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Ileocolonoscopy remains the mainstay of objective disease assessment in Crohn's Disease, and various validated indices are used to grade severity of the disease. The most commonly used indices are the Simple Endoscopic Score for Crohn's Disease (including the size of ulcers) and the Crohn's Disease Endoscopic Index of Severity (including the depth of ulcers). These measurements are highly subjective, especially the depth of an ulcer, and are based solely on the discretion of the endoscopist coupled with the imaging capabilities of the colonoscope and adequacy of the bowel prep. Narula et al. undertook a post hoc analysis of baseline predictors of endoscopic remission (ER) at week 26 in a subset (172 of 508) of moderate-severe Crohn's disease patients participating in the SONIC trial. The authors found no significant differences in the odds of achieving ER when comparing overall or segmental severe inflammation (high Simple Endoscopic Score for Crohn's Disease [>16 overall or >3 per segment] or Crohn's Disease Endoscopic Index of Severity [>12 overall or >3 per segment] scores) with moderate inflammation. The number of affected segments involved also did not impact the likelihood of achieving week 26 ER. The authors then found a potentially synergistic effect with large and deep ulcers in the ileum and rectum. The optimal time to assess whether ulcers ultimately heal or not is unknown, but waiting longer than 26 weeks may negate any lead time bias regarding ulcer size. Therefore, similar to many areas of life, it is likely that size ultimately does not matter, but instead location, location, and location.

We assessed the real-world effectiveness and safety of vedolizumab (VDZ) in moderate-severe Crohn's disease (CD).Retrospective cohort study of seven medical centers, from May 2014 to December 2015. Adults with moderate-severe CD treated with VDZ, with follow-up after initiation of therapy, were included. Using the multivariable Cox proportional hazard analyses, we identified independent predictors of clinical remission or mucosal healing with VDZ. Rates of serious infection (requiring antibiotics, resulting in discontinuation of VDZ, hospitalization or death) and serious adverse events (discontinuation of VDZ, hospitalization or death) were described quantitatively.We included 212 patients with moderate-severe CD (median age 34 years; 40% male; 90% tumor necrosis factor (TNF)-antagonist exposed) with a median follow-up (IQR) of 39 weeks (25-53). Twelve-month cumulative rates of clinical remission, mucosal healing, and deep remission (clinical remission+mucosal healing) were 35%, 63%, and 26%, respectively. Individuals with prior TNF-antagonist exposure (hazard ratio (HR) 0.40; 95% confidence interval (CI): 0.20-0.81), smoking history (HR 0.47; 95% CI: 0.25-0.89), active perianal disease (HR 0.49; 95% CI: 0.27-0.88), and severe disease activity (HR 0.54; 95% CI: 0.31-0.95) were less likely to achieve clinical remission. Those with prior TNF-antagonist exposure (HR 0.29; 95% CI: 0.12-0.73), and severe disease activity (HR 0.54; 95% CI: 0.31-0.95) were less likely to achieve mucosal healing. During 160 patient years of follow-up (PYF) and 1,433 VDZ infusions, 5 patients developed infusion reactions (3.5 per 1,000 infusions), 21 developed serious infections (13 per 100 PYF), and 17 developed serious adverse events (10 per 100 PYF). A minority of adverse events required discontinuation of therapy (6 per 100 PYF).VDZ is a safe and effective treatment option for moderate-severe CD in routine practice. Clinical remission and deep remission (clinical remission and mucosal healing) can be achieved in 1/3 of individuals, and a minority of individuals require discontinuation of therapy due to adverse events.

Infliximab was the first FDA approved biologic for the treatment of Crohn's disease. Data for its use before and during pregnancy in both females and males have been increasing over the last decade, but most studies have had fewer than 100 patients and inconsistent comparison to healthy control outcomes. New data from the TREAT Safety Registry have a robust N of female and male patients exposed to infliximab with known birth outcomes from both academic and community settings. There does not appear to be any increase in adverse pregnancy outcomes from this population.

Maintenance therapy with 5-aminosalicylates (5-ASAs) is recommended in patients with quiescent ulcerative colitis (UC), but compliance rates are low. Once-daily dosing may improve adherence, but impact on the relapse of disease activity is unclear as no previous meta-analysis has studied this issue.MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through April 2011). Eligible randomized controlled trials (RCTs) recruited adults with quiescent UC, and compared once-daily dosing of 5-ASAs with a more frequent dosing schedule of an identical total daily dose of the same 5-ASA drug. Minimum treatment duration was 6 months. Trials reported a dichotomous assessment of relapse of disease activity at last point of follow-up. Data concerning non-compliance and adverse events were extracted, where reported. Effect of once-daily vs. more frequent dosing schedule was reported as relative risk (RR) of relapse with a 95% confidence interval (CI).The search identified 3,061 citations, and seven RCTs containing 2,745 patients were eligible. All RCTs used mesalamine. Relapse rates were not significantly different between once-daily and conventional dosing schedules for mesalamine (RR of relapse=0.94; 95% CI: 0.82-1.08). Non-compliance (RR=0.87; 95% CI: 0.46-1.66) and adverse events were no more likely with once-daily dosing (RR=1.08; 95% CI: 0.97-1.20).Once-daily dosing with mesalamine is as effective as conventional dosing schedules for the prevention of relapse of quiescent UC, although there is no definitive evidence that compliance with once-daily dosing is better. Adverse events occur at a similar frequency.

Crohn ’ s disease (CD) and ulcerative colitis (UC) are chronic infl ammatory disorders of the gastrointestinal tract. Collectively they are termed infl ammatory bowel disease (IBD) and it is estimated that 1.5 million Americans ( 1 ) suff er from UC and CD. Th eir etiologies are unknown, although both are thought to arise from a disordered immune response to the gut contents in genetically predisposed individuals ( 1 ). Th e characteristics of the infl ammatory response are diff erent, with CD typically causing transmural infl ammation and occasionally associated with granulomas, whereas in UC the infl ammation is usually confi ned to the mucosa. Both UC and CD exhibit a relapsing and remitting course and there is a signifi cant, oft en dramatic, reduction in quality of life during exacerbations of the disease ( 2 ). Th is has an impact on psychological health, with active IBD patients experiencing greater levels of distress and feelings of lack of sense of self-control compared with the normal population and patients with inactive IBD ( 3,4 ).

Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract. Evidence for treatment with 5-aminosalicylic acid (5-ASA) drugs is conflicting. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine this issue.MEDLINE, EMBASE, and the Cochrane central register of controlled trials were searched (through December 2010). Authors of studies were contacted to provide additional information on trials where required, and experts in the field were contacted to identify unpublished studies. Eligible trials recruited adults with active or quiescent CD and compared 5-ASAs with placebo, or no treatment. Dichotomous data were pooled to obtain relative risk (RR) of failure to achieve remission in active CD, and RR of relapse of disease activity in quiescent CD, with a 95% confidence interval (CI). The number needed to treat (NNT) was calculated from the reciprocal of the risk difference.The search identified 3,061 citations. Twenty-two RCTs were eligible. Six RCTs compared 5-ASA with placebo in active CD remission. There was a trend towards a benefit with sulfasalazine over placebo (two RCTs, RR of failure to achieve remission=0.83; 95% CI=0.69-1.00), but no definite benefit of mesalamine over placebo (four RCTs, RR=0.91; 95% CI=0.77-1.06). Neither sulfasalazine nor mesalamine were effective in preventing quiescent CD relapse, but in a per protocol analysis mesalamine appeared to reduce risk of relapse (RR=0.79; 95% CI=0.66-0.95, NNT=13).The role of 5-ASAs in inducing remission of active CD and preventing relapse of quiescent CD remains uncertain, and more RCTs are required.

Relatively little attention has been focused on the reproductive and sexual function issues faced by men with inflammatory bowel disease (IBD). Infertility in men with IBD can be caused by medications used to treat the disease (most notably sulfasalazine), by active inflammation, and by the poor nutritional status that can result from IBD. Sexual function can be adversely affected by some medications used to treat IBD, by the depression that can accompany active IBD, and by proctocolectomy. When men with IBD do father children, there appears to be no increased rate of adverse fetal outcomes. Screening for prostate cancer after proctocolectomy can be challenging, but current data support the use of prostate-specific antigen screening for these patients. This review serves as an outline to assist the clinician in discussing sexual and reproductive issues in male patients with IBD.

The Women in Gastroenterology Committee of the American College of Gastroenterology (ACG) conducted a survey among physician members of the ACG to examine the influence of mentoring on career satisfaction. The survey found that the overall rates of career satisfaction and mentorship are high, and that a majority of those without mentors wish that they had had one. Having a mentor who was described as either very effective or extremely effective was associated with higher career satisfaction, but was reported by only 59% of respondents. Factors associated with effective mentoring include frequent meetings, career mentoring, and mentors who are at the rank of professor. If these mentoring rates are representative of rates in the United States, approximately 170 gastroenterology fellows lack mentorship but wish they had it, and 325 more have, at best, moderately effective mentors. We should consider instituting national programs to provide trainees with effective mentorship.

To the Editor: We read with great interest the article by Gisbert et al. (1), which investigated giving vaccine against hepatitis B virus (HBV) at an accelerated, double dosage in patients with inflammatory bowel disease (IBD). The overall seroconversion rate was low, particularly in those receiving biological therapy. Immunosuppressants, however, did not affect vaccine efficacy (1).

In response to an article describing cytomegalovirus (CMV) infection in patients with active inflammatory bowel disease (IBD) the authors review a specific case of a male patient with IBD and its importance for patient education for patient education for patients with IBD. The authors highlight the importance of communicating to male IBD patients prescribed ganciclovir for treatment of CMV infection the need for contraception because of potential teratogenic effects. For other mainstay of IBD treatments paternal use of these agents is associated with either unknown or no increased risk of adverse fetal outcomes.

This letter to the editor discusses a literature review to assess the evidence on the efficacy of oral contraceptives when combined with antibiotic therapy. It formulates a rational guideline for patients with inflammatory bowel disease receiving concomitant oral contraceptives and antibiotic therapy.