Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals.

BACKGROUND AND AIMS: Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be re-evaluated. We tested 3 outreach approaches for transitioning patients to the 10-year interval recommendation. METHODS: This was a 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. The setting was Kaiser Permanente Northern California, a large integrated healthcare system. Participants were patients 54-70 years of age with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all 3 outreach modalities. Patients were randomly assigned to the outreach arm (telephone [n = 200], secure message [n = 203], and mailed letter [n = 201]) stratified by age, sex, and race/ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval. RESULTS: Sixty-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) vs mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared with mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% confidence interval: 8.3%-27.9%) and secure message outreach (13.1%; 97.5% confidence interval: 3.5%-22.7%) vs mailed letter outreach. CONCLUSIONS: Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting. (ClinicalTrials.gov, Number: NCT05389397).

AGA clinical practice guideline on the role of biomarkers for the management of Crohn's Disease

Biomarkers are used frequently for evaluation and monitoring of patients with Crohn's disease (CD). This American Gastroenterological Association (AGA) guideline is intended to support practitioners in decisions about the use of biomarkers for the management of CD. A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to formulate patient-centered clinical questions and review evidence on the performance of fecal calprotectin, serum C-reactive protein (CRP), and Endoscopic Healing Index in patients with established CD who were asymptomatic, had symptoms of varying severity, or were in surgically induced remission. Biomarker performance was assessed against the gold standard of endoscopic activity, defined as a Simple Endoscopic Score for Crohn's Disease ≥3. The panel used the Grading of Recommendations Assessment, Development and Evaluation Evidence-to-Decision framework to develop recommendations for use of biomarkers in various settings. Implementation considerations were formulated for each recommendation to inform clinical practice. The guideline panel made 11 conditional recommendations. In patients with CD in symptomatic remission, the panel suggests use of a biomarker- and symptom-based monitoring strategy over symptoms alone. In patients in symptomatic remission, a fecal calprotectin <150 µg/g and normal CRP rules out active inflammation, avoiding endoscopic evaluation for assessment of disease activity. However, elevated biomarkers in this setting merit confirmation with endoscopy before treatment adjustment. In patients with CD with mild symptoms, neither normal nor elevated biomarkers alone are sufficiently accurate to determine endoscopic activity. In patients with CD with moderate to severe symptoms, elevated fecal calprotectin or serum CRP suggests endoscopic activity, precluding routine endoscopic assessment for disease activity. In patients with CD in surgically induced remission in low-risk patients on pharmacologic prophylaxis, a normal fecal calprotectin reliably rules out endoscopic recurrence. In other postoperative settings, the panel suggests endoscopic assessment for establishing postoperative recurrence. In patients with CD, fecal calprotectin and serum CRP can inform disease management in both asymptomatic and symptomatic disease. Discordance between symptom assessment and biomarker value may merit endoscopic evaluation for confirmation of status of disease activity.

AGA clinical practice guideline on the role of biomarkers for the management of ulcerative colitis

Biomarkers are used frequently for noninvasive monitoring and treatment decision making in the management of patients with ulcerative colitis (UC). This American Gastroenterological Association (AGA) guideline is intended to support practitioners in decisions about the use of biomarkers for the management of UC. A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis on the clinical performance of serum C-reactive protein (CRP), fecal calprotectin, and fecal lactoferrin as biomarkers of disease activity in patients with established UC in symptomatic remission or with active symptoms. The guideline panel used the Evidence-to-Decision framework to develop recommendations for the use of biomarkers for monitoring and management of UC and provided implementation considerations for clinical practice. The guideline panel made 7 conditional recommendations. In patients with UC in symptomatic remission, the panel suggests the use of a biomarker- and symptom-based monitoring strategy over a symptom-based monitoring strategy. For patients in symptomatic remission, the panel suggests using fecal calprotectin <150 µg/g, normal fecal lactoferrin, and/or normal CRP to rule out active inflammation and avoid routine endoscopic assessment of disease. In patients with UC with moderate to severe symptoms, the panel suggests using fecal calprotectin >150 µg/g, elevated fecal lactoferrin, or elevated CRP to inform treatment decisions and avoid routine endoscopic assessment of disease. However, in patients in symptomatic remission but elevated biomarkers, and in patients with moderate to severe symptoms with normal biomarkers, the panel suggests endoscopic assessment of disease to inform treatment decisions. In patients with UC with mild symptoms, the panel suggests endoscopic assessment of disease activity to inform treatment decisions. The panel identified the use of a biomarker-based monitoring strategy over an endoscopy-based monitoring strategy as a knowledge gap. The panel also proposed key implementation considerations for optimal use of biomarkers, and identified areas for future research. In patients with UC, noninvasive biomarkers, including fecal calprotectin, fecal lactoferrin, and serum CRP can inform disease monitoring and management.

Fenotipo e historia natural de la enfermedad inflamatoria intestinal en un centro de referencia en Medellín-Colombia / Phenotypes and natural history of inflammatory bowel disease (IBD) in a referral population in Medellín, Colombia

La frecuencia de enfermedad infl amatoria intestinal, tanto de colitis ulcerativa como enfermedad de Crohn seha incrementado a nivel mundial y es necesario establecer la epidemiología y determinar el comportamientoclínico y endoscópico de estas entidades en nuestro medio. Metodología: Este es un estudio observacional descriptivo, en el que se evaluaron sistemáticamentepacientes con diagnóstico de enfermedad infl amatoria intestinal que consultaron al Hospital Pablo TobónUribe, entre agosto de 2001 y julio de 2009. Resultados: Un total de 202 pacientes presentaba diagnóstico de enfermedad infl amatoria intestinal, conuna relación de colitis ulcerativa (80,7%) y enfermedad de Crohn (15,8%) de 4.9:1, con una distribuciónsimilar por géneros. En cuanto a las manifestaciones clínicas, la colitis ulcerativa presenta más diarrea ysangrado, pero menos dolor abdominal y pérdida de peso, comparados con sujetos con enfermedad deCrohn; esta diferencia fue signifi cativa (p < 0,001). El porcentaje de nuestros pacientes con manifestacionesextraintestinales (27,7%) fue similar al de otras poblaciones, con predominio del compromiso articular. Seencontró asociación signifi cativa entre tabaquismo y enfermedad de Crohn. La distribución de la extensión de colitis ulcerativa en nuestros pacientes es 19,5% proctitis, 45% colitis izquierda y 35,5% colitis extensa. En enfermedad de Crohn, la localización más frecuente fue ileocolónica 50%, íleon terminal 18,8%, colónica 28,1% y solo 3,1% tenía compromiso del tracto digestivo superior. En cuanto a severidad, 17,2% de individuos con colitis ulcerativa son asintomáticos (S0) al ingreso al estudio, 27,8% presentan actividad leve (S1), 32,0% moderada (S2) y 23,1% severa (S4). En enfermedad de Crohn, 34,4% de los pacientes presentan comportamiento infl amatorio, 31,3% estenótico, 21,9% perianal, 6,3% penetrante, y 6,3% tienen comportamiento estenótico y perianal...

Worldwide the frequencies of infl ammatory bowel disease, ulcerative colitis and Crohn’s disease have allincreased. In our own environment it has become necessary to establish the epidemiology of these entitiesand to determine their clinical and endoscopic behavior. Methodology: This is a descriptive observational study which systematically evaluated patients with infl ammatory bowel disease at the Pablo Tobon Uribe Hospital between August 2001 and July 2009. Results: Of 202 patients with diagnoses of infl ammatory bowel disease 80.7% had ulcerative colitis and 15.8% had Crohn’s disease. The ratio was 4.9 to 1 with similar distributions among male and female patients.Patients with ulcerative colitis presented more diarrhea and bleeding, but less abdominal pain and weightloss, than those with Crohn’s disease. This difference was signifi cant (p <0.001). The percentage of ourpatients with extraintestinal manifestations (27.7%) was similar to other populations in which compromisedarticulation predominates. A signifi cant association between smoking and Crohn’s disease was found. 19.5%of our patients had proctitis, 45% had left sided colitis, and 35.5% had extensive colitis. The most commonlocation of Crohn’s disease was in the ileocolonic region (50%), while 18.8% were located in the terminal ileum, and 28.1% were in the colonic region. Only 3.1% had upper gastrointestinal tract involvement...