Current JCC eTOC

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Journal of Crohn's and Colitis Current Issue

European Crohn’s and Colitis Organisation Topical Review on IBD in the Elderly

2016-11-16 by Sturm A, Maaser C, Mendall M, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This ECCO topical review of the European Crohn’s and Colitis Organisation [ECCO] focuses on the epidemiology, pathophysiology, diagnosis, management and outcome of the two most common forms of inflammatory bowel disease, Crohn’s disease and ulcerative colitis, in elderly patients. The objective was to reach expert consensus to provide evidence-based guidance for clinical practice.</span>
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Prevalence of Bowel Damage Assessed by Cross-Sectional Imaging in Early Crohn’s Disease and its Impact on Disease Outcome

2016-10-31 by Fiorino G, Morin M, Bonovas S, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>Bowel damage in Crohn’s disease [CD] is defined as the presence of intestinal strictures, fistulas or abscesses. Early disease may represent a window of opportunity for timely intervention. We evaluated disease activity and severity by the Lémann Index [LI] and the Magnetic Resonance Index of Activity [MaRIA] score, and their prognostic value in early CD.<div class="boxTitle">Methods:</div>All consecutive patients diagnosed with CD in two referral centres, assessed by magnetic resonance imaging or computerized tomography, were prospectively included. Disease activity and bowel damage in early CD, the correlation between the LI and the MaRIA score, and the value of cross-sectional imaging findings in predicting disease progression were assessed. Statistical analyses employed time-to-event methods.<div class="boxTitle">Results:</div>We included 142 consecutive CD patients. Median time from diagnosis to baseline imaging was 0.3 years; median follow-up time was 4.9 years. At diagnosis, 39.4% of CD patients had bowel damage. At multivariable analysis, bowel damage and the LI were independent prognostic factors for intestinal surgery (hazards ratio [HR]: 3.21 and 1.11, respectively, <span style="font-style:italic;">p</span><0.001), and of CD-related hospitalization during patient follow-up [HR: 1.88, <span style="font-style:italic;">p</span>=0.002, and 1.08, <span style="font-style:italic;">p</span><0.001, respectively]. Disease activity as expressed by the MaRIA score did not predict the disease course. The correlation between the LI and MaRIA score was weak [rho: +0.32; <span style="font-style:italic;">p</span><0.001].<div class="boxTitle">Conclusion:</div>Four out of ten CD patients have bowel damage at the time of the first imaging study. The presence of bowel damage, and not the MaRIA score, in early CD is associated with a worse outcome, with increased risks of surgery and hospitalization.</span>
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The Lemann Index—A Glance Through the Window of Opportunity?

2016-10-26 by Kopylov U, Eliakim R.
<span class="paragraphSection">Crohn’s disease [CD] is characterised by a chronic progressive course leading to accumulation of structural intestinal damage. Up to 60% of CD patients eventually develop complications necessitating surgical intervention.<sup><a href="#CIT0001" class="reflinks">1</a></sup> Clearly, the need for surgery manifests the ‘tip of the iceberg’ of a continuous process of gradual accumulation of structural intestinal wall damage. Early and aggressive treatment of CD may be associated with a lower risk for change of phenotype, suggesting a possible ‘therapeutic window’ for disease course modification.<sup><a href="#CIT0002" class="reflinks">2</a></sup> The common paradigm of CD natural history suggests that stricturing and penetrating phenotype are usually absent at disease onset but rather develop as a consequence of a long-standing inflammatory process.<sup><a href="#CIT0001" class="reflinks">1</a></sup> A long diagnostic delay is common in CD, and the inflammatory process is frequently present many years before the actual diagnosis of the disease, further contributing to the risk of surgery.<sup><a href="#CIT0003" class="reflinks">3</a></sup> A thorough evaluation of the small bowel with optimal diagnostic tools such as capsule endoscopy and magnetic resonance enterography may lead to detection of a more aggressive phenotype in a significant proportion of the patients.<sup><a href="#CIT0004" class="reflinks">4</a></sup> It is plausible that early detection of progressing bowel damage may provide the benefits of early treatment, potentially resulting in a reduced risk of structural complications and need for surgery. The concept of progressive structural damage as a therapeutic target, although well established in rheumatology, is still relatively new in the IBD field. The first of such quantitative tools for assessment of bowel damage in CD is the Crohn’s Disease Digestive Damage Score—the Lemann index [LI], which incorporates clinical, surgical, endoscopic, and imaging findings from all segments of the digestive tract into one composite score.<sup><a href="#CIT0005" class="reflinks">5</a></sup></span>
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Smoking is Associated with Higher Disease-related Costs and Lower Health-related Quality of Life in Inflammatory Bowel Disease

2016-10-05 by Severs MM, Mangen MJ, van der Valk ME, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>Smoking affects the course of inflammatory bowel disease [IBD]. We aimed to study the impact of smoking on IBD-specific costs and health-related quality-of-life [HrQoL] among adults with Crohn’s disease [CD] and ulcerative colitis [UC].<div class="boxTitle">Methods:</div>A large cohort of IBD patients was prospectively followed during 1 year using 3-monthly questionnaires on smoking status, health resources, disease activity and HrQoL. Costs were calculated by multiplying used resources with corresponding unit prices. Healthcare costs, patient costs, productivity losses, disease course items and HrQoL were compared between smokers, never-smokers and ex-smokers, adjusted for potential confounders.<div class="boxTitle">Results:</div>In total, 3030 patients [1558 CD, 1054 UC, 418 IBD-unknown] were enrolled; 16% smoked at baseline. In CD, disease course was more severe among smokers. Smoking was associated with > 30% higher annual societal costs in IBD (€7,905 [95% confidence interval €6,234 – €9,864] vs €6,017 [€5,186 – €6,946] in never-smokers and €5,710 [€4,687 – €6,878] in ex-smokers, <span style="font-style:italic;">p</span> = 0.06 and <span style="font-style:italic;">p</span> = 0.04, respectively). In CD, smoking patients generated the highest societal costs, primarily driven by the use of anti-tumour necrosis factor compounds. In UC, societal costs of smoking patients were comparable to those of non-smokers. Societal costs of IBD patients who quitted smoking > 5 years before inclusion were lower than in patients who quitted within the past 5 years (€ 5,135 [95% CI €4,122 – €6,303] vs €9,342 [€6,010 – €12,788], <span style="font-style:italic;">p</span> = 0.01). In both CD and UC, smoking was associated with a lower HrQoL.<div class="boxTitle">Conclusions:</div>Smoking is associated with higher societal costs and lower HrQoL in IBD patients. Smoking cessation may result in considerably lower societal costs.</span>
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Faecal and Serum Metabolomics in Paediatric Inflammatory Bowel Disease

2016-10-04 by Kolho K, Pessia A, Jaakkola T, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background:</div>Inflammatory bowel disease [IBD] is considered to result from the interplay between host and intestinal microbiota but its pathogenesis is incompletely understood. While IBD in adults has shown to be associated with marked changes in body fluid metabolomics, there are only few studies in children. Hence, this prospective study addressed the faecal and serum metabolomics in newly diagnosed paediatric IBD.<div class="boxTitle">Methods:</div>Paediatric patients with IBD undergoing diagnostic endoscopies and controls also with endoscopy but no signs of inflammation provided blood and stool samples in a tertiary care hospital. Blood inflammatory markers and faecal calprotectin levels were determined. The serum and faecal metabolomics were determined using ultra-high pressure liquid chromatography coupled to a mass spectrometer.<div class="boxTitle">Results:</div>Serum and faecal metabolite profiles in newly diagnosed paediatric IBD patients were different from healthy controls and categorized Crohn’s disease and ulcerative colitis [UC] patients into separate groups. In serum, amino acid metabolism, folate biosynthesis and signalling pathways were perturbed in Crohn’s disease; in UC also sphingolipid metabolic pathways were perturbed when compared to controls. In faecal samples, there was an increased level of several metabolites in UC in contrast to low or intermediate levels in Crohn’s disease. There was a clear correlation with the level of inflammation, i.e. faecal calprotectin levels and the profile of various biologically important metabolites [carnosine, ribose and, most significantly, choline].<div class="boxTitle">Conclusion:</div>Characterization of inflammatory pattern using metabolomics analysis is a promising tool for better understanding disease pathogenesis of paediatric IBD.</span>
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A Simplified Geboes Score for Ulcerative Colitis

2016-10-03 by Jauregui-Amezaga A, Geerits A, Das Y, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>The original Geboes Score [OGS] is the most commonly used histological score in ulcerative colitis [UC], but rather complicated to use in daily clinical practice. The aim of this study was to develop a Simplified Geboes Score [SGS] and to compare it with the OGS in patients newly diagnosed with UC.<div class="boxTitle">Methods:</div>All patients diagnosed with UC at a tertiary referral centre between 2005 and 2010, who had serial colonoscopies with biopsies, were retrospectively included. The 5-year endoscopic/histological evolution after diagnosis was recorded. Histological activity was scored by an experienced inflammatory bowel disease pathologist and three trained readers using the OGS and also the new SGS that only includes variables linked to active inflammatory disease. The correlation between endoscopic and histological activity and the histological inter-observer agreement were measured.<div class="boxTitle">Results:</div>A total of 528 slides from 339 colonoscopies of 103 UC patients were reviewed. Forty [12%] colonoscopies presented Mayo 0, 74 [22%] Mayo 1, 107 [31%] Mayo 2 and 118 [35%] Mayo 3. Active microscopic disease [≥ 3.1 in both scores] was described in 10/40 [25%] patients who were in complete endoscopic remission [Mayo 0], and 62/74 [84%] with mild endoscopic lesions [Mayo 1]. The correlation analysis between endoscopy and OGS/SGS did not show significant differences between the histological scores. The inter-observer agreement was moderate for all the grades of the SGS.<div class="boxTitle">Conclusions:</div>The assessments of histological activity based on the OGS and the SGS were comparable in newly diagnosed active UC patients. Further prospective validation should now be done to replace the OGS with the SGS.</span>
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Predicting the Individual Risk of Acute Severe Colitis at Diagnosis

2016-10-03 by Cesarini M, Collins GS, Rönnblom A, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims: </div>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.<div class="boxTitle">Methods:</div>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.<div class="boxTitle">Results:</div>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 [<span style="font-style:italic;">c</span>-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.<div class="boxTitle">Conclusions:</div>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.</span>
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Sarcoidosis-Like Lesions: Another Paradoxical Reaction to Anti-TNF Therapy?

2016-09-30 by Decock A, Van Assche G, Vermeire S, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background:</div>Since the introduction of anti-tumour necrosis factor [TNF] therapy in inflammatory diseases, paradoxical reactions are increasingly being reported. One of these paradoxical reactions is the development of sarcoidosis-like lesions. This presentation is paradoxical since anti-TNF therapy can also be therapeutic in refractory cases of sarcoidosis.<div class="boxTitle">Methods:</div>We report two cases of sarcoidosis-like lesions under anti-TNF therapy. Both were patients with inflammatory bowel disease [IBD], treated successfully with adalimumab. Next, we reviewed the literature for similar cases. Medical subject heading terms ‘adalimumab’, ‘infliximab’, ‘etanercept’, ‘golimumab’ or ‘certolizumab’, and ‘sarcoidosis’ were used to perform key word searches of the PubMed database.<div class="boxTitle">Results:</div>We identified 90 reported cases of sarcoidosis-like lesions, which developed during anti-TNF therapy. In most cases, the anti-TNF drug involved was etanercept. The median age was 43 years and there was a predominance of female patients. The underlying disease was rheumatoid arthritis in most cases, followed by ankylosing spondylitis and psoriasiform arthritis. In six cases, the underlying disease was IBD. In 71 cases there was at least a partial resolution by discontinuation of the anti-TNF treatment, initiation of steroids or both. Re-initiation of anti-TNF therapy gave relapse in seven out of 20 cases.<div class="boxTitle">Conclusion:</div>Sarcoidosis-like lesions are increasingly reported during anti-TNF treatment. Vigilance is appropriate when patients present with symptoms compatible with sarcoidosis.</span>
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Alterations of Enteric Microbiota in Patients with a Normal Ileal Pouch Are Predictive of Pouchitis

2016-09-23 by Maharshak N, Cohen N, Reshef L, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objective:</div>To examine whether patients with a mature normal pouch [> 1 year post ileostomy closure] have microbial stool characteristics that can predict pouch inflammation.<div class="boxTitle">Design:</div>Patients undergoing pouch surgery were recruited prospectively. Microbiota analysis of faecal samples was by 16S rRNA gene pyrosequencing. All patients had a normal pouch at baseline [T1]. Those without pouchitis during the first year of follow-up [T2] comprised the ‘Normal Pouch-sustained’ group and those who had experienced an episode of pouchitis comprised the ‘Pre-Pouchitis’ group.<div class="boxTitle">Results:</div>Twenty patients were recruited (age 53.6±13.1 years, pouch age [time from ileostomy closure] 8.1±5.1 years). Seven patients developed pouchitis during follow-up [within 265±93.6 days] and they were assigned to the Pre-Pouchitis group at T1: they had a decreased microbial diversity at T1 compared with the Normal Pouch-sustained patients [<span style="font-style:italic;">n</span> = 13]. The Shannon diversity index for the Pre-Pouchitis patients was 3.4 vs 4.23 for the Normal Pouch-sustained patients [<span style="font-style:italic;">p</span> = 0.011]. There were no substantial group differences in high taxonomic levels [order or above]. The genus <span style="font-style:italic;">Ruminococcus</span> was significantly decreased in the Pre-Pouchitis patients’ samples compared with those of the Normal Pouch-sustained patients (0.19% vs 0.78%, respectively, false discovery rate [FDR] = 0.05). The linear discriminant analysis with effect size estimation algorithm revealed that <span style="font-style:italic;">Lachnospira</span> and <span style="font-style:italic;">Coprococcus</span> genera were also decreased among Pre-Pouchitis patients compared with Normal Pouch-sustained patients [0.6% vs 1.95% and 2.1% vs 4%, respectively].<div class="boxTitle">Conclusions:</div>Patients with a normal mature pouch may be predisposed to acute pouchitis when faecal microbial diversity and certain microbial groups are decreased. These findings may aid in risk stratification of those patients.</span>
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Identification of Research Priorities for Inflammatory Bowel Disease Nursing in Europe: a Nurses-European Crohn’s and Colitis Organisation Delphi Survey

2016-09-23 by Dibley L, Bager P, Czuber-Dochan W, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background:</div>Robust research evidence should inform clinical practice of inflammatory bowel disease [IBD] specialist nurses, but such research is currently very limited. With no current agreement on research priorities for IBD nursing, this survey aimed to establish topics to guide future IBD nursing research across Europe.<div class="boxTitle">Methods:</div>An online modified Delphi survey with nurse and allied health professional members of the Nurses European Crohn’s and Colitis Organisation [<span style="font-style:italic;">n</span> = 303] was conducted. In Round One, participants proposed topics for research. In Round Two, research topics were rated on a 1–9 scale and subsequently synthesised to create composite research questions. In Round Three, participants selected their top five research questions, rating these on a 1–5 scale.<div class="boxTitle">Results:</div>Representing 13 European countries, 88, 90 and 58 non-medical professionals, predominantly nurses, responded to Rounds One, Two and Three, respectively. In Round One, 173 potential research topics were suggested. In Rounds Two And Three, responders voted for and prioritised 125 and 44 questions, respectively. Round Three votes were weighted [rank of 1 = score of 5], reflecting rank order. The top five research priorities were: interventions to improve self-management of IBD; interventions for symptoms of frequency, urgency and incontinence; the role of the IBD nurse in improving patient outcomes and quality of life; interventions to improve IBD fatigue; and care pathways to optimise clinical outcomes and patient satisfaction.<div class="boxTitle">Conclusions:</div>The prioritised list of topics gives clear direction for future IBD nursing research. Conducting this research has potential to improve clinical practice and patient-reported outcomes.</span>
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Switching from Remicade® to Remsima® is well Tolerated and Feasible: A Prospective, Open-label Study

2016-09-22 by Buer LT, Moum BA, Cvancarova M, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>A biosimilar version of infliximab [CT-P13/Remsima®] recently entered the European market. The clinical data on its use in inflammatory bowel disease [IBD] are sparse, especially on switching from the originator Remicade®. In this study, we aimed to prospectively investigate the feasibility, safety and immunogenicity of switching from Remicade to Remsima in a real-life IBD population.<div class="boxTitle">Methods:</div>All adult patients who were treated with Remicade in the Department of Gastroenterology at Oslo University Hospital were switched to Remsima. The follow-up lasted for 6 months. In addition, a retrospective registration was performed with a start time of 6 months before switching drugs. The primary endpoints were [i] the proportion of patients remaining on medication 6 months after switching and [ii] adverse events during the 6 months after switching. The secondary endpoints included [i] disease activity scores [Harvey-Bradshaw Index and Partial Mayo Score], C-reactive protein, haemoglobin, faecal calprotectin, infliximab dose and interval, and p-infliximab and [ii] the development of antidrug antibodies.<div class="boxTitle">Results:</div>In total, 143 IBD patients were switched, 99 with Crohn’s disease and 44 with ulcerative colitis. The large majority [97%] remained on the medication throughout follow-up. A low number of adverse events were observed. No change in disease activity, C-reactive protein, haemoglobin, faecal calprotectin, infliximab dose and interval or p-infliximab was detected. Three patients developed new detectable antidrug antibodies.<div class="boxTitle">Conclusions:</div>Switching from Remicade to Remsima was feasible and with few adverse events, including very limited antidrug antibody formation and loss of response.</span>
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Impairment of Small Intestinal Function in Ulcerative Colitis: Role of Enteric Innervation

2016-09-21 by Mourad FH, Barada KA, Saade NE.
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Small intestinal dysfunction has been described in patients with ulcerative colitis and in experimental animal models of colitis. This is demonstrated by a decrease in fluid, electrolyte, amino acid, fat and carbohydrate absorption as well as by deranged intestinal motility. Histopathological changes in the small intestines in colitis have not been consistently demonstrated, but there is evidence of structural and biochemical alterations as shown by increased intestinal permeability and a decrease in the expression of multiple brush border membrane enzymes such as disaccharidases and aminopetidases, in both humans and experimental animals. The pathophysiology of this dysfunction has not been elucidated, but it is thought to include alterations in neural circuitry such as increased neuronal excitability, neuronal damage and changes of neuropeptidergic innervation and receptors as well as an increase in local production of pro-inflammatory cytokines and alterations in the production of some neurohumoral mediators. In the following, we provide an update on the advancement of clinical and scientific contributions to elucidate the underlying mechanisms of the alteration of the functions of apparently intact small intestinal segments, induced by ulcerative colitis.</span>
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The Economic Impact of the Introduction of Biosimilars in Inflammatory Bowel Disease

2016-09-14 by Severs MM, Oldenburg BB, van Bodegraven AA, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objective:</div>Inflammatory bowel disease [IBD] entails a high economic burden to society. We aimed to estimate the current and future impact of the introduction of biosimilars for infliximab on IBD-related health care costs.<div class="boxTitle">Methods:</div>We designed a stochastic economic model to simulate the introduction of biosimilars in IBD, using a 5-year time horizon, based on the Dutch situation. Prevalence data on ulcerative colitis [UC] and Crohn’s disease [CD] and IBD-related health care costs data were used as input. Assumptions were made on price reductions of anti-tumour necrosis factor [TNF] therapy, increase of anti-TNF prescription rate, and development of hospitalization costs. The base case scenario included a gradual decrease in prices of biosimilars up to 60%, a gradual decrease in prices of original anti-TNF compounds up to 50%, and an annual increase of anti-TNF prescription rate of 1%, and this was compared with no introduction of biosimilars. Sensitivity analyses were performed.<div class="boxTitle">Results:</div>For the base case, cost savings over the total of 5 years were on average €9,850 per CD patient and €2,250 per UC patient, yielding in €493 million total cost savings [a reduction of 28%] for The Netherlands. Results were predominantly determined by price reduction of anti-TNF therapy, threshold price reduction at which physicians switch patients towards biosimilars and the extent to which switching will take place.<div class="boxTitle">Conclusions:</div>The introduction of biosimilars for infliximab can be expected to have a major impact on the cost profile of IBD. The economic impact will depend on local pricing, procurement policies and the physician’s willingness to switch patients to biosimilars.</span>
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Restoring Mucosal Barrier Function and Modifying Macrophage Phenotype with an Extracellular Matrix Hydrogel: Potential Therapy for Ulcerative Colitis

2016-09-10 by Keane TJ, Dziki J, Sobieski E, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>Despite advances in therapeutic options, more than half of all patients with ulcerative colitis [UC] do not achieve long-term remission, many require colectomy, and the disease still has a marked negative impact on quality of life. Extracellular matrix [ECM] bioscaffolds facilitate the functional repair of many soft tissues by mechanisms that include mitigation of pro-inflammatory macrophage phenotype and mobilization of endogenous stem/progenitor cells. The aim of the present study was to determine if an ECM hydrogel therapy could influence outcomes in an inducible rodent model of UC.<div class="boxTitle">Methods:</div>The dextran sodium sulphate [DSS]-colitis model was used in male Sprague Dawley rats. Animals were treated via enema with an ECM hydrogel and the severity of colitis was determined by clinical and histological criteria. Lamina propria cells were isolated and the production of inflammatory mediators was quantified. Mucosal permeability was assessed in vivo by administering TRITC-dextran and in vitro using transepithelial electrical resistance [TEER].<div class="boxTitle">Results:</div>ECM hydrogel therapy accelerated healing and improved outcome. The hydrogel was adhesive to colonic tissue, which allowed for targeted delivery of the therapy, and resulted in a reduction in clinical and histological signs of disease. ECM hydrogel facilitated functional improvement of colonic epithelial barrier function and the resolution of the pro-inflammatory state of tissue macrophages.<div class="boxTitle">Conclusions:</div>The present study shows that a non-surgical and non-pharmacological ECM-based therapy can abate DSS-colitis not by immunosuppression but by promoting phenotypic change in local macrophage phenotype and rapid replacement of the colonic mucosal barrier.</span>
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Collagenous Colitis Refractory to Budesonide: is the Upper Gastrointestinal Tract Involved?

2016-09-09 by Agudo B, Calvo M, Abreu LE.
<span class="paragraphSection"><strong>To the Editor:</strong> We present a case of a 44-year-old woman with a 2-month history of watery diarrhoea and 10kg weight loss, despite a gluten-free diet. Laboratory data showed low serum levels of total proteins and albumin, low B12 levels, iron difficiency and hypokalaemia. Magentic resonance imaging provided no significant findings. The colonoscopy was normal and random colonic biopsies revealed findings compatible with collagenous colitis [CC]. Therapy was initiated with oral budesonide 9mg/day, with a poor response after 2 weeks. Gastroscopy revealed normal mucosal appearance and biopsies were taken from the duodenum, antrum and body. The histological findings in the duodenum biopsies were infiltration of chronic inflammatory cells in the subepithelial layer, and the deposition of collagen bands thicker than 10 μm in the lamina propria, consistent with collagenous enteritis [<a href="#F1" class="reflinks">Figure 1</a>]. The patient was advised to start prednisone 40 mg daily and her symptoms improved with an excellent response after 6 weeks under treatment, and complete remission after 6 months.</span>
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Previous Exposure to Multiple Anti-TNF Is Associated with Decreased Efficiency in Preventing Postoperative Crohn’s Disease Recurrence

2016-09-09 by Collins M, Sarter H, Gower-Rousseau C, et al.
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims:</div>Infliximab and adalimumab are increasingly used to prevent postoperative recurrence in Crohn’s disease patients. The impact of previous exposure to one or more anti-tumour necrosis factor [TNF] agents before surgery on the efficacy of anti-TNF therapy on postoperative recurrence is unknown.<div class="boxTitle">Methods:</div>We performed a retrospective analysis of Crohn’s disease patients who underwent surgical bowel resection with anastomosis and prophylactic treatment with anti-TNF therapy between January 2005 and June 2013.<div class="boxTitle">Results:</div>A total of 57 consecutive Crohn’s disease patients with bowel resection and anastomosis followed by prophylactic treatment with anti-TNF were included; 21 [37%] and 24 [42%] patients had a previous exposure to one and more than one anti-TNF agents, respectively; 39 patients [68%] had a surveillance colonoscopy. Cumulative rates of postoperative endoscopic recurrence at 2 years were 45.5% [26.6-69.6%] in patients exposed to two or more anti-TNFα as compared with 29.1% [11.5-48.1%] in patients exposed to one or to zero anti-TNFα before surgery [<span style="font-style:italic;">p</span> = 0.07]. Cumulative rates of clinical recurrence at 1 year were 21.6% [9.6-44.4%] in patients exposed to two or more anti-TNFα as compared with 6.9% [1.8-25.1%] in patients exposed to zero or one anti-TNFα before surgery [<span style="font-style:italic;">p</span> = 0.02]. Multivariable analysis identified smoking and previous exposure to two or more anti-TNFα as risk factors for Crohn’s disease clinical or endoscopic postoperative recurrence (hazard ratio [HR] = 3.17; 95% confidence interval [CI]: 1.3-7.8, <span style="font-style:italic;">p</span> = 0.01 and HR = 4.2; 95% CI: 1.8-10.2, <span style="font-style:italic;">p</span> = 0.001, respectively).<div class="boxTitle">Conclusions:</div>Previous exposure to two or more anti-TNF agents was associated with a higher risk of postoperative recurrence in Crohn’s disease patients.</span>
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