Diagnostic Delay of Inflammatory Bowel Disease Is Significantly Higher in Public versus Private Health Care System in Mexican Patients

<b><i>Introduction:</i></b> Inflammatory bowel disease (IBD) includes ulcerative colitis (UC) and Crohn’s disease (CD) characterized by a fluctuating course with periods of clinical activity and remission. No previous studies have demonstrated the frequency of delay at diagnosis and its associated factors in Mexico and Latin America. The aim of this study was to evaluate diagnostic delay of IBD in the last 4 decades in 2 different health care systems (public vs. private) and its associated factors. <b><i>Methods:</i></b> This is a cohort study that included 1,056 patients with a confirmed diagnosis of IBD from public and private health care systems. The diagnostic delay was defined as time &#x3e;1 year from the onset of symptoms to the confirmed diagnosis for patients with UC and 2 years for patients with CD. Statistical analysis was performed with the SPSS v.24 program. A value of <i>p</i> ≤ 0.05 was taken as significant. <b><i>Results:</i></b> The delay at diagnosis decreased significantly by 24.9% in the last 4 decades. The factors associated with the diagnostic delay were proctitis in UC, clinical course &#x3e;2 relapses per year and IBD surgeries for CD. We found a delay at diagnosis in 35.2% of IBD patients in the public versus 16.9% in the private health care system (<i>p</i> = 0.00001). <b><i>Conclusions:</i></b> We found a significant diagnosis delay of IBD in 35.2% from the public health care system versus 16.9% in the private health care system.

Implementing Collaborative Care Management of Behavioral Health for Patients with Inflammatory Bowel Disease

Background Individuals with inflammatory bowel disease (IBD) are up to twice as likely to suffer from anxiety and/or depression. Collaborative care management (CoCM) is an evidenced-based approach to treating behavioral health disorders that has proven effective for a range of conditions in primary care and some specialty settings. This model involves a team-based approach, with care delivered by a care manager (case reviews and behavioral therapy), psychiatrist (case reviews and psychopharmacological recommendations), and medical provider (ongoing care including psychopharmacological prescriptions). We assessed the feasibility and effectiveness of CoCM in reducing anxiety and depressive symptoms in patients with IBD. Methods Patients with psychological distress identified by clinical impression and/or the results of the Patient Health Questionaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were referred to the CoCM program. Data from our 9-month CoCM pilot were collected to assess depression and anxiety response and remission rates. We obtained provider surveys to assess provider acceptability with delivering care in this model. Results Though the coronavirus SARS-CoV2 (COVID-19) pandemic interrupted screening, 39 patients enrolled and 19 active participants completed the program. Overall, 47.4% had either a response or remission in depression, while 36.8% had response or remission in anxiety. The gastroenterologists highly agreed that the program was a beneficial resource for their patients and felt comfortable implementing the recommendations. Discussion CoCM is a potentially feasible and well accepted care delivery model for treatment of depression and anxiety in patients with IBD in a specialty gastroenterology clinic setting

Impact of Diagnostic Delay on Disease Course in Pediatric Versus Adult-onset Patients with Ulcerative Colitis: Data from the Swiss IBD Cohort

Introduction: Given the lack of data we aimed to assess the impact of the length of diagnostic delay on natural history of ulcerative colitis in pediatric (diagnosed <18 years) and adult patients (diagnosed ≥18 years). Methods: Data from the Swiss Inflammatory Bowel Disease cohort study were analyzed. Diagnostic delay was defined as interval between the first appearance of UC-related symptoms until diagnosis. Logistic regression modeling evaluated the appearance of the following complications in the long term according to the length of diagnostic delay: colonic dysplasia, colorectal cancer, UC-related hospitalization, colectomy, and extra-intestinal manifestations (EIM). Results: A total of 184 pediatric and 846 adult patients were included. Median diagnostic delay was 4 [IQR 2-7.5] months for the pediatric-onset group and 3 [IQR 2-10] months for the adult-onset group (P=0.873). In both, pediatric and adult-onset groups, length of diagnostic delay at UC diagnosis was not associated with colectomy, UC-related hospitalization, colon dysplasia, and colorectal cancer. EIM were significantly more prevalent at UC diagnosis in the adult-onset group with long diagnostic delay compared to the adult-onset group with short diagnostic delay (p = 0.022). In the long term, length of diagnostic delay was associated in the adult onset group with colorectal dysplasia (p=0.023), EIMs (p<0.001) and more specifically arthritis/arthralgias (p<0.001) and ankylosing spondylitis/sacroiliitis (p<0.001). In the pediatric-onset UC group, length of diagnostic delay in the long term was associated with arthritis/arthralgias (p=0.017); however, it was not predictive for colectomy and UC-related hospitalization. Conclusions: As colorectal cancer and EIMs are associated with considerable morbidity and costs, every effort should be made to reduce diagnostic delay in UC patients.

Stopping anti-TNF in CD remitters: pros and cons

Background: There is no cure for Crohn’s disease. Available treatments and treatment strategies, particularly anti-TNF, allow to heal intestinal lesions and maintain steroid-free remission in a subset of patients. Having in mind the remitting/relapsing nature of the disease, patients and health care providers often ask themselves whether the treatment could be withdrawn. Several studies have demonstrated a risk of relapse of CD after anti-TNF withdrawal, which varies from 20 to 50% at one year and from 50 to 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients. Summary: Nobody would argue for anti-TNF withdrawal in patients with a high risk of short term relapse. Nevertheless, they also indicate that a minority of patients may not relapse over mid-term and that those who have relapsed may have benefited from a drug-free period before being again treated for a new cycle of treatment. The most relevant question is thus whether in those patients with a low to medium risk of disease relapse, treatment withdrawal could be contemplated. In this specific setting, there may be pros and cons for anti-TNF withdrawal. Amongst the pros are the potential side effects and toxicity of anti-TNF, the risk of loss of response over time, the patient preference allowing the patient to regain control of one’s health and investing in it, also improving adherence, the absence of negative impact on disease evolution of a transient anti-TNF withdrawal and finally the cost. Key messages: Although anti-TNF withdrawal in patients with sustained clinical remission is associated with a high risk of relapse, this risk seems to be much lower in a subgroup of patients, particularly in endoscopic and biologic remission. Stopping anti-TNF in this subgroup of patients may be associated with a favorable benefit/risk ratio.

Living with Ulcerative Colitis in Japan: Biologic Persistence and Health-Care Resource Use

<b><i>Objective:</i></b> The aim of the study was to improve understanding of adherence and persistence to biologics, and their association with health-care resource utilization (HCRU), in Japanese patients with moderate to severe ulcerative colitis (UC). <b><i>Methods:</i></b> Data were from Medical Data Vision, a secondary care administrative database. A retrospective, longitudinal cohort analysis was conducted of data from UC patients initiating biologic therapy between August 2013 and July 2016. Data collected for 2 years prior (baseline) and 2 years after (follow-up) the index date were evaluated. Patients completing biologic induction were identified, and adherence/persistence to biologic therapy calculated. HCRU, steroid, and immunosuppressant use during baseline and follow-up were assessed. Biologic switching during the follow-up was evaluated. Descriptive statistics (e.g., means and proportions) were obtained and inferential analyses (from Student’s <i>t</i> tests, Fisher’s exact tests, χ² tests, the Cox proportional hazard model, and negative binomial regression) were performed. <b><i>Results:</i></b> The analysis included 649 patients (adalimumab: 265; infliximab: 384). Biologic induction was completed by 80% of patients. Adherence to adalimumab was higher than that to infliximab (<i>p</i> &#x3c; 0.001). Persistence at 6, 12, 18, and 24 months was higher with infliximab than with adalimumab (<i>p</i> &#x3c; 0.05). Overall, gastroenterology outpatient visits increased, and hospitalization frequency and duration decreased, from baseline to follow-up. UC-related hospitalizations were fewer and shorter, and endoscopies fewer, in persistent than in nonpersistent patients, although persistent patients made more outpatient visits than nonpersistent patients. Hospitalization duration was lower in persistent than nonpersistent patients. Approximately 50% of patients received an immunosuppressant during biologic therapy; 5% received a concomitant steroid during biologic therapy. Overall, 17% and 3% of patients, respectively, received 2nd line and 3rd line biologics. <b><i>Conclusions:</i></b> Poor biologic persistence was associated with increased non-medication-associated HCRU. Effective treatments with high persistence levels and limited associated HCRU are needed in UC.

DEDICATED PSYCHIATRY CLINIC FOR INFLAMMATORY BOWEL DISEASE PATIENTS HAS A POSITIVE IMPACT ON DEPRESSION SCORES

BACKGROUND: Psychiatric disorders, including anxiety and depression, are significantly more common in patients with inflammatory bowel disease. We established an integrated psychiatry clinic for IBD patients at our tertiary center IBD clinic to provide patients with critical, but frequently unavailable, coordinated mental health services. We undertook this study to evaluate the impact of this service on psychiatric outcomes, quality of life, and symptom experience. METHODS: We performed a longitudinal prospective study comparing patients who had been cared for at our integrated IBD-psychiatry clinic to those who had not. We abstracted demographic and clinical information as well as contemporaneous responses to validated surveys. RESULTS: Thirty-six patients cared for in the IBD-psychiatry clinic were compared to a control cohort of thirty-five IBD patients. There was a significant reduction in the HADS depression score over time in the study cohort (p=0.001), though not in the HADS anxiety score. When compared to the control group, the study cohort showed a significant reduction in the HADS depression score. No significant differences were observed in the HBI, SCCAI or SIBDQ. CONCLUSIONS: This is the first study to evaluate the impact of an integrated psychiatry clinic for IBD patients. Unlike their control counterparts, individuals treated in this clinic had a significant reduction in mean HADS depression score. Larger scale studies are necessary to verify these findings. However, this study suggests that use of an integrated psychiatry-IBD clinic model can result in improvement in mental health outcomes, even in the absence of significant changes in IBD activity.

Behcet’s Disease: An In-depth Review About Pathogenesis, Gastrointestinal Manifestations And Management

Background: Behcet’s Disease (BD) is a complex inflammatory vascular disorder that follows a relapsing-remitting course with diverse clinical manifestations. The prevalence of the disease varies throughout the globe and targets different age groups. There are many variations of BD, however, intestinal BD is not only more common but has many signs and symptoms. Summary: BD is a relapsing-remitting inflammatory vascular disorder with multiple system involvement, affecting vessels of all types and sizes that targets young adults. The etiology of BD is unknown but many factors including genetic mechanisms, vascular changes, hypercoagulability and dysregulation of immune function are believed to be responsible. BD usually presents with signs and symptoms of ulcerative disease of the small intestine; endoscopy being consistent with the clinical manifestations. The mainstay of treatment depends upon the severity of the disease. Corticosteroids are recommended for severe forms of the disease and aminosalicylic acids are used in maintaining remission in mild to moderate forms of the disease. Key messages: In this review, we have tried to summarize in the present review the clinical manifestations, differential diagnoses and management of intestinal BD. Hopefully, this review will enable health policymakers to ponder over establishing clear endpoints for treatment, surveillance investigations and creating robust algorithms.

Mucosal Healing in Crohn’s Disease: Bull’s Eye or Bust? “The Pro Position”

<b><i>Background:</i></b> Crohn’s disease (CD) is a chronic inflammatory disorder affecting the gastrointestinal tract with disease behaviour based on the depth and severity of mucosal injury. Cumulative injury can result in complications including stricture formation and penetrating complications which often require surgical resection of diseased segments of the intestine resulting in significant morbidity. Accurate assessment of disease activity and appropriate treatment is essential in preventing complications. <b><i>Summary:</i></b> Treatment targets in the management of CD have evolved with the advent of more potent immunosuppressive therapy. Targeting the resolution of sub-clinical inflammation and achieving mucosal healing is associated with the prevention of stricturing and penetrating complications. Identifying non-invasive modalities to assess mucosal healing remains a challenge. <b><i>Key Messages:</i></b> Mucosal healing minimizes the risk of developing disease complications, prolongs steroid-free survival, and reduces hospitalization and the need for surgical intervention.

Mucosal Healing in Crohn’s Disease: Bull’s Eye or Bust? The “Relative” Con Position

<b><i>Background:</i></b> Crohn’s disease is a progressive inflammatory bowel disease. Persistent untreated inflammation can cumulatively result in bowel damage in the form of strictures, fistulas, and fibrosis, which can ultimately result in the need for major abdominal surgery. Mucosal healing has emerged as an attractive, yet ambitious goal in the hope of preventing long-term complications. <b><i>Summary:</i></b> Clinical remission is an inadequate measure of disease activity. Noninvasive markers such as fecal calprotectin, CRP, or small bowel ultrasound are useful adjunct tools. However, endoscopic assessment remains the cornerstone in building a treatment plan. Achieving complete mucosal healing has proved to be an elusive goal even in the ideal setting of a clinical trial. <b><i>Key Messages:</i></b> Aiming for complete mucosal healing in all patients may result in overuse of medications, higher costs, and potential side effects of aggressive immunosuppressive treatment. More practical goals such as relative or partial healing, for example, 50% improvement in inflammation and reduction in size of ulcers, ought to be considered, particularly in difficult-to-treat populations.