Evolution of Surgery Risk in Crohn's Disease

While many individuals with Crohn’s disease require surgery for management, the risks of surgery are not well characterized in population-based studies. Advances in medical management may have influenced the risk of surgery over time. However, studies have not adequately evaluated the effect of smoking on temporal trends in surgery risk for Crohn’s disease. A mixed methodology approach was used to: 1) describe the morbidity and mortality associated with surgery in Crohn’s disease; 2) summarize the risk of first and second surgery in Crohn’s disease; 3) evaluate whether the risk of surgery has changed over time; and 4) assess whether smoking has influenced the risk of surgery in Crohn’s disease. In Alberta, postoperative morbidity (25%) and mortality (1.2%) was high for Crohn’s disease. A systematic review and meta-analysis found that the estimated pooled risk of surgery 10 years after the diagnosis of Crohn’s disease was 46.6% (95% Confidence Interval [CI] 37.7%-57.7%); however, the risk of first surgery in Crohn’s disease was significantly decreasing over time (meta-regression p- value40 years at diagnosis) smoking was associated with twice the risk of surgery compared to those who did not smoke. The results of this dissertation demonstrate that surgery is associated with significant morbidity and mortality. Reassuringly, the risk of surgery is decreasing over time. In part, this decrease may be explained by fewer Crohn’s disease patients who are smokers at diagnosis. Thus, public health initiatives that reduce the prevalence of smoking in the general population may reduce the burden of Crohn’s disease

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis

Abstract Background Hyperfunctioning or hot nodules are thought to be rarely malignant. As such, current guidelines recommend that hot nodules be excluded from further malignancy risk stratification. The objective of this systematic review and meta-analysis is to compare the malignancy risk in hot nodules and non-toxic nodules in observational studies. Methods Ovid MEDLINE Daily and Ovid MEDLINE, EMBASE, Scopus, and Web of Science databases were searched. Observational studies which met all of the following were included: (1) use thyroid scintigraphy for nodule assessment, (2) inclusion of both hyperfunctioning and non-functioning nodules based on scintigraphy, (3) available postoperative histopathologic nodule results, (4) published up to November 12, 2020 in either English or French. The following data was extracted: malignancy outcomes include malignancy rate, mapping of the carcinoma within the hot nodule, inclusion of microcarcinomas, and presence of gene mutations. Results Among the seven included studies, overall incidence of malignancy in all hot thyroid nodules ranged from 5 to 100% in comparison with non-toxic nodules, 3.8–46%. Odds of malignancy were also compared between hot and non-toxic thyroid nodules, separated into solitary nodules, multiple nodules and combination of the two. Pooled odds ratio (OR) of solitary thyroid nodules revealed a single hot nodule OR of 0.38 (95% confidence interval (CI) 0.25, 0.59), toxic multinodular goiter OR of 0.51 (95% CI 0.34, 0.75), and a combined hot nodule OR of 0.45 (95% CI 0.31, 0.65). The odds of malignancy are reduced by 55% in hot nodules; however, the incidence was not zero. Conclusions Odds of malignancy of hot nodules is reduced compared with non-toxic nodules; however, the incidence of malignancy reported in hot nodules was higher than expected. These findings highlight the need for further studies into the malignancy risk of hot nodules

The impact of depression and antidepressant usage on primary biliary cholangitis clinical outcomes.

Depression is prevalent in primary biliary cholangitis (PBC) patients. Our aims were to examine the effects of depression and antidepressants on hepatic outcomes of PBC patients.We used the UK Health Improvement Network database to identify PBC patients between 1974 and 2007. Our primary outcome was one of three clinical events: decompensated cirrhosis, liver transplantation and death. We assessed depression and each class of antidepressant medication in adjusted multivariate Cox proportional hazards models to identify independent predictors of outcomes. In a sensitivity analysis, the study population was restricted to PBC patients using ursodeoxycholic acid (UDCA).We identified 1,177 PBC patients during our study period. In our cohort, 86 patients (7.3%) had a depression diagnosis prior to PBC diagnosis, while 79 patients (6.7%) had a depression diagnosis after PBC diagnosis. Ten-year incidence of mortality, decompensated cirrhosis, and liver transplantation were 13.4%, 6.6%, and 2.0%, respectively. In our adjusted models, depression status was not a predictor of poor outcomes. After studying all classes of antidepressants, using the atypical antidepressant mirtazapine after PBC diagnosis was significantly protective (Adjusted HR 0.23: 95% CI 0.07-0.72) against poor liver outcomes (decompensation, liver transplant, mortality), which remained statistically significant in patients using UCDA (HR 0.21: 95% CI 0.05-0.83).In our study, depression was not associated with poor clinical outcomes. However, using the antidepressant mirtazapine was associated with decreased mortality, decompensated cirrhosis and liver transplantation in PBC patients. These findings support further assessment of mirtazapine as a potential treatment for PBC patients

Environment and the Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD), which consists of Crohn disease and ulcerative colitis, are chronic inflammatory conditions of the gas-trointestinal tract. In genetically susceptible individuals, the interaction between environmental factors and normal intestinal commensal flora is believed to lead to an inappropriate immune response that results in chronic inflammation. The incidence of IBD have increased in the past century in developed and developing countries. The purpose of the present review is to summarize the current knowledge of the association between environmental risk factors and IBD. A number of environmental risk factors were investigated including smoking, hygiene, microorganisms, oral contraceptives, antibiotics, diet, breast-feeding, geographical factors, pollution and stress. Inconsistent findings among the studies highlight the complex pathogenesis of IBD. Additional studies are necessary to identify and elucidate the role of environmental factors in IBD etiology

Flow diagram of identified PBC patients in The Health Improvement Network between April 1974 and May 2007.

<p>Flow diagram of identified PBC patients in The Health Improvement Network between April 1974 and May 2007.</p