A recent study (O Olen et al. Gastroenterol 2019; 156: 614-22) was summarized quite succinctly by NEJM journal watch:
Using the Swedish National Patient Registry data, investigators identified 9442 incident cases of IBD diagnosed in patients under age 18 years from 1964 through 2014. Based on 139,000 person-years of follow-up, results were as follows:
- There were 259 deaths among people with IBD (133 were from cancer and 54 from digestive disease).
- The all-cause mortality rate in these patients was 2.1/1000 person-years, compared with 0.7 in matched reference individuals from the general population.
- The average age at death was 61.7 compared with 63.9 years in the reference group.
- The hazard ratio for death was 3.2 and was higher in those with ulcerative colitis (HR, 4.0), especially if they had concomitant primary sclerosing cholangitis (HR, 12.2), a first-degree relative with ulcerative colitis (HR, 8.3), or a history of surgery (HR, 4.6).
- Mortality risks were similar when limited to the period after the introduction of biologics (2002–2014).
My take: This study found that having IBD diagnosed in childhood increased the risk of mortality (~1 extra death for every 700 patients followed for 1 year) especially in patients with concomitant PSC and in patients with severe ulcerative colitis. The study did not see an effect of the newest therapies but was underpowered to directly assess this effect.
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Chattahoochee River, near Azalea Drive
B Kochar et al. Inflamm Bowel Dis 2018; 24: 1833-9. This study reviewed prospectively collected data from 2011-2015 involving 2390 Ileal Pouch Anal Anastomosis (IPAA) surgeries for ulcerative colitis in those ≥18 years of age. Two approaches were compared:
- ‘Traditional’ 2- stage IPAA where the pouch is created with the colectomy
- Or a 3-stage surgery where the pouch is created in a second surgery after the colectomy (delayed pouch creation)
- Delayed pouch creation were significantly less likely to have an unplanned reoperation (RR =0.42, CI 0.24-0.75) and less likely to have major adverse events (RR=0.72, CI 0.52-0.99)
- Those in the delayed pouch creation group were much less likely to be receiving chronic immunosuppression at the time of surgery –15% compared to 51% in 2-stage group
My take: Particularly for sicker patients, delayed pouch creation (3-stage procedure) is likely to be best approach.
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Another study (NZ Borren et al Inflamm Bowel Dis 2017; 23: 1234-9) has shown detrimental outcomes due to distance from the health care team.
In this study with 2136 patients with IBD (1197 Crohn’s disease, 9393 ulcerative colitis) with mean age of 41 years, the distance from the hospital (Massachusetts General) was compared with need for IBD-related surgery and secondary outcomes of needing biological and immunomodulator therapy.
- In the four quartiles, mean distance was 2.5, 8.8, 22.0, and 50.8 miles.
- Need for surgery was increased with distance from hospital: closest with odds ratio of 1.0, quartile 2 had OR of 1.68, quartile 3 had OR of 1.94, and quartile 4 had OR of 2.44
According to the authors, with other indications besides IBD, “over three-quarters of the examined studies demonstrated a distance-decay association with worse outcomes in individuals living further away from health care facilities. Limitation: it is possible that patients who travel a greater distance have more disease severity and that those who have milder diseases are more likely to receive care closer to home.
My take: When highly qualified subspecialists are far away, the associated reduced access likely counters this potential benefit. Early effective therapy is important in reducing complications.
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Shem Creek, SC
A while back there was a movie called “Minority Report.” The movie’s premise was that crimes could be predicted and stopped before they occurred. A recent study (P Lochhead et al. Clin Gastroenterol Hepatol 2016; 14: 818-24) presents intriguing data suggesting a similar scenario for inflammatory bowel disease (IBD).
The authors used a prospective, nested case control study of participants in the Nurses’ Health Study I and II. Median age of patients with Crohn’s disease (CD) (n=83) and ulcerative colitis (UC) (n=90) was 52.7 years and 50.4 years respectively. Key findings:
- Median prediagnostic hsCRP levels (mg/L) were 2.3 in CD, 2.2 in UC and 1.5 in controls (n=344).
- Median prediagnostic IL6 levels (pg/mL) were 1.7 in CD, 1.2 in UC, and 1.0 in controls.
- Median time interval between blood collection and diagnosis was 6.6 years for CD and 6.8 years for UC.
- There was increased odds for developing disease even after adjustment for potentially confounding variables like smoking. This analysis held up even when excluding disease that developed within 2 years of sampling.
Overall, this study suggests that there is a significant population of patients with subclinical IBD which precedes the diagnosis by several years. This report adds to a number of other studies showing potential “preclinical phase” of many diseases including rheumatoid arthritis and type 1 diabetes.
My take: It is fascinating that bloodwork can be abnormal years before clinical symptoms. However, as in “Minority Report” the problem will be with identifying a crime/disease that might never occur.
Unrelated –Chart Depicting Car Temps:
In a population-based inception cohort study (S Yada et al. Clin Gastroenterol Hepatol 2016; 14: 65-70) of 679 patients with inflammatory bowel disease (IBD) followed for a median of more than 19.8 years, it was determined that patients with IBD were ~9 times more likely to develop hidradenitis suppurativa (HS) compared with general population. 8 of 679 patients developed HS; only one had HS prior to IBD.
- Most Crohn’s disease patients with HS had perianal disease. Most ulcerative colitis patients developed HS after colectomy.
- Female sex and obesity were risk factors for HS.
In a second retrospective study (N Kamal et al. Clin Gastroenterol Hepatol 2016; 14: 71-9), the authors identified 15 patients with CD and HS. 10 patients had perianal disease. In this population, “both diseases were characterized by their severity, requirement of systemic medical therapies including anti-TNF and high operative rate.” this article contained some very helpful pictures.
Unrelated article: F Wang, JL Kaplan, BD Gold et al. Cell Reports; 2016: 14: 945-55. This highly technical study used two independent cohorts of patients with Crohn’s disease and non-IBD controls. One cohort, RISK, had over 700 patients and ~30,000 mean number of reads per sample; the other cohort, PIBD-CC, and 87 patients and ~3000 mean number of reads per sample. Overall, the study showed associations between Crohn’s disease and bacteria in the lumen and the study helps provide an information-based method to depict dysbiosis.
Related blog post: Add it to the list
A recent review of children in the Pediatric Inflammatory Bowel Disease Consortium (PediIBDC) examined risk factors for proctocolectomy in children with Ulcerative Colitis (UC) (JPGN 2012; 55: 534-40). Two of the investigators (Stanley Cohen and Ben Gold) are colleagues of mine at GI Care for Kids.
In total, 406 children with UC were reviewed. The average age at diagnosis was 10.6 years. The average followup was 6.8 years. 57 (14%) underwent surgery with a median time to surgery of 3.8 years. Overall risk factors for colectomy included the following:
- Presenting with weight loss, HR 2.55
- Presenting with hypoalbuminemia (<3.5 g/dL), HR 6.05
- First-degree relative with UC, HR 1.81
- Treatment with cyclosporine, HR 6.11
- Treatment with tacrolimus, HR 3.66
While this data expands on the knowledge of these factors in children, the findings are not unexpected. Low albumin levels and poor nutritional status have been identified in other studies as risk factors for UC relapse and for colectomy.
With regard to first-degree relatives, the findings imply that children with a first-degree relative are more likely to have a more severe form of UC.
The use of calcineurin inhibitors, cyclosporine and tacrolimus, are given only in the presence of severe disease. Thus, while use of these agents is associated with an increased risk of colectomy, it is unlikely that this is a causal relationship. Interestingly, the use of infliximab was not identified as a risk factor. However, this retrospective study examined patients between 1999-2003. Since this timeframe, there has been increased use of infliximab for refractory UC.
Going forward, it is likely that contemporary studies would incorporate PUCAI (pediatric UC activity index) measurements and would have the ability to enroll far greater numbers of patients from database consortiums.
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