questionnaires. All individuals were tested for the presence of AF, including self-perception of adverse reaction to food, personal and familial history of atopic disease, elevated total or specific immunoglobulin E against food/inhalant antigens, blood eosinophilia, and skin tests.
IBS patients had significant enhanced colonic permeability, higher number of MCs, and spontaneous release of tryptase than healthy subjects. The severity of IBS was significantly correlated with colonic permeability (r=0.48, P=0.004), MCs counts (r=0.36, P=0.03), and tryptase (r=0.48, P=0.01). In 13 IBS patients (38.2%) having at least three AFs, symptoms scores, colonic permeability, MCs counts, and tryptase release by colonic biopsies were significantly higher than in those with less than three AFs. IBS patients with at least three AFs were more prone to diarrhea or alternating symptoms. None AF was found to be predictive of IBS severity.
In IBS patients, the presence of an allergic background correlates with a more severe disease and diarrhea predominance, possibly by enhancing mucosal MC activation and paracellular permeability.
A subset of patients with irritable bowel syndrome (IBS) have an increased number of mast cells (MCs) in the colonic mucosa. Psychological factors are believed to contribute to the course of IBS.
To ...examine associations between fatigue, depression and MCs of the colonic mucosa in IBS.
Colonic biopsies were taken from 50 Rome II IBS patients, 21 healthy controls and 11 depressed/fatigued patients without IBS. The cellularity of the lamina propria was determined as the number of inflammatory cells per high power field (hpf) through a 400x microscope. The Fatigue Impact Scale (FIS) and the short form Beck Depression Inventory (BDI) evaluated the severity of fatigue and depression.
IBS patients had a significant increase in the cellularity of the lamina propria compared with controls or with depressed patients (mean (SD) 94.5 (48-110) vs 68 (58-82) and 78 (87-90) cells per hpf, p = 0.005 and p = 0.05, respectively), in particular of MCs (9.3 (5.6-11.7) vs 4.0 (2.7-6.8) and 4.3 (2.8-7.8) cells per hpf, p = 0.001 and p = 0.005, respectively). Both the FIS and BDI scores were significantly higher in IBS or in depressed patients than in controls (p<0.001). In IBS, the FIS score correlated significantly with the cellularity of the lamina propria (r = 0.51, p<0.0001) and MCs (r = 0.64, p<0.0001). In IBS, the BDI score correlated significantly with MCs (r = 0.29, p = 0.03).
Elevated MCs counts are a key feature of the low-grade inflammatory infiltrate in the caecal mucosa of IBS. Fatigue and depression are associated with mucosal cell counts, in particular MCs, suggesting that psychological factors are associated with the low-grade inflammatory infiltrate in IBS.
Summary
Background
Aminosalicylates are first‐choice treatment for mild‐to‐moderately active ulcerative colitis (UC); however, multi‐dosing regimens are inconvenient.
Aim
To compare the efficacy and ...safety of once‐ (OD) vs. twice‐ (BD) daily prolonged‐release mesalazine (Pentasa, Ferring, Saint‐Prex, Switzerland) for active mild‐to‐moderate UC in a non‐inferiority study.
Methods
Eligible patients (n = 206) were randomised to 8 weeks of mesalazine (4 g/day), either OD with two sachets of 2 g mesalazine granules in the morning (n = 102) or BD with one 2 g sachet in the morning and one in the evening (n = 104). Patients also received 4 weeks of mesalazine enema 1 g/day. Disease activity was assessed at randomisation, weeks 4, 8 and 12 using the UC Disease Activity Index (UC‐DAI). Clinical and endoscopic remission (primary endpoint) was assessed after 8 weeks. Patients recorded stool frequency and rectal bleeding in a daily diary.
Results
The primary endpoint, non‐inferiority in clinical and endoscopic remission with OD vs. BD mesalazine at 8 weeks, was met (intent‐to‐treat population: 52.1% vs. 41.8%, respectively, 95% confidence interval −3.4, 24.1; P = 0.14). Improvement of UC‐DAI score (92% vs. 79%; P = 0.01) and mucosal healing (87.5% vs. 71.1%; P = 0.007) were significantly better, time to remission significantly shorter (26 vs. 28 days; P = 0.04) and safety similar with OD vs. BD dosing.
Conclusions
When combined with mesalazine enema, prolonged‐release mesalazine once‐daily 4 g is as effective and well tolerated as 2 g twice‐daily for inducing remission in patients with mild‐to‐moderately active ulcerative colitis (Clinicaltrials.gov: NCT00737789).
Summary
Background
Anti‐tumour necrosis factor (TNF) agents have improved the care of Crohn's disease (CD). After the first anti‐TNF discontinuation, it is possible to switch to another anti‐TNF. ...Three anti‐TNF agents are available for ulcerative colitis (infliximab, adalimumab and golimumab), but only the first 2 have been approved for CD because golimumab has not been studied for this indication.
Aim
To report the efficacy and safety of golimumab in CD.
Methods
Crohn's disease patients who received golimumab were identified in 12 French tertiary centres and were retrospectively analysed. The primary endpoint was the duration of golimumab treatment before escalation or discontinuation. The clinical response was defined as a decrease of more than 3 points in the Harvey‐Bradshaw index or by global physician assessment.
Results
One hundred and fifteen patients were included. The golimumab treatment duration was 9.8 months (0.55‐44), and 48.7% of the patients were still under treatment at the end of follow‐up. Clinical response was observed in 55.8% of the patients after a mean duration of 3.8 months. The probability of remaining under treatment without escalation at 6, 12 and 24 months was 54.6%, 34.9% and 19.3% respectively. In multivariate analysis, discontinuation of the first anti‐TNF agent due to intolerance (odds ratio, OR = 2.16; 95% CI, confidence interval 1.25‐3.86; P = .005) and co‐immunosuppression for more than 6 months (OR = 3.98; 95% CI 2.3‐7.1; P < .0001) were predictive factors of efficacy. Six per cent of the patients discontinued treatment due to intolerance.
Conclusion
After failure of infliximab or adalimumab for Crohn's disease, golimumab was safe and seemed beneficial in half of the patients.
Background
Super obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not ...been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients.
Methods
Patients with BMI >45 kg/m
2
selected for LGBP were included and randomized to receive either SMC or IGB. After 6 months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6 months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24 h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications.
Results
Only 115 patients were included (BMI 54.3 ± 8.7 kg/m
2
), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24 h was similar in both groups (
P
= 0.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (
P
< 0.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (
P
= 0.49). Five patients had 1 or more surgical complications, all in the IGB group (
P
= 0.02). Both groups had similar hospitalization stay (
P
= 0.59) and weight loss at M12 (
P
= 0.31).
Conclusion
IGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.
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