A patient having familiar adenomatosis polyposis and an ileo‐rectal anastomosis developed a flat mucosal lesion in the rectum. A punch biopsy revealed a villous adenoma with high‐grade dysplasia. The subsequent surgical specimen indicated that the flat villous adenoma was rich in Paneth cells. Special stains included lysozyme muramidase (to visualize Paneth cells), MIB1 proliferation monoclonal antibody and single and multilabel immunohistochemistry for Paneth cells. Other methods included transmission electron microscopy and quantification with an image quantifier (Program Optilab 2.1) of lysozyme‐stained Paneth cells. The subjective evaluation of hematoxylin‐cosin‐stained preparations demonstrated that the Paneth cells were mainly located in the lower half of the villi. Sections labeled with a specific stain (lysozyme muramidase) revealed more Paneth cells in the villi and electron microscopy showed even more in lysozyme‐negative areas. Obviously some migrating dysplastic Paneth cells had retained their characteristic granules on their way towards the tip of the villi. Quantitative studies indicated that the lysozyme muramidase‐positive material accounted for 41% of the adenomatous tissue. MIB1 revealed intense cell proliferation at the base of the adenoma and in the entire slopes of the villi. Despite the wide distribution of Paneth cells in intestinal metaplasia of the stomach, in the normal small intestine and in the large bowel with chronic inflammatory diseases, it is surprising that tumors arising in Paneth cells are extremely rare. The causes of the apparent natural resistance of Paneth cells to tumor development deserve to be investigated. This is the first case of Paneth cell‐rich flat adenoma of the rectum in the literature.
INTRODUCTION: Most studies on fractures in inflammatory bowel disease (IBD) are based on patients from tertiary centers or patients followed up before the introduction of immunomodulators or biologics. In addition, the role of corticosteroids in fracture risk has rarely been examined. METHODS: We conducted a nationwide population-based cohort study of 83,435 patients with incident IBD (ulcerative colitis [UC]: n = 50,162, Crohn's disease [CD]: n = 26,763, and IBD unclassified: 6,510) and 825,817 reference individuals from 1964 to 2014. Using multivariable Cox regression, we estimated hazard ratios (HRs) for hip fracture and any fracture and the association with cumulative corticosteroid exposure. RESULTS: During 1,225,415 person-years of follow-up in patients with IBD, there were 2,491 first-time hip fractures (203/100,000 person-years) compared with 20,583 hip fractures during 12,405,642 person-years in reference individuals (159/100,000 person-years). This corresponded to an HR of 1.42 (95% confidence interval [CI] = 1.36–1.48). The risk for hip fracture was higher in CD compared with UC ( P < 0.001). Inflammatory bowel disease was also associated with any fracture (IBD: HR = 1.18; 95% CI = 1.15–1.20). Hazard ratios for hip fracture had not changed since the introduction of immunomodulators or biologics. Increasing exposure to corticosteroids was associated with hip fracture in both IBD and non-IBD individuals ( P < 0.001), but only in elderly (>60 years) patients with IBD. The association between IBD and hip fracture was nonsignificant among individuals without corticosteroids (HR = 1.11; 95% CI = 0.86–1.44). CONCLUSIONS: Inflammatory bowel disease (CD and UC) is associated with an increased risk of hip fracture and any fracture, but not in individuals without a history of corticosteroid treatment. The association between corticosteroids and hip fracture was restricted to elderly patients with IBD.
The optimal nutritional management during a severe flare of inflammatory bowel disease is uncertain. The goal of this study was to describe variations in nutritional practices between different countries, professions and types of hospitals, as well as between ulcerative colitis (UC) and Crohn's disease (CD).
Familial adenomatous polyposis (FAP) is an inherited condition that requires prophylactic surgery (colectomy) followed by a lifetime program of endoscopic surveillance to prevent colorectal cancer. Patients are normally free of symptoms before surgery but a majority report problems related to bowel function postoperatively.The aim of the study was to gain a deeper understanding of how FAP affects life by exploring patients' view of what it is like living with the illness and being committed to a lifelong screening program.Three focus group interviews were conducted, and data were analyzed using descriptive qualitative content analysis.The analysis resulted in two categories related to the participants' view of living with FAP. The first category was associated with concerns related to the hereditary and lifelong nature of the disease as well as to the prophylactic surgery and the second category was related to patients' ways of managing life.Most participants expressed unmet needs, such as lack of healthcare providers with good knowledge about FAP, practical and psychosocial support, FAP educational programs, and organized meetings with other persons with the condition.One important aspect of living with FAP shared by the participants concerned ways of managing life concerns, something that healthcare providers caring for patients with FAP should identify and support. Furthermore, continuity of care by health care providers with good knowledge about FAP can be an important way of reducing patient concerns.
Abstract Background Diet is known to affect inflammatory bowel disease (IBD), but the optimal nutritional therapy during a severe flare is uncertain. The goal of this study was to describe variation in nutritional practices across Europe, between professions, types of hospitals and healthcare systems, as well as between ulcerative colitis (UC) and Crohn’s disease (CD). Methods A novel questionnaire comprising 17 questions, of which 5 concerning demographic data, was distributed digitally in the ECCO Congress 2022 and via the ECCO country representatives. In the comparisons of categories (e.g., countries), only categories with at least 25 responses were considered, and Chi-squared test was used. Results The survey was completed by 313 participants. Table 1 summarises their main characteristics. Physicians and dietitians were most commonly responsible for determining nutritional therapy for IBD inpatients (Table 2). The commonest form of nutritional therapy was oral nutritional supplements (ONS) on top of easy to digest food. Total parenteral nutrition (TPN) was used by 10% of respondents for UC patients and 7% for CD. Almost a quarter of respondents reported less than 25% of patients being assessed by a dietitian in the first 3 days of a flare. Energy intake, stool frequency and inflammatory biomarkers were the commonest factors to determine when to change nutritional therapy. No specific nutritional screening tool was used by 45% of respondents. There was significant variation between different European countries and healthcare professions for all the outcomes measured (p<0.050). However, in 7 of total 12 questions the variation between professions was only caused by variation in selecting the “I don’t know” alternative. When countries were grouped by healthcare index (HI), countries with high HI showed higher proportion using ONS on top of easy to digest food in CD (p=0.008), being more likely to use a specific nutritional screening tool for assessment (p<0.001) and using more approximate nutritional monitoring in UC instead of reporting all intake (p=0.002). Moreover, nutritional therapy management did not vary according to hospital type (university versus general), apart from criteria of changing nutritional therapy in CD (p=0.021) and monitoring intake in UC (p=0.046). During the first three days of a severe flare, a diet consisting exclusively of ONS was significantly more frequently used for CD than UC (p=0.018, Figure 1). Otherwise, similar nutritional therapy strategies were reported for CD and UC including using TPN to a similar extent. Conclusion Country is the main determinant of differences in nutritional practice across Europe. Diet consisting exclusively of ONS is more common during a flare of CD than UC.
BACKGROUND: Patients with familial adenomatous polyposis who undergo surgery to prevent colorectal cancer experience various abdominal symptoms that may affect their physical and mental health. OBJECTIVE: This study was designed to investigate self-reported presence, frequency, and troublesomeness of abdominal symptoms in such patients in relation to gender, type of surgery, and physical and mental health. DESIGN: A cohort study with a descriptive and comparative cross-sectional design. SETTING AND PARTICIPANTS: All adult patients in the Swedish Polyposis Registry (Karolinska University Hospital, Stockholm, Sweden) who were diagnosed with familial adenomatous polyposis, had undergone prophylactic colorectal surgery, and were aged 18 to 75 years were invited to return a mailed questionnaire. MAIN OUTCOME MEASURES: Self-reported presence, frequency, and troublesomeness of 21 abdominal symptoms were assessed with the Abdominal Symptom Questionnaire. Physical health and mental health were evaluated with the Medical Outcomes Study Short Form 36 Health Survey. RESULTS: Of 275 eligible patients, 209 (76%) responded. Of respondents, 190 (91%) reported having had at least 1 symptom during the last 3 months. All 21 symptoms investigated were reported. A higher number of symptoms was reported by women than by men: mean, 7.55 (SD, 4.89) vs 5.14 (4.49); P < .01. No significant difference was found between women and men in overall troublesomeness of symptoms: 3.15 (1.30) vs 3.09 (1.27); P = .763. Self-reported number of symptoms was an independent predictor of physical and mental health, with a high number of symptoms related to poor physical and mental health. LIMITATIONS: The Abdominal Symptom Questionnaire has not been previously used in patients with FAP, and measurement of physical and mental health with the Short Form 36 Health Survey may not capture all aspects of health status in patients with familial adenomatous polyposis. CONCLUSION: Patients with familial adenomatous polyposis suffer from a wide variety of abdominal symptoms after colorectal surgery. Identification of patients with a high number of abdominal symptoms is especially important because the number of abdominal symptoms affects patients' physical and mental health.
Spondyloarthritis (SpA) impacts on several aspects of affected individuals9 lives and restricts patients9 ability to participate in society. After diagnosis is set, a period follows during which treatment regimens are adjusted to fit the individual patient9s needs. Better patient functioning is often obtained if treatment is successful or if the natural course of the disease is favorable. This might be reflected by reduced sickness absence over time following diagnosis. Patients with different subgroups of SpA report different impact of the disease on self-reported functioning and participation. Thus, different trends in the subgroup-specific sickness-absence patterns might be present over the years following diagnosis.
Objectives
The aim was to assess whether the trends in the amount of sickness absence during the ten-year period following a SpA diagnosis differed between well-defined cohorts of patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA) and undifferentiated spondyloarthritis (USpA).
Methods
Patients with AS, PsA or USpA were identified through the Skåne Healthcare Register, covering a population of 1.3 million in southern Sweden. First year of diagnosis by a physician between 2003 and 2007 was set as the inclusion year. Information on sickness absence (sick leave and disability pension) during the years following diagnosis up until 2012 was obtained from the Swedish Social Insurance Agency. Years when the patient was between 18 and 67 years of age, resident in the Skåne region and alive by December 31st were considered valid for inclusion. The average number of full days of sickness absence per patient and year following diagnosis was calculated for each cohort. The results were standardized according to the sex and age distribution of all identified SpA patients. Linear regression on the aggregated data was used to test for differences in trends between the cohorts.
Results
The cohorts included 12 476, 18 542 and 6360 person-years from 2408, 3388, and 1251 patients diagnosed with AS, PsA and USpA, respectively. In the USpA cohort, the average number of full days of sickness absence per patient was reduced by 14% during the ten years following diagnosis (Figure). Assuming linear trends, the reduction in average number of full days of sickness absence in the USpA cohort was 1.7 per year following diagnosis (p<0.001) whereas no marked changes occurred in the AS and PsA cohorts.
Conclusions
A decrease in the average number of days of sickness absence occurred among USpA patients during the ten-year period following diagnosis. This suggests that USpA patients regained some of their physical function after diagnosis, likely as the result of successful treatment regimens or a favourable natural course of the disease. No improvement as regards sickness absence was observed in AS and PsA patients.
Abstract Background Serious infections have been observed in patients with inflammatory bowel disease (IBD) on anti-TNF use—but to what extent these infections are due to anti-TNF or the disease activity per se is hard to disentangle. We aimed to describe how the rates of serious infections change over time both before and after starting anti-TNF in IBD. Methods Inflammatory bowel disease patients naïve to anti-TNF treatment were identified at 5 centers participating in the Swedish IBD Quality Register, and their medical records examined in detail. Serious infections, defined as infections requiring in-patient care, the year before and after the start of anti-TNF treatment were evaluated. Results Among 980 patients who started their first anti-TNF therapy between 1999 and 2016, the incidence rate of serious infections was 2.19 (95% CI,1.43-3.36) per 100 person years the year before and 2.11 (95% CI, 1.33-3.34) per 100 person years 1 year after treatment start. This corresponded to an incidence rate ratio 1 year after anti-TNF treatment of 0.97 (95% CI, 0.51-1.84). Compared with before anti-TNF therapy, the incidence of serious infection was significantly decreased more than 1 year after treatment (incidence rate ratio 0.56; 95% CI, 0.33-0.95; P = .03). Conclusions In routine clinical practice in Sweden, the incidence rate of serious infection among IBD patients did not increase with anti-TNF therapy. Instead, serious infections seemed to decrease more than 1 year after initiation of anti-TNF treatment.
