Prospective Evaluation of the Prediction Score for a Mild Course of Crohn's Disease (PreMiCC) in Newly Diagnosed Patients With Crohn's Disease: The PROGNOS Study.

BACKGROUND AND AIMS: The course of Crohn's disease (CD) is highly variable. The Prospektive Evaluation eines Score zur Vorhersage eines milden Verlaufsbei neu diagnostizierten Morbus Crohn-Patienten in gastroenterologischen Fachpraxen (PROGNOS) study aimed to determine the frequency of a mild disease course and validate a proposed prediction score. METHODS: The PROGNOS study is a prospective study of CD patients who were newly diagnosed and, except for 1 course of 5-aminosalicylic acid or steroids for ≤10 days, therapy-naïve. Among other predefined inclusion criteria, the initial diagnosis had to be made ≤6 weeks before enrollment. All inception cohort patients were diagnosed and screened consecutively in participating gastroenterology practices in Germany specialized in inflammatory bowel disease. All screened CD patients were scored and, if possible, included in the study for up to 5 years (NCT02193048). RESULTS: A total of 201 CD patients were included in the study (43.3% male; mean age 33 years, mean follow-up 38 months). Altogether, 29.5% of the patients had a mild course at 36 months. Among those with a score ≤2, therapy escalation at 36 months was necessary for only 24.2%, whereas in the group with a score >2, therapy escalation was necessary for 70.2% of patients. In the Kaplan-Meier curve showing time to therapy escalation in the 2 groups, there was a pronounced and statistically significant divergence of the curves starting at 3 months and extending to 48 months (P < .001). CONCLUSIONS: In this prospective study, about 30% of incident CD patients had a mild disease course. Our suggested PreMiCC (prediction score for a mild course of Crohn's disease) successfully predicted this.

In our study of newly diagnosed Crohn's disease patients, we found that around 30% had a mild disease course. We also successfully tested our proposed PreMiCC (prediction score for a mild course of Crohn's disease), which predicts this mild course.

[Structural, procedural, and personnel requirements for cross-sectoral provision of endoscopic gastroenterological procedures]. / Strukturelle, prozedurale und personelle Voraussetzungen für eine sektorenübergreifende Erbringung endoskopischer gastroenterologischer Leistungen.

Gastroenterology has made crucial advances in diagnostic and interventional endoscopic procedures, opening up improvements in the treatment of many patients. Thus, organ-preserving treatments are increasingly being made possible, replacing more invasive organ resecting surgical procedures. At the same time, the degree of complexity and risks varies widely between different endoscopic procedures. In many cases, simpler endoscopic procedures are now offered on an outpatient basis. Further potential for cross-sectoral performance of endoscopic procedures exists in the case of complex endoscopic procedures, which, however, require special structural, procedural and personnel requirements in order to provide quality-assured treatment, enable post-interventional monitoring and, if necessary, take measures to ensure the success of the treatment. We summarize the essential prerequisites and limitations for cross-sector performance of endoscopic procedures in gastroenterology.

German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management.

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis, epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification.

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

[Diverticula of the colon: Review of related entities]. / Kolondivertikel und Divertikulitis.

Diverticulosis, Diverticular Disease, and Diverticulitis, comprising different entities, pose increasing burdens for health care systems. The introduction of new scientific knowledge into daily clinical work is challenging for attending physicians. This review is related to case presentations and currently debated questions are discussed such as definitions: Which entities are meant by the term "Diverticular Disease", is "uncomplicated symptomatic Diverticular Disease"(SUDD) reality? To classify diverticula related diseases targeted diagnosis including imaging is necessary. The question is ultrasound or computed tomography, or the combination and in which order?Lastly, open questions of treatment have to be addressed: Outpatient care or hospitalisation, always antibiotics or only in defined situations, relapse prevention, indications to operate upon?The present review comes along with revised German guidelines, which will be published later this year on S3-level.

[The gastroenterology during the first and second wave of corona pandemic - two surveys by the working group of the guiding gastroenterologic clinicians (ALGK)]. / Die Gastroenterologie in der ersten und zweiten Corona-Welle ­ zwei Umfragen der Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte (ALGK).

BACKGROUND: An evaluation of the non-university hospitals in Germany with regard to the actual and follow-up working condition, alterations and perspectives during the Corona-crisis is missing. The working group of the guiding gastroenterologic clinicians (ALGK) comprises more than 70% of the head physicians of gastroenterological units leading to representative informations. METHODS: The ALGK conducted two surveys among its members in 2020 during the first and 2021 during the second Corona-wave. 369 members with correct email adresses were contacted. The first survey included 17 and the second survey 21 questions. RESULTS: 58 % of the respondent represented primary and standard care hospitals, 36 % secondary care hospitals, 6 % tertiary hospitals of maximum care, 43 % communal, 38 % confessional and 18 % private hospitals. 87 % of the respondent reported about cancellation of the hospital appointments by the patients (87 %/85 %). In the second survey, appointment cancellation by the physican (58 % vs. 84 %), reduction of emergency cases (16 % vs. 29 %), postponement of diagnostic or therapeutic appointments (85 % vs. 99 %) and reduction of programmed inpatient (65 vs. 91 %) or outpatient treatment (15 % vs. 84 %) were lesser compared to the first survey. Mean reduction of endoscopic procedures per unit were 337/month to 151/month (55 %) for diagnostic endoscopy, 174/month to 84/month (52 %) for therapeutic endoscopy and 56/month to 7/month (87,5 %) for prevention colonoscopy. The comparison between hospital operators revealed more reports on staff to be under quarantine, more very strong or strong feeling of psychological stress, more fear of corona-infection and more suspicion of ambulatory maintenance in gastroenterology in private hospitals. Willingness for vaccination was very high among physicians and nursing staff (92 %/89 %) and not different between the hospital operators. 38 % of the repsondent reported on the fear of existential risk of their hospital because of the Corona-crisis. CONCLUSION: The two ALGK surveys give a reprensentative picture of the situation of non-university gastroenterological units during Corona-pandemic in Germany.

[Quality management in the field of gastroenterology - Proposals of the Quality Commission of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) for Outpatient and Inpatient Quality Assurance]. / Qualität in der Gastroenterologie ­ "Vorschläge der Kommission Qualität der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten zur ambulanten und stationären Qualitätssicherung".

The quality of the medical care depends on numerous factors that can often be influenced by the doctor itself. It is a great challenge to follow the constant scientific progress in practice. Scientific standards in gastroenterology are defined in DGVS guidelines and regularly revised. The implementation of evidence-based recommendations in practice remains challenging. On the basis of the DGVS guidelines, the Quality Commission has therefore developed a selection of quality indicators with particular relevance using standardized criteria, the broad implementation of which could contribute to improved patient care in gastroenterology.

[Diverticular disease. Clinical appearance, conservative treatment, primary and secondary prophylaxis]. / Divertikelkrankheit. Klinisches Erscheinungsbild, konservative Behandlung, Primär- und Sekundärprophylaxe.

Diverticula of the colon are very common and usually asymptomatic but 20% of people with diverticulosis develop symptoms and sometimes also complications, such as diverticulitis with abscesses or perforation and bleeding. In the long-term stenoses or a conglomerate can occur. The treatment depends on the type of diverticular disease, on the knowledge of risk indicators and imaging with sonography or computed tomography (CT). The uncomplicated diverticular disease is treated on an outpatient and conservative basis, while complicated diverticular disease is treated on an inpatient basis and often surgically.

German Guidelines.

Because of its frequency, diverticular disease is a burden on health care systems. Only few formal guidelines covering all aspects of the disease exist. Here, some selected statements from the German guidelines are given. The guidelines include significant recommendations for the diagnosis and management of diverticular disease. Both diagnosis and management depend definitely on clear definitions of the situation of an individual patient. Therefore, a new classification is proposed that is based on earlier suggestions. An internationally established classification would not only enable better patient care but could also lead to studies with comparable results.

White-Light or Narrow-Band Imaging Colonoscopy in Surveillance of Ulcerative Colitis: A Prospective Multicenter Study.

BACKGROUND & AIMS: Early detection of neoplastic lesions is essential in patients with long-standing ulcerative colitis but the best technique of colonoscopy still is controversial. METHODS: We performed a prospective multicenter study in patients with long-standing ulcerative colitis. Two colonoscopies were performed in each patient within 3 weeks to 3 months. In white-light (WL) colonoscopy, stepwise random biopsy specimens (4 biopsy specimens every 10 cm), segmental random biopsies (2 biopsy specimens in 5 segments), and targeted biopsy specimens were taken. In NBI colonoscopy, segmental and targeted biopsy specimens were taken. The sequence of WL and NBI colonoscopy was randomized. RESULTS: In 36 of 159 patients enrolled (22.6%), 54 lesions with intraepithelial neoplasia (IN) were found (51 low-grade, 3 high-grade). In WL colonoscopy we found 11 IN in stepwise biopsy specimens, 4 in segmental biopsy specimens, and 15 in targeted biopsy specimens. In NBI colonoscopy 7 IN were detected in segmental biopsy specimens and 24 IN were detected in targeted biopsy specimens. Almost all IN were found with one technique alone (κ value of WL vs NBI, -0.86; P < .001). Statistically equivalent numbers of IN were found in NBI colonoscopy with targeted and segmental biopsy specimens as in WL colonoscopy with targeted and stepwise biopsy specimens, but with fewer biopsy specimens (11.9 vs 38.6 biopsy specimens, respectively; P < .001), and less withdrawal time was necessary (23 vs 13 min, respectively; P < .001). CONCLUSIONS: Stepwise biopsy specimens are indispensable in WL colonoscopy. The combination of targeted and segmental biopsy specimens in the NBI technique is as sensitive as targeted together with stepwise biopsy specimens in WL colonoscopy, but requires fewer biopsy specimens and less time. The highest sensitivity should be reached by combining the WL and NBI techniques by switching between the modes.

Prevention and Conservative Therapy of Diverticular Disease.

BACKGROUND: Diverticular disease is a common problem. Prevention and treatment of complications depend on the stage of the disease. Lifestyle modifications are suitable preventive measures, aiming to reduce obesity and to balance the diet with a high amount of fiber and a low amount of meat. However, evidence to guide the pharmacological treatment of diverticular disease and diverticulitis is limited. METHODS: Literature review. RESULTS: Antibiotics are not proven to be effective in patients with uncomplicated diverticulitis and without further risk factors; neither do they improve treatment nor prevent complications. Mesalazine might have an effect on pain relief in diverticular disease even though it has no significant effect on the outcome of diverticulitis. In complicated diverticulitis, inpatient treatment including antibiotics is mandatory. CONCLUSION: Evidence for the treatment of diverticular disease is limited. Further research is needed.

The effect of body weight on the severity and clinical course of ulcerative colitis.

PURPOSE: Obesity is a risk factor for inflammatory diseases such as nonalcoholic steatohepatitis, pancreatitis, and Crohn's disease. The effect of being overweight or obese on the severity and clinical course of ulcerative colitis (UC) was assessed in a retrospective analysis of data from 2000-2006. METHODS: Two hundred and two consecutive UC patients were categorized according to body mass index (BMI). Patient and disease characteristics were compared between BMI categories using chi-square or Kruskal-Wallis tests. The percentage of patients with active UC, complications, steroid therapy, or immunosuppressive therapy was calculated for each group, and matched pair analyses were performed. RESULTS: Ten patients (5%) were underweight, 111 (55%) were normal weight, 54 (26.7%) were overweight, and 27 (13.4%) were obese. Pancolitis was inversely related to weight. BMI was also inversely correlated to disease severity, with a significantly smaller proportion of years with chronic active disease among overweight subjects versus normal-weight subjects (17.6 versus 23.9%, p = 0.05). More overweight than normal-weight patients had no chronic active disease in any year (66 versus 49%, p = 0.06), and the proportion of years with disease complications was higher in normal weight than in overweight subjects (1.8 versus 0.4%, p = 0.08). Disease activity during 2000-2006 was higher for underweight versus normal-weight patients, and only 20% of underweight subjects had no hospital admission compared to 80% of normal-weight patients (p = 0.07). CONCLUSIONS: This first study to explore the influence of obesity on UC showed that high BMI had rather a favorable effect on the prognosis, whereas low BMI pointed to a more severe course of the disease.

Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery.

BACKGROUND: Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications. AIM: To create formal guidelines for diagnosis and management. METHODS: Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference. RESULTS: Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment. CONCLUSIONS: New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.

Longitudinal analysis of distribution and function of plasmacytoid dendritic cells in peripheral blood and gut mucosa of HIV infected patients.

Aberrant activation of plasmacytoid dendritic cells (pDCs) with excessive production of interferon alpha (IFNα) represents one of the hallmarks of immune activation during chronic phase of human immunodeficiency virus (HIV) infection. A number of studies have shown that disruption of mucosal integrity in the gut is a cause of persistent immune activation. However, little is known about the role that pDCs play in this process, and our current understanding comes from the simian immunodeficiency virus macaque model. Thus, in the present study we sought to investigate the frequency and function of pDCs in peripheral blood and gut samples from HIV-infected individuals before and 6 months after initiation of antiretroviral therapy (ART). We show that circulating pDCs were depleted in ART-naive HIV+ patients, and upregulated the gut-homing receptor CD103 compared with uninfected controls. By converse, pDCs accumulated in the terminal ileum of ART-naive HIV individuals compared with controls. Baseline levels of IFNα production and markers of immune activation in gut samples of ART-naive HIV subjects were elevated. All these parameters declined after 6 months of ART. Our results suggest that in chronic HIV infection, pDCs migrate from peripheral blood to the gut-associated lymphatic tissue, where they may contribute to immune activation.