Publications by authors named "Talat Bessissow"

76 Publications

Novel Negative Pressure Protective Box in Upper Digestive Endoscopy: A Prospective Case Series.

Am J Gastroenterol 2021 Mar 10. Epub 2021 Mar 10.

Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.

In the context of the Severe Acute Respiratory Syndrome Coronavirus 2 pandemic, we have developed a novel negative pressure aerosol protector for upper endoscopy (TRACEY). TRACEY is the first endoscopic enclosure to have passed stringent testing for aerosol protection. The following describes its clinical use in a single-center prospective case series. Overall, 15 patients were included. All endoscopic procedures were successful without premature removal of TRACEY. In addition, its use did not lead to significant patient discomfort, technical hinderance, or adverse events. TRACEY seems to offer a safe and easy to use aerosol protection for upper endoscopy and a potential Severe Acute Respiratory Syndrome Coronavirus 2 mitigation strategy in endoscopy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/ajg.0000000000001221DOI Listing
March 2021

Differences in HIV burden in the inflamed and non-inflamed colon from a person living with HIV and ulcerative colitis.

J Virus Erad 2021 Mar 15;7(1):100033. Epub 2021 Feb 15.

Infectious Diseases and Immunity in Global Health Program, Research Institute, McGill University Health Centre, Montréal, QC, Canada.

The greatest obstacle to an HIV cure is the persistence of latently infected cellular reservoirs in people living with HIV (PLWH) taking antiretroviral therapy (ART). However, no consensus exists on the direct link between local tissue inflammation and the HIV burden. Herein, we have compared the levels of local inflammation, epithelial integrity and HIV DNA between inflamed and non-inflamed colon tissue in a PLWH who underwent a colectomy due to ulcerative colitis. We have observed a 27-fold higher frequency of cells harboring HIV DNA in inflamed compared to non-inflamed colon tissue. Analysis of the expression of occludin-1 and claudin-3 confirmed our macroscopic characterization of inflamed and non-inflamed colon. Our results confirm that increased gut permeability and inflammation are associated with a higher frequency of infected cells and suggest that restoring gut barrier integrity may be used as a strategy to reduce inflammation and HIV persistence in the gut.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jve.2021.100033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906891PMC
March 2021

TEMPORARY REMOVAL: Canadian Association of Gastroenterology CLINICAL Practice Guideline For Immunizations in Patients with Inflammatory Bowel Disease (IBD). Part 2: Inactivated Vaccines.

Gastroenterology 2021 Feb 19. Epub 2021 Feb 19.

Department of Medicine & Community Health and Epidemiology, Dalhousie University, QE II Health Sciences Center, Halifax, NS.

The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.gastro.2020.12.079DOI Listing
February 2021

Use of various immunotherapies for refractory ulcerative colitis in a person living with HIV: a case report.

Oxf Med Case Reports 2021 Jan 23;2021(1):omaa131. Epub 2021 Jan 23.

Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada.

Cancer therapies include several immune checkpoint or anticytokine therapies whereas ulcerative colitis treatments consist of anticytokine therapies. The development of tolerance and immunogical effects of these agents in people living with HIV are not well assessed as these persons are often excluded from clinical trials. Herein, we report a case of a Caucasian woman who received multiple sequential immunotherapies for severe ulcerative colitis. Due to steroid-refractory disease, receipt of maximal doses of mesalamine and initial repeated decline of surgical intervention, she went on to receive biologic immune inhibitors like tumor necrosis fator-α blockers infliximab and adalimumab, the αβintegrin blocker vedolizumab, anti-interleukin 12/23 blocker ustekinumab and Janus Kinase inihibitor tofacitinib without achieving remission. Only minor infectious complications were encountered and no significant changes in CD4 count nor CD4/CD8 ratio occurred. This case provides support for the safety and tolerability of the above immunotherapies in people living with HIV with suppressed viral load on antiretroviral therapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/omcr/omaa131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846135PMC
January 2021

The Burden of Anemia Remains Significant over Time in Patients with Inflammatory Bowel Diseases at a Tertiary Referral Center.

J Gastrointestin Liver Dis 2020 Dec 12;29(4):555-559. Epub 2020 Dec 12.

McGill University, Division of Gastroenterology Department of Medicine, Montreal, Canada; Semmelweis University, 1st Department of Medicine, Budapest, Hungary.

Background And Aims: Anemia is a common complication of inflammatory bowel diseases (IBD), as well as a predictor of poor outcomes. The aim of this study was to determine the prevalence of anemia over time and the management of moderate to severe anemia at a tertiary referral IBD center.

Methods: We retrospectively reviewed the occurrence of anemia at the time of referral or diagnosis and during follow-up at the McGill University Health Centre IBD center. Consecutive patients presenting with an outpatient visit between July and December 2016 and between December 2018 and March 2019 were included. Disease characteristics, biochemistry and medical management, including the need for intravenous iron therapy were recorded.

Results: 1,356 Crohn's disease (CD) and 1,293 ulcerative colitis (UC) patients [disease duration: 12 (IQR: 6-22) and 10 (IQR: 5-19) years respectively] were included. The prevalence of moderate to severe anemia at referral/diagnosis (15.4% and 8.5%) and during follow-up (11.1% and 8.1%) were higher in CD than in UC patients. In CD, previous resective surgery, perianal disease and elevated C-reactive protein (CRP) at assessment, while in UC steroid therapy, an elevated CRP and fecal calprotectin at assessment were associated with anemia in a multivariate analysis. Anemia improved by >2g/dL in 56.5% after 4-6 weeks (intravenous iron dose >1000 mg in 87% of patients).

Conclusion: Anemia occurred frequently in this IBD cohort, at referral to the center and during follow-up, and contributes to the burden of IBD in referral populations. Most patients were assessed for anemia regularly and with accurate anemia workup; however, the targeted management of moderate to severe anemia was suboptimal.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15403/jgld-2705DOI Listing
December 2020

Adenocarcinoma Within Carpet-Like Pseudopolyposis.

ACG Case Rep J 2020 Jun 23;7(6):e00415. Epub 2020 Jun 23.

Division of Gastroenterology, McGill University, Montreal, Quebec, Canada.

Pseudopolyps are benign lesions without malignant potential and typically do not require biopsy or excision. We describe a 68-year-old man with ulcerative colitis found to have multiple large bridging pseudopolyps. Repeated colonoscopies and extensive biopsies revealed a large ulcerated lesion previously hidden within the pseudopolyps. The pathology of the lesion was consistent with a low-grade adenocarcinoma with invasion into the muscularis propria. This demonstrates that large pseudopolyps, although benign, can obscure other lesions with malignant potential. Therefore, in addition to careful inspection, healthcare providers must perform periodic surveillance colonoscopies and offer surgical resection to patients with giant pseudopolyposis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/crj.0000000000000415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7535685PMC
June 2020

Do You See What I See? An Assessment of Endoscopic Lesions Recognition and Description by Gastroenterology Trainees and Staff Physicians.

J Can Assoc Gastroenterol 2020 Oct 19;3(5):216-221. Epub 2019 Jun 19.

Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada.

Background: Gastroenterologists should accurately describe endoscopic findings and integrate them into management plans. We aimed to determine if trainees and staff are describing inflammatory bowel disease (IBD) lesions in a similar manner.

Methods: Using 20 ileocolonoscopy images, participants described IBD inflammatory burden based on physician severity rating, and Mayo endoscopic score (MES) (ulcerative colitis [UC]) or simple endoscopic score (SES-CD) (Crohn's disease [CD]). Images were selected based on agreement by three IBD experts. Findings of varying severity were presented; 10 images included a question about management. We examined inter-observer agreement among trainees and staff, compared trainees to staff, and determined accuracy of response comparing both groups to IBD experts.

Results: One hundred and twenty-nine staff and 47 trainees participated from across Canada. There was moderate inter-rater agreement using physician severity rating (κ = 0.53 UC and 0.52 CD for staff, κ = 0.51 UC and 0.43 CD for trainees). There was moderate inter-rater agreement for MES for staff and trainees (κ = 0.49 and 0.48, respectively), but fair agreement for SES-CD (κ = 0.37 and 0.32, respectively). For accuracy of response, the mean score was 68.7% for staff and 63.7% for trainees ( = 0.028). Both groups identified healed bowel or severe disease better than mild/moderate ( < 0.05). There was high accuracy for management, but staff scored higher than trainees for UC ( < 0.01).

Conclusion: Inter-rater agreement on description of IBD lesions was moderate at best. Staff and trainees more accurately describe healed and severe disease, and better describe lesions in UC than CD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jcag/gwz022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465549PMC
October 2020

No Change in Surgical and Hospitalization Trends Despite Higher Exposure to Anti-Tumor Necrosis Factor in Inflammatory Bowel Disease in the Québec Provincial Database From 1996 to 2015.

Inflamm Bowel Dis 2021 Apr;27(5):655-661

Division of Gastroenterology, McGill University Health Centre, Montreal, Québec, Canada.

Background: Crohn disease (CD) and ulcerative colitis (UC) have high health care expenditures because of medications, hospitalizations, and surgeries. We evaluated disease outcomes and treatment algorithms of patients with inflammatory bowel disease (IBD) in Québec, comparing periods before and after 2010.

Methods: The province of Québec's public health administrative database was used to identify newly diagnosed patients with IBD between 1996 and 2015. The primary and secondary outcomes included time to and probability of first and second IBD-related hospitalizations, first and second major surgery, and medication exposures. Medication prescriptions were collected from the public prescription database.

Results: We identified 34,644 newly diagnosed patients with IBD (CD = 59.5%). The probability of the first major surgery increased after 2010 in patients with CD (5 years postdiagnosis before and after 2010: 8% [SD = 0.2%] vs 15% [SD = 0.6%]; P < 0.0001) and patients with UC (6% [SD = 0.2%] vs 10% [SD = 0.6%] ;P < 0.0001). The probability of the second major surgery was unchanged in patients with CD. Hospitalization rates remained unchanged. Patients on anti-tumor necrosis factor (anti-TNF) medications had the lowest probability of hospitalizations (overall 5-year probability in patients with IBD stratified by maximal therapeutic step: 5-aminosalicylic acids 37% [SD = 0.6%]; anti-TNFs 31% [SD = 1.8%]; P < 0.0001). Anti-TNFs were more commonly prescribed for patients with CD after 2010 (4% [SD = 0.2%] vs 16% [SD = 0.6%]; P < 0.0001) in the public health insurance plan, especially younger patients. Corticosteroid exposure was unchanged before and after 2010. Immunosuppressant use was low but increased after 2010. The use of 5-ASAs was stable in patients with UC but decreased in patients with CD.

Conclusions: The probability of first and second hospitalizations remained unchanged in Québec and the probability of major surgery was low overall but did increase despite the higher and earlier use of anti-TNFs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ibd/izaa166DOI Listing
April 2021

Poor Drug Sustainability in Inflammatory Bowel Disease Patients in Clinical Remission on Thiopurine Monotherapy.

Dig Dis Sci 2021 May 26;66(5):1650-1657. Epub 2020 Jun 26.

Division of Gastroenterology, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, C7-200, Montreal, QC, H3G 1A4, Canada.

Background: Immunomodulator monotherapy is an important component in the treatment of inflammatory bowel disease (IBD). However, there is conflicting literature about thiopurines maintaining long-term remission in patients with active IBD.

Aim: To determine the durable clinical remission rate in adults with Crohn's disease (CD) or ulcerative colitis (UC) on thiopurine monotherapy over 5 years.

Methods: We performed a retrospective analysis of adult patients identified at McGill University Health Centre from 2009 to 2012. We included IBD patients who initiated thiopurine monotherapy and were in remission for at least 3 months (Harvey-Bradshaw Index (HBI) < 5 points for CD and partial Mayo Score (pMS) < 2 points in UC). The primary endpoint was sustained clinical remission on thiopurines during a 5-year follow-up. This included patients who had not relapsed or discontinued the drug due to side effects. The secondary endpoint was clinical relapse over the follow-up period, which was defined as HBI > 5 in CD and pMS > 2 in UC.

Results: There were 148 patients included in the study (100 CD; 48 UC). At 5 years, 23% (34/148) patients remained in clinical remission on thiopurine monotherapy (25 CD and 9 UC patients). Thirty-three percent (33/100) of CD and 46% (22/48) of UC patients relapsed while on thiopurines. There was no difference in relapse rates between CD and UC patients. Eighty-four percent (42/50) of patients with CD with side effects and all UC (17/17) patients who experienced side effects discontinued the drug.

Conclusion: This analysis demonstrates that there is poor sustainability of clinical remission in IBD patients on thiopurine monotherapy given that a high proportion of patients discontinue thiopurines due to either relapse or side effects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-020-06427-8DOI Listing
May 2021

Esophageal Squamous Cell Carcinoma With Colonic Metastases.

ACG Case Rep J 2020 Feb 24;7(2):e00335. Epub 2020 Feb 24.

Division of Gastroenterology, McGill University, Montreal, Quebec, Canada.

Esophageal squamous cell carcinoma (ESCC) is recognized as one of the most lethal malignancies worldwide. The disease's tendency to quickly metastasize precludes many patients from receiving curative therapy. The most common sites of distal metastases include the liver, lungs, bones, and brain. We report a case of ESCC metastasizing to the rectosigmoid region years after treatment with neoadjuvant chemoradiation and esophagectomy. To our knowledge, only a handful of cases of ESCC with colonic metastases have been previously documented.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14309/crj.0000000000000335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145180PMC
February 2020

Concordance between tuberculin skin test and interferon-gamma release assay for latent tuberculosis screening in inflammatory bowel disease.

Intest Res 2020 Jul 20;18(3):306-314. Epub 2020 Mar 20.

Department of Gastroenterology, McGill University, Montreal, QC, Canada.

Background/aims: Latent tuberculosis screening is mandatory prior to initiating anti-tumor necrosis factor (anti-TNF) medications. Guidelines recommend interferon-gamma release assays (IGRA) as first line screening method for the general population. Studies provided conflicting evidence on IGRA and tuberculin skin test (TST) performance in inflammatory bowel disease (IBD) patients. We assessed test concordance and the effects of immunosuppression on their performance in IBD patients.

Methods: We searched MEDLINE, Embase and Cochrane databases (2011-2018) for studies testing TST and IGRA in IBD. Primary outcome was TST and IGRA concordance. Secondary outcomes were effects of immunosuppressive therapy on performance. Immunosuppression defined as either steroids, thiopurine, methotrexate or cyclosporine use. We used the pooled random effects model to adjust for heterogeneity analyzed using (I2-Q statistics). We compared the fixed model to exclude smaller study effects.

Results: Sixteen studies (2,488 patients) were included. Pooled TST and IGRA concordance was 85% (95% confidence interval [CI], 81%-88%; P=0.01). Effects of immunosuppression were reported in 8 studies (814 patients). The odds ratio of testing positive by IGRA decreased to 0.57 if immunosuppressed (95% CI, 0.31-1.03; P=0.06). The odds ratio of testing positive by TST if immunosuppressed was 1.14 (95% CI, 0.61-2.12; P=0.69). The fixed model yielded similar results, however the negative effect of immunosuppression on IGRA reached statistical significance (P=0.01).

Conclusions: While concordance was 85% between TST and IGRA, the performance of IGRA seems to be negatively affected by immunosuppression. Given the importance of detecting latent tuberculosis prior to anti-TNF initiation, further randomized controlled trials comparing the performance of TST and IGRA in IBD patients are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5217/ir.2019.00116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385575PMC
July 2020

Endoscopic surveillance strategies for dysplasia in ulcerative colitis.

Frontline Gastroenterol 2020 Mar 12;11(2):124-132. Epub 2019 Apr 12.

Gastroenterology, McGill University Health Centre, Montreal, Québec, Canada.

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder with an increased risk of colorectal cancer (CRC). This has led to the implementation of surveillance programmes to minimise this risk. Overall, these proactive programmes in association with better medical therapies have reduced the incidence of CRC in this population. Specific populations remain at increased risk, such as younger age at diagnosis, primary sclerosing cholangitis, colonic strictures and pseudopolyps. The majority of gastrointestinal international societies favour chromoendoscopy with targeted biopsies or random biopsies. The aim of this review is to present the current literature on dysplasia surveillance, the methodology and endoscopic technology available to assess dysplasia in UC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/flgastro-2018-101056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043085PMC
March 2020

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center: Access, resource utilization and outcomes.

World J Gastroenterol 2020 Feb;26(7):759-769

First Department of Medicine, Semmelweis University, Budapest H-1083, Hungary.

Background: Emergency situations in inflammatory bowel diseases (IBD) put significant burden on both the patient and the healthcare system.

Aim: To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service (RAC) at a tertiary IBD center.

Methods: Patient access, resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study. For comparing resource utilization and healthcare costs, emergency department (ED) visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019. Time to appointment, diagnostic methods, change in medical therapy, unplanned ED visits, hospitalizations and surgical admissions were calculated and compared.

Results: 488 patients (Crohn's disease: 68.4%/ulcerative colitis: 31.6%) contacted the RAC with a valid medical reason. Median time to visit with an IBD specialist following the index contact was 2 d. Patients had objective clinical and laboratory assessment (C-reactive protein and fecal calprotectin in 91% and 73%). Fast-track colonoscopy/sigmoidoscopy was performed in 24.6% of the patients, while computed tomography/magnetic resonance imaging in only 8.1%. Medical therapy was changed in 54.4%. ED visits within 30 d following the RAC visit occurred in 8.8% (unplanned ED visit rate: 5.9%). Diagnostic procedures and resource utilization at the ED ( = 135 patients) were substantially different compared to RAC users: Abdominal computed tomography was more frequent (65.7%, < 0.001), coupled with multiple specialist consults, more frequent hospital admission ( < 0.001), higher steroid initiation ( < 0.001). Average medical cost estimates of diagnostic procedures and services per patient was $403 CAD $1885 CAD comparing all RAC and ED visits.

Conclusion: Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care, optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3748/wjg.v26.i7.759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039829PMC
February 2020

Management of Acute Severe Colitis in the Era of Biologicals and Small Molecules.

J Clin Med 2019 Dec 8;8(12). Epub 2019 Dec 8.

Division of Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada.

Acute severe ulcerative colitis (ASUC) is a medical emergency which occurs in about 20%-30% of patients with ulcerative colitis during their lifetime, and does carry a mortality risk of 1%. The management of inflammatory bowel diseases has evolved with changes in objective patient monitoring, as well as the availability of new treatment options with the development of new biological and small molecules; however, data is limited regarding their use in the context of ASUC. This review aims to discuss the emerging data regarding biologicals and small molecules therapies in the context of ASUC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm8122169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947608PMC
December 2019

Low Rate of Drug Discontinuation, Frequent Need for Dose Adjustment, and No Association with Development of New Arthralgia in Patients Treated with Vedolizumab: Results from a Tertiary Referral IBD Center.

Dig Dis Sci 2020 07 7;65(7):2046-2053. Epub 2019 Dec 7.

Division of Gastroenterology, McGill University Health Centre (MUHC), Montreal General Hospital, 1650 Ave. Cedar, D16.173.1, Montreal, QC, H3G 1A4, Canada.

Background: Evaluating clinical data on the safety and efficacy of vedolizumab (VDZ) in 'real-world' setting is still desirable. Recent reports have raised concerns that arthralgia may be associated with VDZ.

Aims: The aim of this study is to present clinical experience with VDZ from a tertiary IBD center.

Methods: Retrospective chart reviews were performed of consecutive patients exposed to VDZ between 2015 and 2018. Clinical, biomarker, and endoscopic efficacy and safety data were evaluated.

Results: A total of 130 IBD (75CD, 55UC) patients were included. Median duration of VDZ therapy was 65 weeks. Probability of drug discontinuation was 4.9% and 9.4% at 1 and 2 years. Dose intensification was more frequent in CD compared to UC (at 1 and 2 years: 64.8/87.9% vs. 26.5/35.7%, p < 0.001). Clinical remission rates at 3-, 6- and 12 months were 44.4%, 71.4% and 77.1% in UC, and 9.1%, 26.7% and 29.2% in CD patients, respectively. Prior use of multiple biologic agents was associated with diminished efficacy of VDZ in CD. Three new cases of arthralgia were encountered during follow-up.

Conclusion: Vedolizumab (VDZ) therapy displayed good drug sustainability and clinical efficacy in a population with severe disease phenotype and high rates of previous anti-TNF failure. Frequent dose intensification was required. The safety profile was good, and no association between newly onset arthralgia and VDZ therapy was observed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-019-05982-zDOI Listing
July 2020

Disease monitoring strategies in inflammatory bowel diseases: What do we mean by "tight control"?

World J Gastroenterol 2019 Nov;25(41):6172-6189

First Department of Medicine, Semmelweis University, Budapest H-1083, Hungary.

In recent years, there has been a critical change in treatment paradigms in inflammatory bowel diseases (IBD) triggered by the arrival of new effective treatments aiming to prevent disease progression, bowel damage and disability. The insufficiency of symptomatic disease control and the well-known discordance between symptoms and objective measures of disease activity lead to the need of reviewing conventional treatment algorithms and developing new concepts of optimal therapeutic strategy. The treat-to-target strategies, defined by the selecting therapeutic targets in inflammatory bowel disease consensus recommendation, move away from only symptomatic disease control and support targeting composite therapeutic endpoints (clinical and endoscopical remission) and timely assessment. Emerging data suggest that early therapy using a treat-to-target approach and an algorithmic therapy escalation using regular disease monitoring by clinical and biochemical markers (fecal calprotectin and C-reactive protein) leads to improved outcomes. This review aims to present the emerging strategies and supporting evidence in the current therapeutic paradigm of IBD including the concepts of "early intervention", "treat-to-target" and "tight control" strategies. We also discuss the real-word experience and applicability of these new strategies and give an overview on the future perspectives and areas in need of further research and potential improvement regarding treatment targets and ("tight") disease monitoring strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3748/wjg.v25.i41.6172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848014PMC
November 2019

Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape.

World J Gastroenterol 2019 Aug;25(30):4158-4171

Department of Adult Gastroenterology, McGill University Health Centre, Montreal, QC H3G 1A4, Canada.

High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3748/wjg.v25.i30.4158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6700701PMC
August 2019

Ver(s)ifying the Efficacy of Vedolizumab Therapy on Mucosal Healing in Patients With Crohn's Disease.

Gastroenterology 2019 10 26;157(4):925-927. Epub 2019 Jul 26.

First Department of Medicine, Semmelweis University, Budapest, Hungary and Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.gastro.2019.07.032DOI Listing
October 2019

Endoscopic scoring systems for the evaluation and monitoring of disease activity in Crohn's disease.

Best Pract Res Clin Gastroenterol 2019 Feb - Apr;38-39:101616. Epub 2019 May 28.

Division of Gastroenterology, Department of Medicine, McGill University Health Center (MUHC), Montreal General Hospital, 1650 Cedar Ave, C7-200, Montreal, QC, H3G 1A4, Canada. Electronic address:

Crohn's disease is a chronic relapsing idiopathic condition that can affect any part of the gastrointestinal tract. It has been shown that mucosal healing is associated with improved clinical outcomes such as reduced risk of surgery, hospitalization and complications. Nowadays mucosal healing is considered the optimal target of medical therapy. To evaluate the mucosa in an objective and standardized manner, it is important to rely on accurate and validated endoscopic scores. The Crohn's disease endoscopic index of severity, the simple endoscopic score for Crohn's disease as well as the Rutgeerts score will be reviewed. Their clinical implications and limitations will be discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bpg.2019.05.003DOI Listing
November 2019

Faecal Calprotectin Predicts Endoscopic and Histological Activity in Clinically Quiescent Ulcerative Colitis.

J Crohns Colitis 2020 Jan;14(1):46-52

Division of Gastroenterology, Department of Medicine, McGill University, Montreal, QC, Canada.

Introduction: Faecal calprotectin [FC] is a reliable surrogate marker for disease activity in ulcerative colitis [UC]; however, there are no consensus cut-off values for remission. The study aim was to correlate FC with Mayo Endoscopic Score [MES] and histological disease activity of UC patients in clinical remission.

Methods: Our study recruited adult UC patients at the McGill IBD Center between 2013 and 2017. Patients in clinical remission [partial Mayo score ≤2], undergoing endoscopy for disease activity or dysplasia surveillance, were enrolled. Before bowel preparation, FC was collected. MES was documented during colonoscopy. Biopsies were taken; histological activity was assessed using Geboes score and the presence of basal plasmacytosis.

Results: A total of 185 patients were recruited. The area under the curve [AUC] in receiver operating characteristic [ROC] analysis to predict MES 1-3 [from 0] was 0.743 [95% CI 0.67-0.82; p <0.001] with an FC cut-off value 170 µg/g [64% sensitivity, 74% specificity], and to predict MES 2-3 [from 0-1] was 0.722 [95% CI 0.61-0.83; p <0.001] with an FC cut-off value 170 µg/g [69% sensitivity, 65% specificity]. To differentiate MES 0 from MES 1, an FC value 130 µg/g yields a 70% sensitivity and 68% specificity. The AUC in ROC analysis to predict Geboes <3.1 was 0.627 [95% CI 0.55-0.71; p = 0.003], with an FC value 135 µg/g [54% sensitivity, 69% specificity].

Conclusions: In this large study, FC ≥170 µg/g predicts endoscopic activity and FC ≥135 µg/g predicts histological activity. Therefore in clinical practice, lower faecal calprotectin thresholds can be chosen to optimise identification of patients with ongoing endoscopic and histological disease activity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ecco-jcc/jjz107DOI Listing
January 2020

Comparison of the Boston Bowel Preparation Scale with an Auditable Application of the US Multi-Society Task Force Guidelines.

J Can Assoc Gastroenterol 2019 May 29;2(2):57-62. Epub 2018 Jun 29.

Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montréal, Québec, Canada.

Background: Existing bowel preparation scales (BPS) only modestly predict interval to next colonoscopy. The US Multi-Society Task Force (MSTF) recommends repeating colonoscopies within the year if the preparation does not allow detection of polyps over 5 mm.

Aim: This study aims to assess reliability and validity of an auditable application of the MSTF compared with the Boston BPS (BBPS).

Methods: We compared an auditable application of MSTF guidelines termed the Montreal BPS (MBPS) with the BBPS using a total cut-off score ≥6 with each segment score ≥2 (BBPS2-6). In sensitivity analyses, we applied the MBPS using a cut-off of 3 mm rather than 5 mm and also assessed the BBPS using an adequacy threshold of total score ≥5 (BBPS5). Videos of 83 colonoscopies (eight for intra-rater agreements) were independently evaluated by nine physicians. Weighted kappas quantified intra- and inter-rater agreements. Associations between scores and clinical outcomes were assessed.

Results: The BBPS2-6 and 5 mm MBPS showed moderate to substantial intra-rater agreements (κ=0.44 to 0.63 and κ=0.50 to 0.53, respectively); inter-rater agreements were only fair to moderate and slight to moderate (κ=0.25 to 0.48 and κ=0.19 to 0.50, respectively). Similar results were noted using alternate thresholds of BBPS5 and 3 mm MBPS. No significant associations were found between scores and clinical outcomes.

Conclusion: For all scales, intra-rater kappas were superior to inter-rater values, the latter reflecting at best moderate agreement. This modest performance may reflect the dichotomized interpretation of the scales (adequate versus inadequate), differing from previous publications assessing scores as continuous variables. Further studies are required to optimally interpret bowel preparation scales with regard to interval to next colonoscopy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jcag/gwy027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507282PMC
May 2019

Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon?

Gastrointest Endosc Clin N Am 2019 Jul 10;29(3):549-562. Epub 2019 Apr 10.

Division of Gastroenterology, McGill University Health Centre, Montreal General Hospital, 1650 Ave. Cedar, D16.173.1, Montreal, QC, H3G 1A4, Canada. Electronic address:

Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.giec.2019.02.009DOI Listing
July 2019

High Adherence to Surveillance Guidelines in Inflammatory Bowel Disease Patients Results in Low Colorectal Cancer and Dysplasia Rates, While Rates of Dysplasia are Low Before the Suggested Onset of Surveillance.

J Crohns Colitis 2019 Sep;13(10):1343-1350

Division of Gastroenterology, Department of Medicine, McGill University, Montreal QC, Canada.

Background: Patients with Crohn's disease [CD] and ulcerative colitis [UC] are at increased risk for colorectal dysplasia [CRD] and colorectal cancer [CRC]. Adherence to CRC surveillance guidelines is reportedly low internationally.

Aim: To evaluate surveillance practices at the tertiary IBD Center of the McGill University Health Center [MUHC] and to determine CRD/CRC incidence.

Methods: A representative inflammatory bowel disease cohort with at least 8 years of disease duration [or with primary sclerosing cholangitis] who visited the MUHC between July 1 and December 31, 2016 were included. Adherence to surveillance guidelines was compared to modified 2010 British Society of Gastroenterology guidelines. Incidence rates of CRC, high-grade dysplasia [HGD], low-grade dysplasia [LGD] and colorectal adenomas [CRA] were calculated based on pathology.

Results: In total, 1356 CD and UC patients (disease duration: 12 [interquartile range: 6-22) and 10 [interquartile range: 5-19] years) were identified. The surveillance cohort consisted of 680 patients [296 UC and 384 CD]. Adherence to surveillance guidelines was 76/82% in UC/colonic CD. An adequate number of biopsies were taken in 54/54% of UC/colonic CD patients. The incidence of CRC/HGD in UC and CD with colonic involvement was 19.5/58.5 and 25.1/37.6 per 100,000 patient-years, respectively. The incidence of dysplasia before 8 years of disease duration was low in both UC/CD [19.5 and 12.5/100,000 patient-years] with no CRC detected. The CRA rate was 30/38% in UC/colonic CD.

Conclusion: High adherence to surveillance guidelines and low CRC and dysplasia, but not CRA rates were found, suggesting that adhering to updated, stratified, surveillance recommendations may result in low advanced neoplasia rates. The incidence of dysplasia before the start of surveillance was low.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ecco-jcc/jjz066DOI Listing
September 2019

Maladaptive coping, low self-efficacy and disease activity are associated with poorer patient-reported outcomes in inflammatory bowel disease.

Saudi J Gastroenterol 2019 May-Jun;25(3):159-166

Division of Gastroenterology, McGill University Health Centre, Montreal, Canada.

Background/aims: Patient-reported outcomes (PRO) are key aspects in the management of inflammatory bowel disease (IBD). This study aims to evaluate factors associated with adverse PRO, including modifiable social constructs of maladaptive coping and self-efficacy as well as physician-patient concordance on PRO.

Patients And Methods: This cross-sectional study was performed in patients with Crohn's disease (CD) or ulcerative colitis (UC) from September 2015 to March 2016. Validated questionnaires were used to assess quality of life (Short IBD Questionnaire), disability (IBD disability index), productivity (work productivity and activity impairment questionnaire), anxiety/depression (Hospital Anxiety and Depression Scale), coping strategies [Brief Coping Operations Preference Enquiry (Brief COPE)], and self-efficacy (General Self-Efficacy Scale). Independent physician assessment was used to compare concordance with patients.

Results: In all, 207 (CD: 144 and UC: 63) patients, with median age of 39 years, were included, with 42.5% males. Significant proportion of patients reported moderate/severe impairment of disability (30.5%), quality of life (29.4%), productivity (52.4%), anxiety (32.9%) and depression (23.3%). Disease activity and maladaptive coping were independently associated with unfavourable PRO, whereas self-efficacy had a positive effect in multivariate analysis. Physicians could accurately identify the magnitude of PRO impairment in standard clinical settings (r = 0.59-0.65, P < 0.001).

Conclusion: Disease activity and modifiable psychological constructs are associated with unfavorable PRO in patients with IBD. These factors could assist with identifying high-risk patients, many of whom may benefit from targeted interventions to improve health outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/sjg.SJG_566_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526742PMC
April 2020

Reply to "Transient Elastography in IBD Patients".

Inflamm Bowel Dis 2019 07;25(8):e95

Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ibd/izz048DOI Listing
July 2019

Perceived Quality of Care is Associated with Disease Activity, Quality of Life, Work Productivity, and Gender, but not Disease Phenotype: A Prospective Study in a High-volume IBD Centre.

J Crohns Colitis 2019 Sep;13(9):1138-1147

First Department of Medicine, Semmelweis University, Budapest, Hungary.

Background And Aims: Measuring quality of care [QoC] in inflammatory bowel diseases [IBD] has become increasingly important, yet complex assessment of QoC from the patients' perspective is rare. We evaluated perceived QoC using the Quality of Care Through the Patient's Eyes-IBD [QUOTE-IBD] questionnaire, and investigated associations between QoC, disease phenotype, work productivity, and health-related quality of life [HRQoL] in a high-volume IBD centre.

Methods: Consecutive patients attending McGill University Health Centre [MUHC]-IBD Centre completed the QUOTE-IBD, Short Inflammatory Bowel Disease Questionnaire [SIBDQ], IBD-Control, and Work Productivity and Activity Impairment [WPAI] questionnaires. The QUOTE-IBD comprises 23 questions, each rated by a quality impact [QI] score. QI scores were calculated for the evaluation of IBD specialists, general practitioners [GPs], and hospital care.

Results: In all, 525 patients completed the questionnaire. Total QI scores for IBD specialists, GPs, and hospital care were 8.57, 8.70, and 8.33, respectively. The lowest QI scores were related to 'accessibility' for both IBD specialists and GPs. Female gender, current disease activity, poor HRQoL [SIBDQ score ≤50], and poor disease control [IBD-Control score <13] were associated with lower mean QI scores [p <0.001 for all]. Disease phenotype was not associated with QI scores in either Crohn's disease [CD] or ulcerative colitis [UC] [p = 0.69, p = 0.791, respectively]. An inverse correlation was found between total QI scores and work productivity loss [IBD specialist: p <0.001; GP: p = 0.004].

Conclusions: Overall patient satisfaction with QoC was good; however, improving patient accessibility to care is warranted. Disease phenotype was not associated with patient satisfaction, whereas female gender, current disease activity, HRQoL, and work productivity loss were associated with patients' quality assessment, underlining that perceived QoC could be partly subjective regarding disease control and quality of life.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ecco-jcc/jjz035DOI Listing
September 2019

Low endoscopy bleeding risk in patients with congenital bleeding disorders.

Haemophilia 2019 Mar 12;25(2):289-295. Epub 2019 Feb 12.

Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada.

Introduction: Haemophilia A and haemophilia B, von Willebrand disease (VWD), factor VII deficiency and factor XI deficiency are congenital bleeding disorders predisposing to bleeding during invasive procedures. The ageing population of people with congenital bleeding disorders will likely increasingly require gastrointestinal endoscopy. The bleeding risk postgastrointestinal endoscopy and optimal prophylactic treatment regimens are not well described.

Methods: We performed a retrospective chart review at the McGill University Health Centre. Adult patients with haemophilia A or B, VWD, FVII deficiency and FXI deficiency who underwent gastrointestinal endoscopic procedures were included. Bleeding prophylaxis included combinations of plasma-derived factor (VWD) or recombinant factor (haemophilia A and haemophilia B), desmopressin and/or tranexamic acid. Our primary outcome was the 72-hour postendoscopy bleeding rate.

Results: One hundred and four endoscopies were performed in 48 patients. Haemophilia A (45.3% of endoscopies) was the most common bleeding disorder, followed by VWD (38.5%), FXI deficiency (8.7%), haemophilia B (4.8%) and FVII deficiency (2.9%). All patients were reviewed by the Haemophilia Treatment Center with peri-procedure treatment protocols put in place as required. The overall 72-hour bleeding rate was 0.96%, confidence interval (CI) 95% (0.17%-5.25%). The colonoscopic postpolypectomy bleeding rate was 1/21 (4.8%, CI 95% (0.9%-22.7%)) in comparison with the general population rate of 0.3%-10% for high-risk endoscopy (including colonoscopic polypectomy).

Conclusion: To the best of our knowledge, this is the largest study describing patients with inherited bleeding disorders undergoing gastrointestinal endoscopy. The bleeding risk is not significantly higher to the general population when haemostatically managed by a team experienced in bleeding disorders.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/hae.13691DOI Listing
March 2019

Impact of endoscopy system, high definition, and virtual chromoendoscopy in daily routine colonoscopy: a randomized trial.

Endoscopy 2019 03 15;51(3):237-243. Epub 2019 Jan 15.

Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.

Background: To improve detection of mucosal lesions during colonoscopy a number of imaging modalities have been suggested, including high definition and virtual chromoendoscopy. Given the theoretical advantage of these new imaging techniques, we aimed to investigate their use for the detection of polyps in patients referred for colonoscopy in a large tertiary hospital.

Methods: Demographic, endoscopic, and histological data from 1855 consecutive patients undergoing colonoscopy were collected prospectively. Patients were randomly assigned to three endoscopy systems (Fujinon, Olympus, or Pentax) in combination with four modalities: conventional white-light colonoscopy (n = 505), high definition white-light colonoscopy (n = 582), virtual chromoendoscopy (n = 285) and high definition virtual chromoendoscopy (n = 483).

Results: The mean adenoma detection rate (ADR) was 34.9 %, and the adenoma per colonoscopy rate (APCR) was 2.1. No significant differences were noted between the three endoscopy systems. Moreover, no differences in ADR or APCR were observed between the four imaging modalities. High definition white-light colonoscopy resulted in a significantly higher detection of sessile serrated adenomas (8.2 % vs. 3.8 %;  < 0.01) and adenocarcinomas (2.6 % vs. 0.5 %;  < 0.05) compared with the conventional procedure.

Conclusions: No significant differences in ADR or APCR between different endoscopy systems, high definition, and/or virtual chromoendoscopy could be observed in routine colonoscopies in the general population. High definition endoscopy was associated with a significantly higher detection rate of serrated adenomas and adenocarcinomas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-0755-7471DOI Listing
March 2019

Systematic Review and Meta-analysis: Optimal Salvage Therapy in Acute Severe Ulcerative Colitis.

Inflamm Bowel Dis 2019 06;25(7):1169-1186

Department of Gastroenterology, Austin Hospital, Melbourne, Australia.

Background: Infliximab is an effective salvage therapy in acute severe ulcerative colitis; however, the optimal dosing strategy is unknown. We performed a systematic review and meta-analysis to examine the impact of infliximab dosage and intensification on colectomy-free survival in acute severe ulcerative colitis.

Methods: Studies reporting outcomes of hospitalized steroid-refractory acute severe ulcerative colitis treated with infliximab salvage were identified. Infliximab use was categorized by dose, dose number, and schedule. The primary outcome was colectomy-free survival at 3 months. Pooled proportions and odds ratios with 95% confidence intervals were reported.

Results: Forty-one cohorts (n = 2158 cases) were included. Overall colectomy-free survival with infliximab salvage was 79.7% (95% confidence interval [CI], 75.48% to 83.6%) at 3 months and 69.8% (95% CI, 65.7% to 73.7%) at 12 months. Colectomy-free survival at 3 months was superior with 5-mg/kg multiple (≥2) doses compared with single-dose induction (odds ratio [OR], 4.24; 95% CI, 2.44 to 7.36; P < 0.001). However, dose intensification with either high-dose or accelerated strategies was not significantly different to 5-mg/kg standard induction at 3 months (OR, 0.70; 95% CI, 0.39 to 1.27; P = 0.24) despite being utilized in patients with a significantly higher mean C-reactive protein and lower albumin levels.

Conclusions: In acute severe ulcerative colitis, multiple 5-mg/kg infliximab doses are superior to single-dose salvage. Dose-intensified induction outcomes were not significantly different compared to standard induction and were more often used in patients with increased disease severity, which may have confounded the results. This meta-analysis highlights the marked variability in the management of infliximab salvage therapy and the need for further studies to determine the optimal dose strategy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ibd/izy383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783899PMC
June 2019

Harmonization of quality of care in an IBD center impacts disease outcomes: Importance of structure, process indicators and rapid access clinic.

Dig Liver Dis 2019 03 3;51(3):340-345. Epub 2018 Dec 3.

Inflammatory Bowel Disease Centre, Division of Gastroenterology, McGill University Health Centre (MUHC), Montreal, Quebec, Canada; 1st Department of Medicine, Semmelweis University, Budapest, Hungary. Electronic address:

Background And Aims: We aimed to evaluate the quality of care at a tertiary inflammatory bowel disease (IBD) center using quality of care indicators (QIs) including patient assessment strategy, monitoring, treatment decisions and outcomes.

Methods: We retrospectively reviewed the quality of care pre- and post-referral and during follow-up at the at the McGill University Health Center (MUHC) IBD center. Consecutive patients were included presenting with an outpatient visit ('index visit') between July and December 2016. Disease characteristics, biochemistry, imaging and endoscopy data, changes in medications, and vaccination profiles were captured.

Results: 1357 patients were included. At referral, a large proportion of patients were objectively re-evaluated (ileocolonoscopy: 79%, cross-sectional imaging: 39.3%, biomarkers: 89.9%, 81.9%). Therapeutic strategy was changed in 53.6% with 22.5% of patients starting biologics. Tight objective patient monitoring was applied during follow-up (colonoscopy: 79%, cross-sectional imaging: 61.8% were available at index visit; C-reactive protein: 78%, Faecal calprotectin: 37.6%, therapeutic drug monitoring: 16.3% were performed additionally). Maximum therapeutic step was biologicals in 48.8% of the patients, while only 6.6% of all patients were steroid dependent. Implementation of a rapid access clinic improved healthcare delivery.

Conclusions: Our data support that tight monitoring was applied at the MUHC IBD center with a high emphasis on objective patient (re)evaluation, timely access and accelerated treatment strategy at referral and during follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.dld.2018.11.013DOI Listing
March 2019