Medical treatment options and strategies for Crohn's disease (CD) have changed over the past decades. To assess its impact, we studied the evolution of the long-term disease outcome in the Dutch ...Inflammatory Bowel Disease South Limburg (IBDSL) cohort.
In total, 1,162 CD patients were included. Three eras were distinguished: 1991-1998 (n=316), 1999-2005 (n=387), and 2006-2011 (n=459), and patients were followed until 2014. Medication exposure and the rates of hospitalization, surgery, and phenotype progression were estimated using Kaplan-Meier survival analyses and compared between eras by multivariable Cox regression models. Second, propensity score matching was used to assess the relation between medication use and the long-term outcome.
Over time, the immunomodulator exposure rate increased from 30.6% in the era 1991-1998 to 70.8% in the era 2006-2011 at 5 years. Similar, biological exposure increased from 3.1% (era 1991-1998) to 41.2% (era 2006-2011). In parallel, the hospitalization rate attenuated from 65.9% to 44.2% and the surgery rate from 42.9% to 17.4% at 5 years, respectively (both P<0.01). Progression to a complicated phenotype has not changed over time (21.2% in the era 1991-1998 vs. 21.3% in the era 2006-2011, P=0.93). Immunomodulator users had a similar risk of hospitalization, surgery, or phenotype progression as propensity score-matched nonusers (P>0.05 for all analyses). Similar results were found for biological users (P>0.05 for all analyses).
Between 1991 and 2014, the hospitalization and surgery rates decreased, whereas progression to complicated disease is still common in CD. These improvements were not significantly related to the use of immunomodulators and biologicals.
Tight and personalised control of inflammatory bowel disease in a traditional setting is challenging because of the disease complexity, high pressure on outpatient clinics, and rising incidence. We ...compared the effects of self-management with a telemedicine system, which was developed for all subtypes of inflammatory bowel disease, on health-care utilisation and patient-reported quality of care versus standard care.
We did this pragmatic, randomised trial in two academic and two non-academic hospitals in the Netherlands. Outpatients aged 18–75 years with inflammatory bowel disease and without an ileoanal or ileorectal pouch anastomosis, who had internet access and Dutch proficiency, were randomly assigned (1:1) to care via a telemedicine system (myIBDcoach) that monitors and registers disease activity or standard care and followed up for 12 months. Randomisation was done with a computer-generated sequence and used the minimisation method. Participants, health-care providers, and staff who assessed outcome measures were not masked to treatment allocation. Primary outcomes were the number of outpatient visits and patient-reported quality of care (assessed by visual analogue scale score 0–10). Safety endpoints were the numbers of flares, corticosteroid courses, hospital admissions, emergency visits, and surgeries. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02173002.
Between Sept 9, 2014, and May 18, 2015, 909 patients were randomly assigned to telemedicine (n=465) or standard care (n=444). At 12 months, the mean number of outpatient visits to the gastroenterologist or nurse was significantly lower in the telemedicine group (1·55 SD 1·50) than in the standard care group (2·34 1·64; difference −0·79 95% CI −0·98 to −0·59; p<0·0001), as was the mean number of hospital admissions (0·05 0·28 vs 0·10 0·43; difference −0·05 –0·10 to 0·00; p=0·046). At 12 months, both groups reported high mean patient-reported quality of care scores (8·16 1·37 in the telemedicine group vs 8·27 1·28 in the standard care group; difference 0·10 –0·13 to 0·32; p=0·411). The mean numbers of flares, corticosteroid courses, emergency visits, and surgeries did not differ between groups.
Telemedicine was safe and reduced outpatient visits and hospital admissions compared with standard care. This self-management tool might be useful for reorganising care of inflammatory bowel disease towards personalised and value-based health care.
Maastricht University Medical Centre and Ferring.
Elderly onset (EO) inflammatory bowel disease (IBD) may become a more common entity as a result of population aging and the rising IBD incidence. Its management is challenging, because of ...multimorbidity, polypharmacy, and frailty. Insight into the long-term outcome is essential for optimal patient counseling and treatment. We studied the incidence and disease outcome of elderly-onset IBD in direct comparison to adult-onset (AO) IBD.
All 2823 cases with IBD from the Dutch population-based IBD South Limburg cohort, diagnosed between 1991 and 2011, were included. Long-term outcome (hospitalization, surgery, and disease phenotype) was compared between AO (<60 years at diagnosis) and EO (≥60 years at diagnosis) disease, for Crohn's disease (CD) and ulcerative colitis (UC) separately.
In total, 1162 patients with CD (136 EO/1026 AO) and 1661 patients with UC (373 EO/1288 AO) were included. The EO IBD incidence increased from 11.71 per 100,000 persons in 1991 to 23.66 per 100,000 persons in 2010, P < 0.01. Immunomodulators were less often used in EO CD (61.8% versus 77.1%, P = 0.03) and EO UC (22.8% versus 35.4%, P < 0.01), even as biologicals (25.1% versus 55.1%, P = 0.03 and 7.8% versus 18.0%, P < 0.01, respectively). No differences were observed in surgery risk (CD: hazard ratio HR 1.19; 95% confidence interval CI, 0.85-1.67 and UC: HR, 0.88; 95% CI, 0.53-1.46), or in CD phenotype progression (HR, 0.81; 95% CI, 0.52-1.25), but more patients with EO UC required hospitalization (HR, 1.29; 95% CI, 1.01-1.63).
EO IBD is rising, warranting physicians' alertness for IBD in elderly patients. The long-term outcome was not different from AO disease, despite a less frequent use of immunomodulators and biologicals.
The management of inflammatory bowel disease (IBD) has changed since the mid‐1990s (e.g., use of thiopurines/anti‐TNFα agents, improved surveillance programs), possibly affecting cancer risk. To ...establish current cancer risk in IBD, updates are warranted from cohorts covering this time span, and detailed enough to study associations with phenotype and medication. We studied intestinal‐, extra‐intestinal‐ and overall cancer risk in the Dutch population‐based IBDSL cohort. In total, 1,157 Crohn's disease (CD) and 1,644 ulcerative colitis (UC) patients were diagnosed between 1991 and 2011, and followed until 2013. Standardized incidence ratios (SIRs) were calculated for CD and UC separately, as well as for gender‐, phenotype‐, disease duration‐, diagnosis era‐ and medication groups. We found an increased risk for colorectal cancer in CD patients with colon involvement (SIR 2.97; 95% CI 1.08–6.46), but not in the total CD or UC population. In addition, CD patients were at increased risk for hematologic‐ (2.41; 1.04–4.76), overall skin‐ (1.55; 1.06–2.19), skin squamous cell‐ (SCC; 3.83; 1.83–7.04) and overall cancer (1.28; 1.01–1.60), whereas UC patients had no increased risk for extra‐intestinal‐ and overall cancer. Finally, in a medication analysis on CD and UC together, long‐term immunosuppression exposure (>12 months) was associated with an increased risk for hematologic cancer, non‐Hodgkin lymphoma, SCC and overall cancer, and this increase was mainly attributed to thiopurines. IBD patients with long‐term immunosuppression exposure can be considered as having a higher cancer risk, and our data support the advice in recent IBD guidelines to consider skin cancer screening in these patients.
What's new?
The management of inflammatory bowel disease (IBD) has changed markedly since the mid‐1990s, possibly affecting cancer risk. To establish current cancer risk, updates are warranted from cohorts covering this timespan and detailed enough to study associations with phenotype and medication. Here, using the Dutch population‐based IBDSL cohort, the authors found that colorectal cancer risk is currently lower in both CD and UC than previously mentioned in literature. CD patients however show an increased overall cancer risk. Altogether, long‐term immunosuppression exposure brings an additional cancer risk to IBD patients, a finding that may be relevant in other auto‐immune diseases with similar medication.
The endoscopically placed duodenal-jejunal bypass sleeve or EndoBarrier Gastrointestinal Liner has been designed to achieve weight loss in morbidly obese patients. We report on the first European ...experience with this device.
A multicenter, randomized clinical trial was performed. Forty-one patients were included and 30 underwent sleeve implantation. Eleven patients served as a diet control group. All patients followed the same low-calorie diet during the study period. The purpose of the study was to determine the safety and efficacy of the device.
Twenty-six devices were successfully implanted. In 4 patients, implantation could not be achieved. Four devices were explanted prior to the initial protocol end point because of migration (1), dislocation of the anchor (1), sleeve obstruction (1), and continuous epigastric pain (1). The remaining patients all completed the study. Mean procedure time was 35 minutes (range: 12-102 minutes) for a successful implantation and 17 minutes (range: 5-99 minutes) for explantation. There were no procedure related adverse events. During the study period the 26 duodenal-jejunal bypass sleeve patients (100%) had at least one adverse event, mainly abdominal pain and nausea during the first week after implantation. Initial mean body mass index (BMI, kg/m2) was 48.9 and 47.4 kg/m2 for the device and control patients, respectively. Mean excess weight loss after 3 months was 19.0% for device patients versus 6.9% for control patients (P < 0.002). Absolute change in BMI at 3 months was 5.5 and 1.9 kg/m2, respectively. Type 2 diabetes mellitus was present at baseline in 8 patients of the device group and improved in 7 patients during the study period (lower glucose levels, HbA1c, and medication requirements).
The EndoBarrier Gastrointestinal Liner is a feasible and safe noninvasive device with excellent short-term weight loss results. The device also has a significant positive effect on type 2 diabetes mellitus. Long-term randomized and sham studies for weight loss and treatment of diabetes are necessary to determine the role of the device in the treatment of morbid obesity.This study was registered at www.clinicaltrials.gov (registration number: NCT00830440).
Colorectal cancer surveillance guidelines rely on clinicohistologic features of adenomas. Unfortunately, in common practice, recording of these features lacks precision and uniformity, which might ...hamper appropriate follow-up decisions. Confocal laser endomicroscopy (CLE) is a novel technology that allows real-time in vivo microscopy of the mucosa and provides accurate histopathology. The aims of this study were (1) to define and validate differential features of adenomatous and nonadenomatous colorectal polyps by chromoendoscopy-guided CLE (C-CLE) and (2) to assess predictive value of this technique for diagnosis of colorectal neoplasia.
Patients at risk for colorectal cancer were prospectively investigated by using CLE. During extubation, fluorescein 10% was used in conjunction with acriflavine hydrochloride 0.05% to characterize global tissue architecture as well as cytonuclear features of colorectal epithelium. Ex vivo histology was used as gold standard. Reproducibility tests were performed.
In total, 116 colorectal polyps from 72 patients were examined. Ex vivo histology showed 68 adenomas, 6 invasive carcinomas, 30 hyperplastic polyps, and 12 inflammatory polyps. C-CLE of adenomas revealed lack of epithelial surface maturation, crypt budding, altered vascular pattern, and loss of cell polarity. In contrast, C-CLE of nonadenomatous polyps revealed epithelial surface maturation, and minor abnormalities of crypt architecture and of vascular pattern, and maintained cell polarity. Adenoma dysplasia score reliably discriminated high-grade dysplasia from low-grade dysplasia (accuracy, 96.7%). Interobserver agreement was high (K coefficients: pathologist, 0.92; endomicroscopist, 0.88). In vivo histology predicted ex vivo data with sensitivity of 97.3%, specificity of 92.8%, and accuracy of 95.7%.
C-CLE accurately discriminates adenomatous from nonadenomatous colorectal polyps and enables evaluation of degree of dysplasia during ongoing endoscopy. This technology might offer considerable potential to ultimately fine-tune surveillance programs, particularly in high-risk groups.
Abstract
Background
The aim was to study temporal changes in incidence, disease phenotype at diagnosis, and mortality of adult inflammatory bowel disease IBD patients in South Limburg, The ...Netherlands, diagnosed between 1991 and 2010. In addition, the 2010 IBD prevalence was estimated.
Methods
A multi-faceted approach including hospital administrations, the national pathology registry PALGA, and general practitioners led to the identification of 1162 patients with Crohn’s disease CD, 1663 with ulcerative colitis UC, and 84 with unclassified IBD IBD-U. Temporal changes in incidence, disease phenotype, and mortality were studied using linear, multinomial regression analyses, and standardised mortality rates SMR, respectively.
Results
The annual incidences increased from 17.90/100000 in 1991 to 40.36/100000 in 2010 for IBD, from 5.84/100000 to 17.49/100000 for CD, and from 11.67/100000 to 21.47/100000 for UC p < 0.01 for all. A shift towards milder disease at diagnosis was observed over time eg decrease of complicated disease in CD, increase of proctitis in UC. IBD mortality was similar to that in the general population (SMR 0.92; 95% confidence interval CI 0.81–1.05), and did not change over time. The estimated IBD prevalence was 830/100000.
Conclusions
The IBD incidence in South Limburg increased significantly between 1991 and 2010. The shift towards milder disease at diagnosis in parallel with the improved diagnostics and ability to detect low-grade inflammation was suggestive of an important role of diagnostic factors in this increase. Environmental factors probably played a role as well. The mortality was low and, together with the increasing incidence, led to the high prevalence of IBD in South Limburg.
Inflammatory bowel disease (IBD) patients are at risk of an impaired nutritional status. The impact thereof on the IBD relapse risk is clinically relevant, though sparsely investigated.
The aim was ...to explore the association between an impaired nutritional status risk and the occurrence of disease flares in IBD outpatients participating in a longitudinal telemedicine study.
IBD outpatients were recruited from the myIBDcoach study cohort, with one year clinical follow-up. Through myIBDcoach, a telemedicine tool, patients reported on disease activity and risk of impaired nutritional status (i.e. Short Nutritional Assessment Questionnaire >1 and/or BMI < 18.5 kg/m2) every one to three months. Data was analysed by generalized estimating equation modelling.
In total, 417 patients were included. During follow-up, 49 patients (11.8%) flared after initial clinical remission and 53 patients (12.7%) showed an increased risk of impaired nutritional status. The risk of impaired nutritional status was associated with flare occurrence (OR 2.61 (95% CI 1.02–6.69)).
The risk of an impaired nutritional status was associated with subsequent flares in IBD outpatients. This emphasizes the importance of monitoring disease activity in IBD patients at risk of impaired nutritional status.
Background and Aims:
In the past decades, treatment options and strategies for ulcerative colitis UC have radically changed. Whether these developments have altered the disease outcome at population ...level is yet unknown. Therefore, we evaluated the disease outcome of UC over the past two decades in the South-Limburg area of The Netherlands.
Methods:
In the Dutch population-based IBDSL cohort, three time cohorts were defined: cohort 1991–1997 cohort A, cohort 1998–2005 cohort B, and cohort 2006–2010 cohort C. The colectomy and hospitalisation rates were compared between cohorts by Kaplan-Meier survival analyses. Hazard ratios HR for early colectomy within 6 months after diagnosis, late colectomy beyond 6 months after diagnosis, and hospitalisation were calculated using Cox regression models.
Results:
In total, 476 UC patients were included in cohort A, 587 patients in cohort B, and 598 patients in cohort C. Over time, an increase in the use of immunomodulators 8.1%, 22.8% and 21.7%, respectively, p < 0.01 and biological agents 0%, 4.3% and 10.6%, respectively, p < 0.01 was observed. The early colectomy rate decreased from 1.5% in cohort A to 0.5% in cohort B HR 0.14; 95% confidence interval 0.04–0.47, with no further decrease in cohort C 0.3%, HR 0.98; 95% confidence interval 0.20–4.85. Late colectomy rate remained unchanged over time 4.0% vs 5.2% vs 3.6%, respectively, p = 0.54. Hospitalisation rate was also similar among cohorts 22.3% vs 19.5% vs 18.3%, respectively, p = 0.10.
Conclusion:
Over the past two decades, a reduction in early colectomy rate was observed, with no further reduction in the most recent era. Late colectomy rate and hospitalisation rate remained unchanged over time.
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