Incidence of inflammatory bowel disease in Italy: a nationwide population-based study. Gruppo Italiano per lo Studio del Colon e del Retto (GISC)

BACKGROUND: The epidemiology of inflammatory bowel disease (IBD) in Southern Europe is still unclear. Sporadic reports suggest a lower incidence of IBD in Italy than in other Western Countries and the USA. METHODS: A nationwide population-based study was carried out to estimate IBD incidence rates in eight Italian cities. All new cases of IBD diagnosed over 4 years in the target populations were collected from multiple information sources. RESULTS: From 1989 to 1992, 509 ulcerative colitis (UC), 222 Crohn's disease (CD) and 10 undefined IBD cases were collected, giving age-adjusted incidence rates (per 100,000 per year) of 5.2 for UC and 2.3 for CD. Using the capture-recapture method, an estimated completeness of 0.81 was obtained for case archives, without appreciable and significant differences between areas. The rates computed after correcting underestimation were 6.8 for UC and 2.8 for CD. The sex ratio M/F was 1.7 for UC and 1.0 for CD. The highest age-specific incidence rates were between 30 and 39 years for UC and between 20 and 29 years for CD. CONCLUSIONS: The incidence rate of CD in italy is homogeneous between the cities investigated and lower than those reported for other Mediterranean countries. In contrast, the UC incidence rate is within the range of those reported in European studies. A wide variability in the UC rates between the cities was also observed. These results could be related to different environmental factors or the genetic background of the populations, or both.

Risk of inflammatory bowel disease attributable to smoking, oral contraception and breastfeeding in Italy: a nationwide case-control study. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC).

BACKGROUND: Using data from a case-control study carried out in Italy 1989-1992, we estimated the odds ratios (OR) and the population attributable risks (AR) for inflammatory bowel diseases (IBD) in relation to smoking, oral contraception and breastfeeding in infancy. METHODS: The study focused on 819 cases of IBD (594 ulcerative colitis: UC; 225 Crohn's disease: CD) originating from populations resident in 10 Italian areas, and age-sex matched paired controls. RESULTS: Compared with non-smokers, former smokers were at increased risk of UC (OR = 3.0; 95% confidence interval [CI]: 2.1-4.3), whereas current smokers were at increased risk of CD (OR = 1.7; 95% CI: 1.1-2.6). Females who reported use of oral contraceptives for at least one month before onset of symptoms had a higher risk of CD (OR = 3.4; 95% CI: 1.0-11.9), whereas no significant risk was observed for UC. Lack of breastfeeding was associated with an increased risk of UC (OR = 1.5; 95% CI: 1.1-2.1) and CD (OR = 1.9; 95% CI: 1.1-3.3). Being a 'former smoker' was the factor with the highest attributable risk of UC both in males (AR = 28%; 95% CI: 20-35 %) and in females (AR = 12%; 95% CI: 5-18%). Smoking was the factor with the highest attributable risk for CD in males (AR = 31%; 95% CI: 11-50%). Lack of breastfeeding accounted for the highest proportion of CD in females (AR = 11%; 95% CI: 1-22%). Oral contraceptive use accounted for 7% of cases of UC and for 11% of cases of CD. CONCLUSIONS: Taken together, the considered factors were responsible for a proportion of IBD ranging from 26% (CD females) to 36% (CD males). It is concluded that other environmental and genetic factors may be involved in the aetiology of IBD.

Dietary habits as risk factors for inflammatory bowel disease.

OBJECTIVE: To examine the influence of dietary factors in Italian patients with ulcerative colitis and Crohn's disease. DESIGN: We studied dietary habits immediately prior to the onset of disease in 104 patients enrolled in a prospective, epidemiological study of the incidence of inflammatory bowel disease in Italy. METHODS: Each patient was interviewed using a recall questionnaire to provide information on the daily intake of nutrients. The differences in diet between patients and healthy subjects matched for age, sex and city of residence were determined. RESULTS: Our data confirm that patients with Crohn's disease and ulcerative colitis have a high intake of total carbohydrate, starch and refined sugar. This resulted in a significantly higher relative risk (P < 0.001) in both ulcerative colitis and Crohn's disease patients. Total protein intake was significantly higher in ulcerative colitis, but not in Crohn's disease patients, than in controls. Fibre consumption did not differ between patients and controls. CONCLUSIONS: Our results confirm that carbohydrate consumption is significantly higher in IBD patients than in healthy controls. Ulcerative colitis patients also consumed more total protein than controls. The pathogenetic significance of these findings, however, remains unclear.

Difficult hospital discharges in internal medicine wards.

OBJECTIVE: Investigate the prevalence of difficult hospital discharges (DHD), describe clinical and social patients' characteristics as potential reasons for discharge delays in an internal medicine ward and implement tailored post-discharge care. METHODS: During the year 2005 we analysed, in a middle-sized country hospital, all the patients for which some delay for discharge, owing to their whole complexity, was presumable. Comprehensive multidimensional assessment, clinical-social risk score, specific needs of care, mean of stay and outcomes were evaluated. RESULTS: 68.5% of DHD patients were >/=80 years old, with 3.8 the mean number of diseases per patient; 57.5% presented a loss of autonomy (ADL) just before acute deterioration; 80% were functionally and/or cognitively impaired. Only 5% had suitable family support; 5.1% were living at a nursing home; 2% were living alone. The most frequent causes of admission were stroke, cognitive impairment-dementia, cardiovascular diseases, fractures and cancer. Mean length of stay was 12 days. Fifty-two percent of patients were discharged home, 30% were admitted to a long-term care facility, 1% to hospice and 17% died during their hospital stay. CONCLUSIONS: The aim of "coordinated care" (i.e., targeting "at-risk" patients with assessment of medical, functional, social and emotional needs; provision of optimal medical treatment, self-care education, integrated services, monitoring of progress and early signs of problems) is to improve health outcomes and reduce costs. More than 80% of DHDs patients, with specific tailored programmes, may be discharged from hospital, with satisfactory solutions for them and their families.

Epidemiological characteristics of inflammatory bowel disease in Bologna, Italy--incidence and risk factors.

Recently, in Bologna, an inflammatory bowel disease incidence of 7.7/10(5)/year has been calculated, about one third of that reported in Northern Europe, confirming the existence of a 'North-South gradient'. A first peak of incidence was observed at 20-29 years of age and a second peak at 60-69 years of age for ulcerative colitis (UC) alone. A prevalence of UC males, mainly after the 7th decade, and of Crohn's disease (CD) females in the first peak was found. A greater frequency of ex-smokers in UC, with a relative risk (RR) significantly higher in males for all age groups (RR = 6.1; p < 0.01) and of smokers in CD with a RR significantly higher in 20- to 29-year-old females (RR = 11.6; p < 0.05) was observed. A different pattern for the two diseases exists: male ex-smokers and young female smokers are at risk of developing UC and CD, respectively.

A laboratory index for predicting relapse in asymptomatic patients with Crohn's disease.

Currently there are no completely reliable methods for predicting an impending relapse in Crohn's disease. As approximately 50% of patients in remission [Crohn's disease activity index (CDAI) less than 150] show some laboratory abnormalities, we inquired whether these alterations might be of value for predicting relapse. We prospectively studied 41 patients with Crohn's disease who had been showing CDAI less than 150 for at least 6 mo before entering the study and who were not receiving any long-term treatment. The 41 patients were studied at the ninth and at the 18th month after inclusion in the study. Disease activity was monitored by CDAI calculation and by measurement of erythrocyte sedimentation rate, white blood cell count, hemoglobin, albumin, alpha 2-globulin, serum iron, C-reactive protein, alpha 1-glycoprotein, and alpha 2-antitrypsin. Seventeen of the 41 patients had a clinical relapse during follow-up. At the beginning of the study the patients who later relapsed showed a remarkable alteration of acid alpha 1-glycoprotein (p less than 0.0001), alpha 2-globulin (p less than 0.0003), and erythrocyte sedimentation rate (p less than 0.0006), in comparison with the patients who remained in remission. by discriminant analysis a prognostic index with these laboratory investigations provided a high percentage (88%) of accuracy according to the outcome at the 18th month.

Acute pancreatitis after azathioprine treatment for ulcerative colitis.

Inflammatory bowel disease, in addition to intestinal involvement, may be complicated also by other extra-intestinal manifestations. Moreover, drugs commonly employed in the treatment of ulcerative colitis and Crohn's disease may induce iatrogenic pancreatitis. Acute pancreatitis is described in two ulcerative colitis patients following azathioprine treatment.

The possible utility of steroids in the prevention of relapses of Crohn's disease in remission. A preliminary study.

In Crohn's disease, prednisone is believed to be ineffective for relapse prevention. Because all patients with Crohn's Disease Activity Index lower than 150 and with some altered lab tests (erythrocyte sedimentation rate, C-reactive protein, alpha-1-acid glycoprotein, alpha-1-acid antitrypsin, and white blood cell count) had a clinical relapse in 18 months of follow-up, we tried to ascertain whether methylprednisolone could reduce the risk of clinical relapse in such patients. Eighteen patients were included in a controlled study against placebo. Nine patients were treated with methylprednisolone at a dosage of 0.25 mg/kg daily for a period of 6 months; treatment was discontinued if disease relapsed or if lab tests were normalized. During the steroid treatment, 1 of 9 patients showed a clinical relapse; in 7, the normalization of lab tests was obtained; in 5 of these 7 patients a relapse occurred within 1 month after the suspension of the treatment; in 1 patient, lab tests remained altered. In those 9 patients on placebo, relapses occurred in 7. We conclude that methylprednisolone was effective in the prevention of relapses for patients in clinical remission but with altered lab tests.

Importance of laboratory parameters in the evaluation of Crohn's disease activity.

Some laboratory investigations are abnormal during the course of Crohn's disease (CD). We investigated the trend of some of these laboratory tests in a group of patients with CD to study the relationships between an activity index made up of such laboratory parameters only (LCDAI) and the usual Crohn's disease activity index (CDAI). One hundred thirty-one examinations of 63 patients were evaluated. At each investigation, besides calculation of the CDAI, 10 laboratory investigations were carried out. Three gastroenterologists independently gave an overall evaluation of the laboratory activity for each of the 131 examinations on the basis of the results of the blood tests alone. The sum of the evaluations was used as an independent variable on which a laboratory index was developed by multiple regression analysis. C reactive protein, red cell sedimentation rate, acid alpha 1-glycoprotein, alpha 1-antitrypsin, and white blood cells had an important share in the development of this laboratory index. The evaluation of the relationships existing between LCDAI and CDAI showed that in patients with moderate to severe clinical disease activity, LCDAI was constantly altered. The same happened in 55% of cases in clinical remission, which suggests an inflammatory activity that is not clinically evident. These results point to the advisability of supplementing a predominantly clinical index, such as CDAI, with a laboratory index such as LCDAI in the evaluation of CD.

Clinical course of Crohn's disease in Italy.

The clinical course of Crohn's disease in 131 patients was studied for a mean period of 4.2 +/- 3.2 years. The clinical activity of the disease, expressed as percentage of patients per year in an active phase, is high in the first year (70.2 percent) and progressively decreases during subsequent years (25 percent after seven years). The percentage of patients who needed steroid treatment is high during the first year (68 percent) and falls to 19 percent after seven years. An operative risk rate of 54 percent was registered, with a probability of reoperation equal to 34 percent. Clinical relapse after the first surgery occurred in 70 percent of cases. The registered mortality was 6.9 percent, with a ratio of 6 to 1 between observed and expected mortality. In conclusion, the disease, while showing a tendency to reduce its activity over the years, is burdened by a risk of surgery and mortality which progressively increases with time.