Real-world treatment patterns and disease control over one year in patients with inflammatory bowel disease in Brazil.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBDs) with a remission-relapsing presentation and symptomatic exacerbations that have detrimental impacts on patient quality of life and are associated with a high cost burden, especially in patients with moderate-to-severe disease. The Real-world Data of Moderate-to-Severe Inflammatory Bowel Disease in Brazil (RISE BR) study was a noninterventional study designed to evaluate disease control, treatment patterns, disease burden and health-related quality of life in patients with moderate-to-severe active IBD. We report findings from the prospective follow-up phase of the RISE BR study in patients with active UC or CD. AIM: To describe the 12-mo disease evolution and treatment patterns among patients with active moderate-to-severe IBD in Brazil. METHODS: This was a prospective, noninterventional study of adult patients with active Crohn's disease (CD: Harvey-Bradshaw Index ≥ 8, CD Activity Index ≥ 220), inadequate CD control (i.e., calprotectin > 200 µg/g or colonoscopy previous results), or active ulcerative colitis (UC: Partial Mayo score ≥ 5). Enrollment occurred in 14 centers from October 2016 to February 2017. The proportion of active IBD patients after 9-12 mo of follow-up, Kaplan-Meier estimates of the time to mild or no activity and a summary of treatment initiation, discontinuation and dose changes were examined. RESULTS: The study included 118 CD and 36 UC patients, with mean ± SD ages of 43.3 ± 12.6 and 44.9 ± 16.5 years, respectively. The most frequent drug classes at index were biologics for CD (62.7%) and 5-aminosalicylate derivates for UC patients (91.7%). During follow-up, 65.3% of CD and 86.1% of UC patients initiated a new treatment at least once. Discontinuations/dose changes occurred in 68.1% of CD patients [median 2.0 (IQR: 2-5)] and 94.3% of UC patients [median 4.0 (IQR: 3-7)]. On average, CD and UC patients had 4.4 ± 2.6 and 5.0 ± 3.3 outpatient visits, respectively. The median time to first mild or no activity was 319 (IQR: 239-358) d for CD and 320 (IQR: 288-358) d for UC patients. At 9-12 mo, 22.0% of CD and 20.0% of UC patients had active disease. CONCLUSION: Although a marked proportion of active IBD patients achieved disease control within one year, the considerable time to achieve this outcome represents an unmet medical need of the current standard of care in a Brazilian real-world setting.

Real-world disease activity and sociodemographic, clinical and treatment characteristics of moderate-to-severe inflammatory bowel disease in Brazil.

BACKGROUND: Understanding the treatment landscape of inflammatory bowel diseases (IBD) is essential for improving disease management and patient outcomes. Brazil is the largest Latin American country, and it presents socioeconomic and health care differences across its geographical regions. This country has the highest increase in IBD incidence and prevalence in Latin America, but information about the clinical and treatment characteristics of IBD is scarce. AIM: To describe the sociodemographic, clinical, and treatment characteristics of IBD outpatients in Brazil overall and in the Southeast, South and Northeast/Midwest regions. METHODS: Multicenter, cross-sectional study with a 3-year retrospective chart review component. Patients with moderate-to-severe Crohn's disease (CD) or ulcerative colitis (UC) were consecutively enrolled between October 2016 and February 2017. Active CD at enrollment was defined as a Harvey Bradshaw Index ≥ 8 or a CD Activity Index ≥ 220 or a calprotectin level > 200 µg/g or an active result based on colonoscopy suggestive of inadequate control during the previous year; active UC was defined as a partial Mayo score ≥ 5. Descriptive statistics were used to analyze all variables. RESULTS: In a total of 407 included patients, CD was more frequent than UC, both overall (264 CD/143 UC patients) and by region (CD:UC ratios of 2.1 in the Southeast, 1.6 in the South and 1.2 in the Northeast/Midwest). The majority of patients were female (54.2% of CD; 56.6% of UC), and the mean ages were 45.9 ± 13.8 years (CD) and 42.9 ± 13.0 years (UC). The median disease duration was 10.0 (range: 0.5-45) years for both IBD types. At enrollment, 44.7% [95% confidence interval (CI): 38.7-50.7] of CD patients and 25.2% (95%CI: 18.1-32.3) of UC patients presented with active disease. More than 95% of IBD patients were receiving treatment at enrollment; CD patients were commonly treated with biologics (71.6%) and immunosuppressors (67.4%), and UC patients were commonly treated with mesalazine [5-Aminosalicylic acid (5-ASA)] derivates (69.9%) and immunosuppressors (44.1%). More than 50% of the CD patients had ileocolonic disease, and 41.7% presented with stricturing disease. One-quarter of CD patients had undergone CD-related surgery in the past 3 years, and this proportion was lower in the Northeast/Midwest region (2.9%). CONCLUSION: In Brazil, there are regional variations in IBD management. CD outweighs UC in both frequency and disease activity. However, one-quarter of UC patients have active disease, and most are receiving 5-ASA treatment.

Quality of life, work productivity impairment and healthcare resources in inflammatory bowel diseases in Brazil.

BACKGROUND: Inflammatory bowel diseases (IBD) have been associated with a low quality of life (QoL) and a negative impact on work productivity compared to the general population. Information about disease control, patient-reported outcomes (PROs), treatment patterns and use of healthcare resources is relevant to optimizing IBD management. AIM: To describe QoL and work productivity and activity impairment (WPAI), treatment patterns and use of healthcare resources among IBD patients in Brazil. METHODS: A multicenter cross-sectional study included adult outpatients who were previously diagnosed with moderate to severe Crohn's disease (CD) or ulcerative colitis (UC). At enrolment, active CD and UC were defined as having a Harvey Bradshaw Index ≥ 8 or a CD Activity Index ≥ 220 or calprotectin > 200 µg/g or previous colonoscopy results suggestive of inadequate control (per investigator criteria) and a 9-point partial Mayo score ≥ 5, respectively. The PRO assessment included the QoL questionnaires SF-36 and EQ-5D-5L, the Inflammatory Bowel Disease Questionnaire (IBDQ), and the WPAI questionnaire. Information about healthcare resources and treatment during the previous 3 years was collected from medical records. Chi-square, Fisher's exact and Student's t-/Mann-Whitney U tests were used to compare PROs, treatment patterns and the use of healthcare resources by disease activity (α = 0.05). RESULTS: Of the 407 patients in this study (CD/UC: 64.9%/35.1%, mean age 42.9/45.9 years, 54.2%/56.6% female, 38.3%/37.1% employed), 44.7%/25.2% presented moderate-to-severe CD/UC activity, respectively, at baseline. Expressed in median values for CD/UC, respectively, the SF-36 physical component was 46.6/44.7 and the mental component was 45.2/44.2, the EQ-visual analog scale score was 80.0/70.0, and the IBDQ overall score was 164.0/165.0. Moderate to severe activity, female gender, being unemployed, a lower educational level and lower income were associated with lower QoL (P < 0.05). Median work productivity impairment was 20% and 5% for CD and UC patients, respectively, and activity impairment was 30%, the latter being higher among patients with moderate to severe disease activity compared to patients with mild or no disease activity (75.0% vs 10.0%, P < 0.001). For CD/UC patients, respectively, 25.4%/2.8% had at least one surgery, 38.3%/19.6% were hospitalized, and 70.7%/77.6% changed IBD treatment at least once during the last 3 years. The most common treatments at baseline were biologics (75.3%) and immunosuppressants (70.9%) for CD patients and 5-ASA compounds (77.5%) for UC patients. CONCLUSION: Moderate to severe IBD activity, especially among CD patients, is associated with a substantial impact on QoL, work productivity impairment and an increased number of IBD surgeries and hospitalizations in Brazil.

IMMUNIZATION STATUS OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE.

BACKGROUND: Treatment for inflammatory bowel disease (IBD) includes a variety of immunosuppressants and biological agents, which increase the risk of infections due to altered cellular and humoral immunity. Prevention of these infections can be done through vaccination, however, patients with IBD are usually under-immunized. OBJECTIVE: Analyze the immunization status of patients with IBD and confront it with the current recommendations to verify if the immunization guidelines are being followed correctly. METHODS: Analytical cross-sectional study including 239 IBD patients being regularly followed in the Gastroenterology Service from Hospital de Clínicas da Universidade Federal do Paraná, which were subjected to a survey about their relevant demographic data and immunization status. RESULTS: The amount of patients that declared being unaware of their immunization status is high - between 34.3% (Tdap) and 52% (meningococcal) - excepting IIV, hepatitis B and HPV. The vaccines with the largest rates of patients declaring to have taken it are inactivated influenza vaccine (72.4%), BCG (55.3%), hepatitis B (48.3%), measles, mumps and rubella vaccine (43.8%) and DTaP (43%). The vaccines with the lowest rates of patients declaring to have taken it are Haemophilus influenza type b (0.8%), herpes zoster (2.1%) and HPV (3.4%). Patients that are being treated or have been treated with biological therapy have the largest immunization coverage for inactivated influenza vaccine (81%) and PPSV23 (25.9%), also they have the largest awareness rates for those vaccines. CONCLUSION: Although being a specialized service linked to a university hospital, vaccination coverage and patients' awareness rates proved to be below the desirable level. Vaccination and recovery of the immunization history is recommended immediately after the diagnosis of IBD, regardless of the use of biological agents. Those findings support the need of implementing hospital guidelines and constantly verifying its application by the multidisciplinary team in specialized services in IBD.

Situação vacinal de pacientes com doença inflamatória intestinal / Immunization status of patients with inflammatory bowel disease

ABSTRACT BACKGROUND: Treatment for inflammatory bowel disease (IBD) includes a variety of immunosuppressants and biological agents, which increase the risk of infections due to altered cellular and humoral immunity. Prevention of these infections can be done through vaccination, however, patients with IBD are usually under-immunized. OBJECTIVE: Analyze the immunization status of patients with IBD and confront it with the current recommendations to verify if the immunization guidelines are being followed correctly. METHODS: Analytical cross-sectional study including 239 IBD patients being regularly followed in the Gastroenterology Service from Hospital de Clínicas da Universidade Federal do Paraná, which were subjected to a survey about their relevant demographic data and immunization status. RESULTS: The amount of patients that declared being unaware of their immunization status is high - between 34.3% (Tdap) and 52% (meningococcal) - excepting IIV, hepatitis B and HPV. The vaccines with the largest rates of patients declaring to have taken it are inactivated influenza vaccine (72.4%), BCG (55.3%), hepatitis B (48.3%), measles, mumps and rubella vaccine (43.8%) and DTaP (43%). The vaccines with the lowest rates of patients declaring to have taken it are Haemophilus influenza type b (0.8%), herpes zoster (2.1%) and HPV (3.4%). Patients that are being treated or have been treated with biological therapy have the largest immunization coverage for inactivated influenza vaccine (81%) and PPSV23 (25.9%), also they have the largest awareness rates for those vaccines. CONCLUSION: Although being a specialized service linked to a university hospital, vaccination coverage and patients' awareness rates proved to be below the desirable level. Vaccination and recovery of the immunization history is recommended immediately after the diagnosis of IBD, regardless of the use of biological agents. Those findings support the need of implementing hospital guidelines and constantly verifying its application by the multidisciplinary team in specialized services in IBD.

RESUMO CONTEXTO: No tratamento de doenças inflamatórias intestinais (DII) são usados imunossupressores e agentes biológicos, o que aumenta o risco de infecções pela alteração da imunidade celular e humoral. A prevenção de algumas dessas infecções pode ser feita pela vacinação, entretanto pacientes com DII apresentam baixas taxas de cobertura vacinal. OBJETIVO: Analisar a situação vacinal de pacientes com DII e comparar com a recomendação vigente na literatura para verificar se os esquemas de imunização estão sendo corretamente aplicados nessa população. MÉTODOS: Estudo transversal analítico com 239 pacientes com DII em acompanhamento no Serviço de Gastroenterologia do Hospital de Clínicas da Universidade Federal do Paraná, os quais foram submetidos a um questionário sobre dados demográficos relevantes e sobre a situação vacinal. RESULTADOS: A taxa de pacientes que declarou não ter conhecimento de sua situação vacinal é alta - entre 34,3% (dTpa) e 52% (meningocócica) - com exceção das vacinas influenza, hepatite B e HPV. As vacinas com maior taxa de pacientes que declararam ter recebido a vacina são influenza (72,4%), BCG (55,3%), hepatite B (48,3%), tríplice viral (43,8%) e DTPa (43%). As vacinas com menor taxa de pacientes que declararam ter recebido a vacina são Haemophilus influenza b (0,8%), herpes zoster (2,1%) e HPV (3,4%). Pacientes que fazem ou já fizeram tratamento com agentes biológicos têm melhor cobertura vacinal das vacinas para influenza (81%) e PP23V (25,9%), além de maior conhecimento sobre o estado vacinal para essas vacinas. CONCLUSÃO: Apesar de se tratar de um serviço especializado ligado a um hospital universitário, a cobertura vacinal e o conhecimento dos pacientes sobre as vacinas estão abaixo do desejado. A recuperação do histórico vacinal e a recomendação das vacinas necessárias devem ser realizadas logo após o diagnóstico de DII, independentemente do uso de agentes biológicos. Esses achados indicam a necessidade da criação e monitoramento constante da aplicação de um protocolo pela equipe multidisciplinar de serviços especializados em DII.

Crohn's disease - treatment with biological medication.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Crohn's disease - treatment with biological medication

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Metastatic cutaneous Crohn's disease as an important differential diagnosis of granulomatous skin disease / Doença de Crohn metastática cutânea como importante diagnóstico diferencial de doença granulomatosa em pele

ABSTRACT Patients with Crohn's disease may show extraintestinal manifestations, including cutaneous, whose frequency ranges from 2% to 34%. Metastatic cutaneous Crohn's disease is considered a specific and rare manifestation, since the histopathology reveals granulomatous pattern with the same characteristics of the underlying bowel condition. The objective of this study is to report two cases of metastatic cutaneous Crohn's disease confirmed by histopathologic analysis, after excluding other granulomatous skin diseases. Case 1: Adult woman with pruritic erythematous scaly plaques disseminated on the upper limbs. Case 2: Adult man with grayish hyperchromic plaque infiltrated on the left buttock.

RESUMO Pacientes portadores de doença de Crohn podem apresentar manifestações extraintestinais, inclusive cutâneas, cuja frequência varia de 2% a 34%. A doença de Crohn metastática cutânea é considerada manifestação específica e rara, visto que apresenta à histopatologia padrão granulomatoso com as mesmas características da condição intestinal subjacente. O objetivo deste estudo é relatar dois casos de doença de Crohn metastática cutânea confirmados por análise histopatológica, após exclusão de outras doenças granulomatosas da pele. Caso 1: Mulher adulta com placas eritematodescamativas pruriginosas disseminadas em membros superiores. Caso 2: Homem adulto com placa hipercrômica acinzentada e infiltrada em nádega esquerda.

Clinical-pathological and p53 protein expression study in dysplasia associated with ulcerative colitis / Estudo clínico-patológico e da expressão da proteína p53 nas displasias associadas à retocolite ulcerativa

Background: The association between ulcerative colitis and adenocarcinoma determined strategies for patient follow-up and early detection of dysplastic and neoplastic lesions. Aims: To analyze the incidence of dysplasia in patients with ulcerative colitis, comparing clinical data of patients with and without dysplasia and check immunohistochemical expression of p53 protein in dysplasias. Materials and methods: We analyzed biopsy samples and clinical data of 124 patients with ulcerative colitis at Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil. Results: Dysplasia incidence was low (9.67%) and all cases with low-grade dysplasia. Patients clinical data comparison with and without dysplasia did not show significant statistical differences with regard to the race, age at the start of the disease, age at last biopsy, duration and anatomic extent of ulcerative colitis. Significant difference was found between males and females with predominance of males (58.34%) for dysplasia. Seventeenth biopsy samples of 12 patients with dysplasia, 5 (29.4%) were p53 positive. Conclusions: From these results it is concluded that the incidence of dysplasia was low, higher in males and there was positivity of p53 protein in dysplasia. .

Racional: A associação entre retocolite ulcerativa e adenocarcinoma determinou estratégias para seguimento dos pacientes e detecção precoce das lesões displásicas e neoplásicas. Objetivos: Analisar a incidência de displasia nos pacientes com retocolite ulcerativa, comparar dados clínicos dos pacientes com e sem displasia e verificar a expressão imunoistoquimica da proteína p53 nas displasias. Material e Métodos: Foram estudados os exames anatomopatológicos e dados clínicos de 124 pacientes com e sem displasia, portadores de retocolite ulcerativa no Hospital de Clínicas da Universidade Federal do Paraná. Resultados: A incidência de displasia foi de 9,67% e todos os casos foram de displasia de baixo grau. Na comparação dos dados clínicos dos pacientes com e sem displasia não houve diferença estatisticamente significativa com relação à cor, idade no início da doença, idade na última biópsia, extensão da doença e tempo de evolução da doença. Houve diferença estatística com predomínio de pacientes do sexo masculino (58,34%) em relação ao feminino para displasia. Dos 17 exames avaliados de 12 pacientes com displasia, em 5 exames (29,4%) a expressão da proteína p53 foi positiva. Conclusões: Desses resultados conclui-se que a incidência de displasia foi baixa, maior no sexo masculino e houve positividade da proteína p53 nas displasias. .

Padronização e quantificação de critérios histopatológicos melhoram o diagnóstico da doença intestinal inflamatória? / Do standardization and quantification of histopathological criteria improve the diagnosis of inflammatory bowel disease?

Introduction: Inflammatory bowel disease comprises two major categories: Crohn's disease and ulcerative rectocolitis, both with different clinical and histological aspects, causing sometimes significant morbidity. Objectives: Choose and apply standardized and quantified histopathological diagnosis method, and compare the results and quality index with the original diagnosis. Materials and methods: 43 histological colonoscopic biopsies of 37 patients were re-evaluated by standardized system. Results and discussion: The original diagnoses were more inconclusive (23.3%) than those standardized (2.3%). The agreement with gold standard (clinical, colonoscopical, and radiological diagnosis) was higher on standardized diagnoses (95.3%) than in original (74.4%), especially in relation to Crohn's disease, which percentages were 92.3% and 46.1%, respectively. The quality index was calculated in conclusive diagnosis of each method. For ulcerative rectocolitis, both methods showed sensitivity and negative predictive value of 100%; otherwise the original diagnosis demonstrated specificity of 85.7%, positive predictive value of 96.3% and accuracy of 97.0%, and the standardized diagnosis 92.3%, 96.7% and 97.6%, respectively. For Crohn's disease, there is specificity and positive predictive value of 100% in both methods; the original diagnosis showed sensitivity of 85.7%, negative predictive value of 96.3% and accuracy of 97%, while for the standardized diagnoses 92.3%, 96.7%, and 97.6%, respectively. Conclusion: The standardized diagnosis presented a higher percentage of correct and conclusive diagnoses than those presented in the original diagnosis, especially for Crohn's disease, as well as equal or slightly higher values in some quality index...

Introdução: Duas são as formas de manifestação da doença intestinal inflamatória: doença de Crohn e retocolite ulcerativa, ambas com evolução clínica, tratamento e aspectos histopatológicos diferentes, causando, por vezes, significativa morbidade. Objetivos: Escolher e aplicar método padronizado e quantificado de diagnóstico histopatológico e comparar os resultados e os índices de qualidade, com os dos diagnósticos originais. Materiais e métodos: Foram reavaliadas histologicamente 43 biópsias colonoscópicas seriadas de 37 pacientes por sistema padronizado. Resultado e discussão: Os diagnósticos originais foram mais inconclusivos (23,3%) do que os padronizados (2,3%). A concordância com o padrão-ouro (diagnóstico clínico, colonoscópico e radiológico) foi maior nos diagnósticos padronizados (95,3%) do que nos originais (74,4%), principalmente em relação à doença de Crohn, cujos percentuais foram de 92,3% e 46,1%, respectivamente. Para retocolite ulcerativa, ambos os métodos apresentaram sensibilidade e valor preditivo negativo de 100%; já nos diagnósticos originais, foram verificados especificidade de 85,7%, valor preditivo positivo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Para doença de Crohn, verificaram-se especificidade e valor preditivo positivo de 100% nos dois métodos; nos diagnósticos originais, sensibilidade de 85,7%, valor preditivo negativo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Conclusão: O diagnóstico padronizado apresentou maior percentual de diagnósticos corretos e conclusivos do que os apresentados no diagnóstico original, principalmente para doença...

Optimising monitoring in the management of Crohn's disease: a physician's perspective.

Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.

Ingestão alimentar em pacientes com doença inflamatória intestinal / Food intake in patients with inflammatory bowel disease

RACIONAL: Pacientes com doença inflamatória intestinal podem apresentar deficiências nutricionais. OBJETIVO: Verificar a adequação da ingestão alimentar de pacientes com doença de Crohn e retocolite ulcerativa inespecífica. MÉTODOS: Para avaliação da ingestão alimentar de 55 pacientes, 28 com doença de Crohn e 27 com retocolite ulcerativa atendidos em ambulatório de gastroenterologia, utilizou-se o Recordatório Alimentar de 24 Horas e o Questionário de Frequência Alimentar. A atividade inflamatória da doença foi avaliada pelos níveis séricos de proteína C reativa e o Índice de Harvey e Bradshaw. Para comparação de médias foi usado o teste t não pareado e, para as médias não paramétricas, o teste de Mann-Whitney, considerando nível de significância valor de p<0,05. RESULTADOS: Os pacientes tinham idade entre 19 e 63 anos e tempo de diagnóstico de 7,9 anos (1 a 22). De acordo com a ingestão alimentar identificou-se deficiência na ingestão de energia, fibras, ferro, potássio, sódio, magnésio, cálcio, menadiona, riboflavina, niacina, folato, ácido pantotênico, tocoferol e colecalciferol na doença de Crohn e na retocolite ulcerativa em atividade ou em remissão. A ingestão de legumes, frutas, laticínios e feijão foi baixa, e a de doces e gorduras foi maior que as recomendações. CONCLUSÃO: Houve deficiência na ingestão alimentar tanto na doença de Crohn como na retocolite ulcerativa, em atividade e em remissão. Essas deficiências podem afetar negativamente o curso da doença e justificam a necessidade de intervenção nutricional com esses pacientes.

BACKGROUND: Patients with inflammatory bowel disease may have nutritional deficiencies. AIM: To verify the adequacy of dietary intake of patients with Crohn's disease and ulcerative colitis. METHODS: To assess food intake of 55 patients, 28 with Crohn's disease and 27 with ulcerative colitis treated in the gastroenterology clinic, was used the 24-Hour Food Recall and Food Frequency Questionnaire. The inflammatory activity of the disease was evaluated by serum C-reactive protein and Harvey and Bradshaw Index. For comparison of means t test was used, and the average on non-parametric, the Mann-Whitney test, with level of significance p <0.05. RESULTS: The patients were aged between 19 and 63 years and time since diagnosis was 7.9 years (1 to 22). According to the food intake was identified deficiency in energy intake, fiber, iron, potassium, sodium, magnesium, calcium, menadione, riboflavin, niacin, folate, pantothenic acid, tocopherol and cholecalciferol in Crohn's disease and ulcerative colitis, active or in remission. The intake of vegetables, fruits, dairy products and beans were low, and intake of fats and sweets was higher than the recommendations. CONCLUSION: There was a deficiency in food intake both in Crohn's disease and in ulcerative colitis, in activity and in remission. These deficiencies can adversely affect the disease course, and justify the need for nutritional intervention with these patients.

Relação entre estado nutricional e atividade inflamatória em pacientes com doença inflamatória intestinal / Relationship between nutritional status and inflammatory activity in patients with inflammatory bowel disease

RACIONAL: As doenças inflamatórias intestinais caracterizam-se por diversos sintomas que afetam o aparelho digestório e, consequentemente, podem interferir sobre o estado nutricional. OBJETIVO: Avaliar o estado nutricional de pacientes com doença inflamatória intestinal em diferentes estágios de atividade inflamatória. MÉTODOS: Foram avaliados 55 pacientes com doença inflamatória intestinal, por meio de dados antropométricos, com aferição de peso, altura, circunferência do braço e prega cutânea do tríceps e tiveram sua composição corporal determinada por impedância bioelétrica. Para determinação de atividade inflamatória da doença foram utilizados os níveis séricos de proteína C reativa e o índice de Harvey e Bradshaw. Para comparação de médias foi usado o teste t não pareado, e para as médias não paramétricas, o teste de Mann-Whitney, considerando nível de significância valor de p<0,05. RESULTADOS: Entre os pacientes avaliados, 28 apresentavam doença de Crohn e 27 retocolite ulcerativa inespecífica, com idade entre 19 e 63 anos e tempo de diagnóstico de 1 a 22 anos. Não houve diferença nas medidas antropométricas e na composição corporal dos pacientes cuja doença inflamatória estava em atividade ou em remissão. Os que usaram glicocorticóides nos seis meses anteriores à avaliação apresentaram percentual de gordura corporal de 23,4±8,2 por cento, enquanto para os que não usaram o percentual foi de 30,7±11,3 (p<0,0199). Os sintomas gastrintestinais mais comuns foram distensão abdominal (41 por cento), diarréia (18 por cento), náusea (13 por cento), obstipação (12 por cento), inapetência (11 por cento) e vômito (5 por cento). Todos os sintomas foram mais frequentes nos pacientes com maior índice de massa corporal e de gordura corporal. CONCLUSÃO: Houve maior número de pacientes com excesso de peso e de gordura corporal, sendo que esses pacientes foram mais sintomáticos e apresentaram maiores valores de proteína C reativa.

BACKGROUND: The inflammatory bowel diseases are characterized by multiple digestive tract symptoms and therefore may interfere with nutritional status. AIM: To assess the nutritional status of patients with inflammatory bowel disease in different stages of inflammatory activity. METHODS: Fifty five patients with inflammatory bowel disease were demographically evaluated with weight measurement, height, arm circumference and triceps skinfold and had their body composition determined by bioelectrical impedance. For determination of inflammatory activity of the disease were used serum C-reactive protein and the index of Harvey and Bradshaw. To compare means it was used the unpaired t test, and the average non-parametric, the Mann-Whitney test, level of significance p <0.05. RESULTS: Among the patients, 28 had Crohn's disease and 27 ulcerative colitis, aged between 19 and 63 years and time since diagnosis 1-22 years. There was no difference in anthropometric measurements and body composition of patients whose disease was inflammatory activity or in remission. Patients who used glucocorticoids in the six months preceding the assessment showed body fat percentage of 23.4 ± 8.2 percent whilst those who did not use the percentage was 30.7 ± 11.3 (p <0.0199). The most common gastrointestinal symptoms were abdominal distension (41 percent), diarrhea (18 percent), nausea (13 percent), constipation (12 percent), anorexia (11 percent) and vomiting (5 percent). All symptoms were more common in patients with higher body mass index and body fat. CONCLUSION: There were more patients with excess weight and body fat, and these patients were more symptomatic and had higher values of C-reactive protein.

Diagnostic role and clinical association of ASCA and ANCA in Brazilian patients with inflammatory bowel disease.

BACKGROUND: Anti-Saccharomyces cerevisae antibody (ASCA) and perinuclear anti-neutrophil cytoplasmatic antibody (pANCA) remain the most well-established markers in inflammatory bowel disease (IBD), and both may be associated with disease phenotype. AIM: To determine the utility of ASCA and pANCA as markers in a Brazilian cohort of IBD patients. MATERIALS AND METHODS: A total of 90 patients with ulcerative colitis (UC), 77 patients with Crohn's disease (CD), and 57 healthy individuals were included in the study. ASCA was determined by enzyme-linked immunosorbent assay (ELISA) and pANCA by immunofluorescence assay. RESULTS: In support of diagnosis of UC, the sensitivity and specificity of pANCA were 51% and 100%, respectively. ASCA (IgA or IgG isotypes) presented sensitivity of 62% and specificity of 93% for CD. The combination of ASCA negativity and pANCA positivity (ASCA-/pANCA+) displayed sensitivity of 43% and specificity of 100% for diagnosis to UC. In CD patients, ASCA+/pANCA- presented sensitivity and specificity of 57% and 93%, respectively. Additionally, ASCA positivity correlated with early age at disease onset and ileal location in CD patients. In UC patients, pANCA positivity was correlated with pancolitis or left colitis. CONCLUSIONS: The results evidenced that low sensitivity of ASCA and pANCA markers limits their use in IBD screening in the general population; however, their specificity may contribute to differentiation between CD and UC in IBD patients. Our study lends further support to the suggestion that serologic assessment identifies different subtypes of IBD.

[Low levels of 25-hydroxyvitamin D (25OHD) in patients with inflammatory bowel disease and its correlation with bone mineral density]. / Níveis baixos de 25-hidroxivitamina D (25OHD) em pacientes com doença inflamatória intestinal e sua correlação com a densidade mineral óssea.

UNLABELLED: Patients with inflammatory bowel disease (IBD) are at risk of having vitamin D deficiency (25-OHD) and low bone mineral density (BMD). OBJECTIVES: To measure 25OHD in a young group of IBD patients submitted to a clinical evaluation, routine biochemistry and BMD measurement (lumbar spine and proximal femur). RESULTS: 39 Crohn disease (CD) and 37 ulcerative colitis (UC) patients had lower serum levels of 25OHD compared to the control group (CD p = 0.003; UC p < 0.001), and 48.5% of the UC patients were 25OHD deficient. Lumbar spine BMD was lower in patients than controls (CD p = 0.001; UC p = 0.008). In CD patients, serum levels of 25OHD were significantly correlated with total femur (r = 0.391; p = 0.027) and femoral neck (r = 0.384; p = 0.03) BMD. CONCLUSION: It was found lower levels of 25OHD and BMD in young IBD patients compared to normal controls, suggesting an important role of 25OHD deficiency in the pathogenesis of the IBD bone disease.

Níveis baixos de 25-hidroxivitamina D (25OHD) em pacientes com doença inflamatória intestinal e sua correlação com a densidade mineral óssea / Low levels of 25-hydroxyvitamin D (25OHD) in patients with inflammatory bowel disease and its correlation with bone mineral density

INTRODUÇÃO: Pacientes com doenças inflamatórias intestinais (DII) estão propensos a apresentar níveis baixos de vitamina D (25OHD) e densidade mineral óssea (DMO) diminuída. OBJETIVO: Verificar o nível de 25OHD em jovens com DII submetidos à avaliação clínica, dosagens bioquímicas rotineiras e medida da DMO de coluna lombar e fêmur, comparando-os com controles saudáveis. RESULTADOS: 39 pacientes com doença de Crohn (DC) (p = 0, 003) e 37 com retocolite ulcerativa inespecífica (RCUI) (p < 0,001) apresentaram níveis mais baixos de 25OHD comparados aos controles, 48,5 por cento dos pacientes com RCUI tinham deficiência de 25OHD. A DMO em coluna lombar foi mais baixa nos doentes (DC p = 0,001; RCUI p = 0,008). A 25OHD correlacionou-se significativamente com a DMO do fêmur total (r = 0,391; p = 0,027) e colo do fêmur (r = 0,384; p = 0,03) na DC. CONCLUSÃO: Foram encontrados níveis baixos de 25OHD e DMO em jovens com DII, sugerindo papel importante desta deficiência na patogênese da doença óssea desses pacientes.

Patients with inflammatory bowel disease (IBD) are at risk of having vitamin D deficiency (25-OHD) and low bone mineral density (BMD). OBJECTIVES: To measure 25OHD in a young group of IBD patients submitted to a clinical evaluation, routine biochemistry and BMD measurement (lumbar spine and proximal femur). RESULTS: 39 Crohn disease (CD) and 37 ulcerative colitis (UC) patients had lower serum levels of 25OHD compared to the control group (CD p = 0,003; UC p < 0,001), and 48.5 percent of the UC patients were 25OHD deficient. Lumbar spine BMD was lower in patients than controls (CD p = 0,001; UC p = 0,008). In CD patients, serum levels of 25OHD were significantly correlated with total femur (r = 0,391; p = 0,027) and femoral neck (r = 0,384; p = 0,03) BMD. CONCLUSION: It was found lower levels of 25OHD and BMD in young IBD patients compared to normal controls, suggesting an important role of 25OHD deficiency in the pathogenesis of the IBD bone disease.

CARD15 and IL23R influences Crohn's disease susceptibility but not disease phenotype in a Brazilian population.

BACKGROUND: Although many genetic variants are identified in association with Crohn's disease (CD), CARD15, IL23R, and ATG16L1 association with CD have been firmly confirmed in Caucasians of European ancestry. The prevalence of CD is rapidly rising in Brazil, where European ancestry is firmly admixed with natives and Africans, resulting in a heterogeneous population. We investigated the contribution of CARD15, IL23R, and ATG16L1 with CD risk in a heterogeneous Brazilian population. METHODS: Genotyping for CARD15 (R702W, G908R, 3020insC), IL23R (rs1004819, rs7517847, rs11209026, rs10889677, rs1495965), and ATG16L1 (rs2241880) was performed in 187 children and adults with CD and 255 healthy ethnically matched controls. Clinical records were systematically reviewed and detailed phenotypic information was obtained. RESULTS: At least 1 CARD15 risk allele was present in 30% of the CD patients compared with 10% of controls. Variants of CARD15 (3020insC and R702W) and IL23R (rs1004819, rs11209026, and rs1088967) were associated with CD. However, no genotype-phenotype correlations were found among the Brazilian CD population with CARD15 or IL23R variants. No significant association was achieved with ATG16L1. CONCLUSIONS: CARD15 and IL23R confer susceptibility to CD in the Brazilian population. However, the presence of these variants did not influence disease phenotype. Further research should be focused on larger sample sizes with population admixture analysis to better understand the risks and genotype-phenotype correlation in populations like Brazil where the prevalence of CD is rapidly rising.

[Correlation of Doppler ultrasound of the portal system with endoscopic changes caused by portal hypertension in cirrhotic patients]. / Correlação das características do ecodoppler do sistema porta com presença de alterações endoscópicas secundárias à hipertensão porta em pacientes com cirrose hepática.

BACKGROUND: The portal hypertension in cirrhotic patients is the main cause of this illness complication, that are clinically translated to visible collateral circulation in the abdominal wall, ascites and esophageal varices. AIM: To evaluate if the portal system echodoppler is able to estimate the presence of esophageal varices, gastric varices and congestive gastropathy in patients with hepatic cirrhosis. PATIENTS AND METHODS: One hundred and eighty six patients of the gastroenterology and hepatology ambulatory of the Clinical Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, had been selected for evaluation. Of those, 145 had completed all the stages of the evaluation and 133 had been enclosed in the final analysis. All had been submitted to high digestive endoscopy for evaluation of esophagogastric varices and congestive gastropathy and then to Doppler ultrasound of the portal system with study of the systolic peak speed of the portal vein, diameter of the portal and splenic vein and spleen size, presence of the umbilical vein recanalization and hepatofugal flow. RESULTS: The patients with esophagogastric varices had significant difference of the spleen size when compared to patients without these change. However, none of the Doppler ultrasound parameters showed good accuracy and specificity in this group of cirrhotic patients. Congestive gastropathy patients had their diagnosis predict with significant manner not only by the portal and splenic vein diameter but also by the spleen size. Similarly to that described above, they do not have a good accuracy and specificity. These evaluations were validated by the construction of ROC (Receiver Operating Characteristic) curves, whose areas below the curves had always been less than 0,8. CONCLUSION: There was not a good correlation of the Doppler ultrasound parameters of the portal system to the presence of the main endoscopic alterations (esophagogastric varices and congestive gastropathy) in patients with hepatic cirrhosis.

Correlação das características do ecodoppler do sistema porta com presença de alterações endoscópicas secundárias à hipertensão porta em pacientes com cirrose hepática / Correlation of Doppler ultrasound of the portal system with endoscopic changes caused by portal hypertension in cirrhotic patients / Correlation of Doppler ultrasound of the portal system with endoscopic changes caused by portal hypertension in cirrhotic patients

RACIONAL: A hipertensão portal é a causa principal das complicações da cirrose hepática, traduzidas clinicamente por circulação colateral visível na parede abdominal, ascite e varizes esofágicas. OBJETIVO: Avaliar a capacidade do ecodoppler do sistema porta no diagnóstico de alterações esôfago-gástricas endoscópicas secundárias à hipertensão porta em pacientes com cirrose hepática. PACIENTES E MÉTODOS: Cento e oitenta e seis pacientes dos ambulatórios de gastroenterologia e hepatologia do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, foram selecionados para avaliação. Destes, 145 completaram todas as etapas e 133 puderam ser incluídos na análise final dos dados. Todos foram submetidos a endoscopia digestiva alta, visando determinar presença e grau de varizes esofágicas e gástricas e de gastropatia congestiva e ao ecodoppler do sistema porta para medir/aferir pico de velocidade sistólica da veia porta, diâmetro das veias porta e esplênica, tamanho do baço, presença de recanalização da veia umbilical e de fluxo hepatofugal. RESULTADOS: Os pacientes com varizes esofágicas e gástricas tiveram diferença significativa do tamanho do baço quando comparados com os pacientes sem essas alterações. No entanto, a exatidão e a especificidade deste parâmetro não foi adequada. O diagnóstico de gastropatia congestiva pode ser predito de maneira significativa, tanto pelo diâmetro da veia porta, quanto pelo da esplênica e também pelo tamanho do baço. Da mesma forma, todavia, a exatidão e especificidade destes parâmetros foram ruins. As medidas foram validadas pela construção de curvas ROC ("Receiver Operating Characteristic"), cujas áreas sob as curvas foram sempre menores que 0,8. CONCLUSÃO: Nesta série de pacientes não houve boa correlação dos parâmetros do ecodoppler do sistema porta com a presença das principais alterações endoscópicas (varizes esofágicas, varizes gástricas, gastropatia congestiva) em pacientes com cirrose hepática.

BACKGROUND: The portal hypertension in cirrhotic patients is the main cause of this illness complication, that are clinically translated to visible collateral circulation in the abdominal wall, ascites and esophageal varices. AIM: To evaluate if the portal system echodoppler is able to estimate the presence of esophageal varices, gastric varices and congestive gastropathy in patients with hepatic cirrhosis. PATIENTS AND METHODS: One hundred and eighty six patients of the gastroenterology and hepatology ambulatory of the Clinical Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, had been selected for evaluation. Of those, 145 had completed all the stages of the evaluation and 133 had been enclosed in the final analysis. All had been submitted to high digestive endoscopy for evaluation of esophagogastric varices and congestive gastropathy and then to Doppler ultrasound of the portal system with study of the systolic peak speed of the portal vein, diameter of the portal and splenic vein and spleen size, presence of the umbilical vein recanalization and hepatofugal flow. RESULTS: The patients with esophagogastric varices had significant difference of the spleen size when compared to patients without these change. However, none of the Doppler ultrasound parameters showed good accuracy and specificity in this group of cirrhotic patients. Congestive gastropathy patients had their diagnosis predict with significant manner not only by the portal and splenic vein diameter but also by the spleen size. Similarly to that described above, they do not have a good accuracy and specificity. These evaluations were validated by the construction of ROC (Receiver Operating Characteristic) curves, whose areas below the curves had always been less than 0,8. CONCLUSION: There was not a good correlation of the Doppler ultrasound parameters of the portal system to the presence of the main endoscopic alterations (esophagogastric varices and congestive gastropathy) in ...