Natural Disease Course of Ulcerative Colitis During the First Five Years of Follow-up in a European Population-based Inception Cohort-An Epi-IBD Study

International audienceBackground and Aims: Few population-based cohort studies have assessed the disease course of ulcerative colitis [UC] in the era of biological therapy and widespread use of immunomodulators. The aim of this study was to assess the 5-year outcome and disease course of patients with UC in the Epi-IBD cohort. Methods: In a prospective, population-based inception cohort of unselected patients with UC, patients were followed up from the time of their diagnosis, which included the collection of their clinical data, demographics, disease activity, medical therapy, and rates of surgery, cancers, and deaths. Associations between outcomes and multiple covariates were analysed by Cox regression analysis. Results: A total of 717 patients were included in the study. During follow-up, 43 [6%] patients underwent a colectomy and 163 [23%] patients were hospitalised. Of patients with limited colitis [distal to the left flexure], 90 [21%] progressed to extensive colitis. In addition, 92 [27%] patients with extensive colitis experienced a regression in disease extent, which was associated with a reduced risk of hospitalisation (hazard ratio [HR]: 0.5 95% CI: 0.3-0.8]. Overall, patients were treated similarly in both geographical regions; 80 [11%] patients needed biological therapy and 210 [29%] patients received immunomodulators. Treatment with immunomodulators was found to reduce the risk of hospitalisation [HR: 0.5 95% CI: 0.3-0.8]. Conclusions: Although patients in this population-based cohort were treated more aggressively with immunomodulators and biological therapy than in cohorts from the previous two decades, their disease outcomes, including colectomy rates, were no different. However, treatment with immunomodulators was found to reduce the risk of hospitalisation

Simple scoring system to predict in-hospital mortality after surgery for infective endocarditis

BACKGROUND: Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis. METHODS AND RESULTS: Outcomes of 361 consecutive patients (mean age, 59.1\ub115.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty-six (15.5%) patients died postsurgery. BMI >27 kg/m2 (odds ratio [OR], 1.79; P=0.049), estimated glomerular filtration rate 55 mm Hg (OR, 1.78; P=0.032), and critical state (OR, 2.37; P=0.017) were independent predictors of in-hospital death. A scoring system was devised to predict in-hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734-0.822). The score performed better than 5 of 6 scoring systems for in-hospital death after cardiac surgery that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk postsurgery in patients with IE

Systematic review and network meta-analysis: first- and second-line biologic therapies for moderate-severe Crohn's disease

International audienceBackground: There are limited data to inform positioning of agents for treating moderate-severe Crohn's disease (CD). Aim: We assessed comparative efficacy and safety of first-line (biologic-naive) and second-line (prior exposure to anti-tumour necrosis factor [TNF]-alpha) agents) biologic therapy for moderate-severe CD, through a systematic review and network meta-analysis, and appraised quality of evidence (QoE) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Methods: We identified randomised controlled trials (RCTs) in adults with moderate-severe CD treated with approved anti-TNF agents, anti-integrin agents and anti-IL12/23 agents, first-line or second-line, and compared with placebo or another active agent. Efficacy outcomes were induction and maintenance of clinical remission; safety outcomes were serious adverse events and infections. Network meta-analyses were performed, and ranking was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results: No head-to-head trials were identified. In biologic-naive patients, infliximab (SUCRA, 0.93) and adalimumab (SUCRA, 0.75) were ranked highest for induction of clinical remission (moderate QoE). In patients with prior anti-TNF exposure, adalimumab (SUCRA, 0.91; low QoE, in patients with prior response or intolerance to anti-TNF agents) and ustekinumab (SUCRA, 0.71) were ranked highest for induction of clinical remission. In patients with response to induction therapy, adalimumab (SUCRA, 0.97) and infliximab (SUCRA, 0.68) were ranked highest for maintenance of remission. Ustekinumab had lowest risk of serious adverse events (SUCRA, 0.72) and infection (SUCRA, 0.71; along with infliximab, SUCRA, 0.83) in maintenance trials. Conclusion: Indirect comparisons suggest that infliximab or adalimumab may be preferred first-line agents, and ustekinumab a preferred second-line agent, for induction of remission in patients with moderate-severe CD. Head-to-head trials are warranted

Intérêt et technique de la transplantation fécale

Fecal transplantation (FT) is the infusion of fecal suspension from a healthy subject to the digestive tract of another individual. The objective of FT is to restore a suitable microbial ecology in diseases where the microbiota was unbalanced. The formal demonstration of the effectiveness of FT in the Clostridium difficile infection has encouraged its development for new indications such as metabolic or inflammatory diseases. However, the protocols and the effectiveness of FT reported in literature differ. Current data relate excellent safety, its indications should therefore increase. Guidelines are required to standardize the donor's selection and the effective preparation technique. (C) 2013 Published by Elsevier Masson SAS.La transplantation fécale (TF) désigne l’infusion d’une suspension fécale d’un sujet sain vers le tube digestif d’un autre individu. L’objectif de la TF est de restaurer une écologie microbienne adaptée au cours de maladies où le microbiote a été déséquilibré. La démonstration formelle de l’efficacité de la TF dans l’infection à Clostridium difficile a favorisé son développement dans de nouvelles indications comme les maladies métaboliques ou inflammatoires. Cependant, les protocoles et l’efficacité de la TF rapportés dans la littérature différent. Les données actuelles rapportent une tolérance excellente, ses indications devraient donc se multiplier, nécessitant d’établir des recommandations pour encadrer la sélection des donneurs et homogénéiser la technique de préparation

Systematic review: fertility in non-surgically treated inflammatory bowel disease

International audienceBackgroundInflammatory bowel diseases (IBD) typically affect young patients during the reproductive years, and reproductive issues are of key concern to them.AimTo evaluate the impact of IBD on fertility in both women and men with IBD who had no history of surgical treatment for IBD.MethodsWe searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated fertility in Crohn's disease (CD) and/or ulcerative colitis (UC) in women and/or men.ResultsEleven studies matching our criteria were included. In women with CD, there was a 17–44% reduction in fertility as compared with controls. Reduction in fertility was linked to voluntary childlessness, while there was no evidence of physiological causes of infertility. Most studies did not find any reduction in fertility in women with UC as compared with controls. In men with CD, there was an 18–50% reduction in fertility as compared with controls with no difference in reproductive capacity. There was no evidence of reduced fertility in men with UC.ConclusionsThe infertility observed in both women and men with CD is due to voluntary childlessness as opposed to involuntary infertility. This voluntary childlessness is often based on incorrect beliefs about the impact of the disease on fertility and pregnancy outcomes. Our results reinforce the need to increase awareness among male and female patients that IBD does not itself lead to reduced fertility

Gastrointestinal: Ano-popliteal fistula in Crohn's disease

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Long‐term effectiveness and acceptability of switching from intravenous to subcutaneous infliximab in patients with inflammatory bowel disease treated with intensified doses: The REMSWITCH‐LT study

International audienceSummary Background The long‐term risk of relapse after switching from intravenous (IV) to subcutaneous (SC) infliximab remains unknown in inflammatory bowel disease (IBD). Aims To assess the long‐term effectiveness and acceptability of switching from IV to SC infliximab in patients with IBD treated with or without an intensified IV regimen. Methods We extended the follow‐up of the REMSWITCH study including patients with IBD in clinical remission who were switched from IV to SC infliximab (120 mg/2 weeks). Relapse was defined as clinical relapse or faecal calprotectin increase ≥150 μg/g compared to baseline. Results After median follow‐up of 18 [15–20] months, among 128 patients, rates of relapse were 13.8% (8/58), 18.4% (7/38), 35.3% (6/17) and 86.7% (13/15) at last follow‐up ( p < 0.001), in those receiving 5 mg/kg/8 weeks, 10 mg/kg/8 weeks, 10 mg/kg/6 weeks and 10 mg/kg/4 weeks at baseline, respectively. Among relapsing patients, dose escalation led to clinical remission in 82.1% (23/28). In multivariable analyses, factors associated with higher risk of relapse were IV infliximab 10 mg/kg/4 weeks (OR = 61.0 [6.1–607.0], p < 0.001) or 10 mg/kg/6 weeks (OR = 4.7 [1.1–20.2], p = 0.017), and decreased (OR = 5.6 [1.5–20.3], p = 0.004) or stable (OR = 5.0 [1.6–15.0], p = 0.009) serum levels of infliximab between baseline and first post‐switch visit. Acceptability was improved at 6 months and did not decrease over time (6.9 ± 1.6 before the switch vs. 8.8 ± 1.3 at 6 months and 8.8 ± 1.3 at last follow‐up; p < 0.001). No severe adverse events were reported. Conclusions Switching from IV to SC infliximab 120 mg every other week is safe and well accepted leading to low long‐term risk of relapse. Tight monitoring and dose escalation should be recommended for patients receiving 10 mg/kg/6 weeks and 4 weeks, respectively