Journal of Crohn's & colitis最新文献

Background: The incidence and prevalence of inflammatory bowel disease [IBD] have increased significantly in low- and middle-income countries [LMICs] in recent decades. Managing IBD in these settings presents substantial challenges. This consensus aims to describe the epidemiology of IBD in LMICs and to highlight the key challenges in its diagnosis and treatment.

Method: The consensus-defining strategy followed the previous European Crohn's and Colitis Organisation [ECCO] consensus guidelines [available at www.ecco-ibd.eu]. The authors reviewed the available evidence and formulated statements accordingly. Provisional ECCO statements and supporting text were drafted based on a comprehensive literature review and further refined through two voting rounds, which included external reviewers and national representatives from ECCO's 36 member countries. The final ECCO statements, representing a consensus of at least 80% agreement among participants, were approved during an online meeting. Consensus statements should be interpreted in context with their accompanying commentary rather than in isolation and should not be used solely to guide patient management. The supporting text was finalized under the guidance of each working group leader [VP, HY, TK, AH] and subsequently integrated by the consensus leader [AE].

Results: Data on IBD epidemiology in LMICs remain limited. Public and healthcare professional awareness and timely access to early diagnostic modalities, advanced medical and surgical therapies, and specialist multidisciplinary care are key gaps in IBD care in LMICs. The complexity and chronic nature of IBD, along with the necessity for a multidisciplinary approach, pose significant challenges to adopting a holistic management strategy in LMICs.

Conclusion: There is a critical need for further studies to assess the specific needs of LMICs. Such research will help guide resource allocation and improve IBD management in these settings.

Background and aims: This study aims to evaluate the diagnostic accuracy of tools commonly employed in clinical practice for the assessment of malnutrition in patients with inflammatory bowel disease (IBD), including Global Leadership Initiative on Malnutrition (GLIM) criteria, Subjective Global Assessment (SGA), European Society of Parenteral and Enteral Nutrition (ESPEN) criteria, and World Health Organization (WHO)-related body mass index (BMI).

Methods: Eligible observational studies and randomized controlled trials (RCTs) were identified through searches of databases, including PubMed, Scopus, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos, until August 2024. Clinical trial registries, grey literature, and reference lists of included studies were also screened. Study selection, data extraction, and quality assessment were conducted independently by two reviewers. A bivariate mixed-effects model was utilized to evaluate the diagnostic test accuracy, producing pooled estimates for sensitivity and specificity with the corresponding confidence intervals (CIs), using SGA as a reference method for malnutrition diagnosis.

Results: Nine primary studies (1420 participants) and data from one unpublished work were included in the present systematic review. Based on data derived from three studies, GLIM criteria demonstrated high sensitivity (0.80, 95% CI: 0.68-0.88) and moderate specificity (0.71, 95% CI: 0.53-0.84) using SGA as a reference standard. The certainty of the evidence supporting these findings was rated as very low.

Conclusions: The GLIM criteria demonstrate potential as an effective tool for diagnosing malnutrition in patients with IBD. However, further validation is necessary, requiring additional diagnostic accuracy studies to enhance their reliability and establish their clinical applicability.

The rising global prevalence of inflammatory bowel disease (IBD) and costs of care associated with its management mandates the need to constrain costs whilst improving patient outcomes. Traditional care models such as fee for service do not capture the functional impact of IBD across the whole patient journey. There is a need to develop innovative care models to better address the multifaceted needs of patients with IBD. Values-based healthcare (VBHC) is a model of care that aims to deliver quality care by prioritizing outcomes that matter to patients in a manner that demonstrates cost-effectiveness of health service provision. In this comprehensive scoping review of the literature, we examine the implementation of VBHC-orientated approaches to IBD care delivery and assess how they have demonstrated value in relation to clinical outcomes, patient-reported outcomes, costs (direct and indirect), and healthcare utilization. In addition, we outline key enablers and barriers to implementation of VBHC models in IBD. We then describe the ideal composition of IBD VBHC models and parameters required for implementation and demonstration of their value proposition.

Introduction: ESGE have recently defined important performance measures for endoscopy in IBD. The role of patient experience in quality assessment of endoscopy in IBD is yet to be defined. We undertook an observational study based on analysis of a large multi-centre dataset with national coverage in Ireland. The aim was to analyse individual and composite metrics that reflect patients' experience with endoscopic procedures for IBD.

Methods: Anonymised data was extracted from electronic procedure records of patients who underwent colonoscopy in 24 Irish hospitals. The Performance Indicator of colonic intubation (PICI), a novel composite score reflecting sedation rates and patient comfort, and IBD-specific endoscopic domains were evaluated.

Results: Data from 261,524 colonoscopies were analysed from 2014-2020. CD patients had significantly lower OR of achieving PICI compared to non-IBD patients (0.69, 0-65-0.74 p < 0.001). Severe colitis was also associated with a significantly lower OR of achieving PICI (OR 0.53 (0.38-0.74, p,0.001). 80.2% of CD patients had a comfort score ≤2 compared to 87.8% of those with UC and 84.2% without IBD. 60.7% of patients with CD required Midazolam dose of 3 mg or more compared to 50.4% of those with UC and 76.7% of those without IBD. . 50% of CD patients required Fentanyl doses >50mcg compared to 34% of UC patients and 30.3% of patients without IBD.

Conclusion: This analysis of a large national endoscopy dataset highlights variability in quality metrics for IBD endoscopy and underscores the need for a metric like PICI to more accurately capture and reflect patient endoscopic experience with IBD.

Surgery is a pivotal component of the management of Crohn's disease (CD), particularly in cases of disease-related complications or failure of medical therapy. However, the risk of short bowel syndrome following multiple large resections makes bowel preservation strategies a major therapeutic priority. This review gathers insights from a diverse group of inflammatory bowel disease specialists, exploring the full spectrum of bowel-preserving strategies, from conservative surgical techniques and peri-operative optimization to emerging innovations in robotic surgery. The therapeutic paradigm of treat-to-target and tight disease monitoring is shifting the focus from reactive interventions to proactive and personalized care. Looking ahead, the evolving implementation of multi-omics profiling and artificial intelligence holds promise to reshape the role of surgery in CD. Surgery should no longer be viewed solely as a response to complications, but rather as an individualized, biology-driven strategy that prioritizes bowel preservation. In this rapidly advancing field, innovation is measured not only by clinical outcomes but also by every centimeter of bowel preserved.

Background: Crohn's disease (CD) is characterized by chronic intestinal inflammation. Previous single-cell transcriptomic studies have mostly focused on established disease, leaving a knowledge gap in relation to treatment-naive profiles across multiple regions of the gut.

Methods: To study disease onset, a treatment-naive pediatric CD cohort was recruited, and single-cell transcriptomics was performed on ileum, colon, and rectum biopsies collected at initial endoscopy. A clustering stability assessment workflow was developed to ensure clustering and downstream results were robust.

Results: Inflammation did not strongly influence cellular proportion due to heterogeneity across donor and tissue. Tensor decomposition revealed distinct mesenchymal and myeloid cell-mediated sources of disease pathology, corresponding to previously identified fibrotic and pro-inflammatory disease progression. Integrating transcriptomics and genome-wide association summary statistics for CD suggested myeloid and T cells drive disease, highlighting potential cellular therapeutic targets.

Conclusion: Tensor decomposition stratified donors into clinically meaningful groups based on their transcriptomic profile, suggesting these signatures can be utilized for personalized medicine.

Background and aims: The necessity of diverting loop-ileostomy after a staged ileoanal pouch for ulcerative colitis (UC) remains unclear. This study aimed to compare postoperative outcomes between modified-two-stage and three-stage ileoanal pouch procedures for UC.

Methods: This retrospective cohort study included patients ≥18 years with UC or unclassified inflammatory bowel disease who underwent modified-two-stage or three-stage ileoanal pouch surgery from 2016 to 2021 in six European centers, with a follow-up of more than 12 months. The primary outcome was stoma-free rate at the end of follow-up. Secondary outcomes included perioperative practise, length of hospital stay, anastomotic leakage rate, and timing of diagnosis and treatment.

Results: Overall, 370 patients were included, of whom 228 (61.6%) underwent a modified-two-stage approach and 142 (38.4%) a three-stage approach. The median length of follow-up was 3.6 years (range: 1.0-7.7). Stoma-free rate was 93.8% (213/227) in modified-two-stage patients and 91.5% (130/142) in three-stage patients (P = .404). Notably, 78.4% of modified-two-stage patients never required an ileostomy, while the remaining 21.6% did receive a secondary ileostomy. While the median length of hospital stay for pouch surgery was longer in the modified-two-stage group, total median length of hospital stay after 1 year was shorter (median 7.0 days [IQR 6.0-11.0] vs 9.0 days [IQR 7.0-12.5], P = .015). The Clavien-Dindo score was higher than II in 22.6% of modified-two-stage patients and in 8.7% of three-stage patients (P < .001). Anastomotic leakage rate was higher after the modified-two-stage procedure (18% vs 5%, P < .001), but diagnosis and treatment occurred earlier (86% within 21 days vs 43%, P = .009).

Conclusions: Both approaches have comparable high stoma-free rates at the end of follow-up. Modified-two-stage avoids a temporary stoma in more than 75% of patients, but has a significantly higher rate of anastomotic leakages. Active and early surveillance of the anastomosis after three-stage procedures could improve postoperative outcomes in this group.

Background and aims: Upadacitinib (UPA)-an oral, reversible selective Janus kinase inhibitor-has a favorable benefit-risk profile for patients with Crohn's disease (CD) and ulcerative colitis (UC). We evaluated the benefit-risk of UPA in select subgroups with CD or UC.

Methods: Patients were randomized to UPA 45 mg (UPA45) once daily (QD) or placebo (PBO) induction for 12 (CD: U-EXCEED, U-EXCEL) or 8 weeks (UC: U-ACHIEVE, U-ACCOMPLISH). Clinical responders were re-randomized to QD UPA 15 mg (UPA15), UPA 30 mg (UPA30), or PBO for 52-week maintenance (CD: U-ENDURE; UC: U-ACHIEVE). This exploratory post hoc analysis assessed efficacy and safety outcomes (adverse events of special interest [AESIs]: serious infections, major adverse cardiovascular [CV] events, malignancies, and venous thromboembolic events) by CV risk, prior treatment failure, and age.

Results: This analysis included 1021 patients with CD and 1097 with UC during induction, and 673 with CD and 746 with UC during maintenance. Improved efficacy outcomes comparable to the overall study populations were observed with UPA versus PBO across subgroups. Patients receiving UPA30 generally showed numerically higher rates of improvements versus UPA15. AESI rates were generally comparable between UPA and PBO across subgroups except for numerically higher rates of herpes zoster and serious infections in CD with UPA.

Conclusions: UPA resulted in consistent benefit versus placebo across CV risk, prior treatment failure, and age subgroups. No treatment differences were seen in AESIs across subgroups except herpes zoster and serious infections, reinforcing the favorable benefit-risk profile for UPA in CD and UC seen in the overall study populations.

Clinical trial numbers: NCT02819635, NCT03653026, NCT03345836, NCT03345849, NCT03345823.