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Ustekinumab and tofacitinib have recently been approved for the management of moderate to severe ulcerative colitis (UC). However, there is no evidence on how they should be positioned in the therapeutic algorithm. The aim of this study was to compare tofacitinib and ustekinumab as third‐line therapies in UC patients in whom anti‐TNF and vedolizumab had failed. This was a multicenter retrospective observational study. The primary outcome was disease progression, defined as the need for steroids, therapy escalation, UC‐related hospitalization and/or surgery. Secondary outcomes were clinical remission, normalization of C‐reactive protein, endoscopic remission, treatment withdrawal, and adverse events. One‐hundred seventeen UC patients were included in the study and followed for a median time of 11.6 months (q1–q3,5.5–18.7). Overall, 65% of patients were treated with tofacitinib and 35% with ustekinumab. In the entire study cohort, 63 patients (54%) had disease progression during the follow‐up period. Treatment with ustekinumab predicted increased risk of disease progression compared to treatment with tofacitinib in Cox regression analysis (HR: 1.93 [95% CI: 1.06–3.50] p= 0.030). Twenty‐eight (68%) patients in the ustekinumab group and 35 (46%) in the tofacitinib group had disease progression over the follow‐up period (log‐rank test, p< 0.054). No significant differences were observed for the secondary outcomes. Six and 22 adverse events occurred in the ustekinumab and tofacitinib groups, respectively (15% vs. 31%, p= 0.11). Tofacitinib was more efficacious in reducing disease progression than ustekinumab in this cohort of refractory UC patients. However, prospective head‐to‐head clinical trials are needed as to confirm these data.

Atrial fibrillation is the most common arrhythmia in clinical practice and it is associated with increased morbidity and mortality. Atrial fibrillation is linked with inflammatory signaling while inflammation and oxidative stress promote atrial remodeling promoting the development and perpetuation of the arrhythmia. On the other hand, inflammatory bowel disease (IBD) is considered a chronic inflammatory condition with flares and remissions. IBD has been associated with an increased risk of atherosclerotic cardiovascular disease but its relationship with atrial fibrillation has not been studied well. Recent epidemiological evidence indicates an association between IBD and atrial fibrillation, especially during flares/hospitalizations. This brief review provides a concise overview of all available data regarding the association between IBD and atrial fibrillation including the predictive role of electrocardiographic and echocardiographic markers. Several unresolved issues including the thromboembolic risk in this setting and the potential role of antiinflammatory interventions are also discussed.

The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.

Background The lack of scientific evidence regarding the effectiveness of 5-aminosalicylate in patients with Crohn’s disease is in sharp contrast to its widespread use in clinical practice.Aims The aim of the study was to investigate the use of 5-aminosalicylate in patients with Crohn’s disease as well as the disease course of a subgroup of patients who were treated with 5-aminosalicylate as maintenance monotherapy during the first year of disease.Methods In a European community-based inception cohort, 488 patients with Crohn’s disease were followed from the time of their diagnosis. Information on clinical data, demographics, disease activity, medical therapy and rates of surgery, cancers and deaths was collected prospectively. Patient management was left to the discretion of the treating gastroenterologists.Results Overall, 292 (60%) patients with Crohn’s disease received 5-aminosalicylate period during follow-up for a median duration of 28 months (interquartile range 6–60). Of these, 78 (16%) patients received 5-aminosalicylate monotherapy during the first year following diagnosis. Patients who received monotherapy with 5-aminosalicylate experienced a mild disease course with only nine (12%) who required hospitalization, surgery, or developed stricturing or penetrating disease, and most never needed more intensive therapy. The remaining 214 patients were treated with 5-aminosalicylate as the first maintenance drug although most eventually needed to step up to other treatments including immunomodulators (75 (35%)), biological therapy (49 (23%)) or surgery (38 (18%)).Conclusion In this European community-based inception cohort of unselected Crohn’s disease patients, 5-aminosalicylate was commonly used. A substantial group of these patients experienced a quiescent disease course without need of additional treatment during follow-up. Therefore, despite the controversy regarding the efficacy of 5-aminosalicylate in Crohn’s disease, its use seems to result in a satisfying disease course for both patients and physicians.

The lack of scientific evidence regarding the effectiveness of 5-aminosalicylate in patients with Crohn’s disease is in sharp contrast to its widespread use in clinical practice. The aim of the study was to investigate the use of 5-aminosalicylate in patients with Crohn’s disease as well as the disease course of a subgroup of patients who were treated with 5-aminosalicylate as maintenance monotherapy during the first year of disease. In a European community-based inception cohort, 488 patients with Crohn’s disease were followed from the time of their diagnosis. Information on clinical data, demographics, disease activity, medical therapy and rates of surgery, cancers and deaths was collected prospectively. Patient management was left to the discretion of the treating gastroenterologists. Overall, 292 (60%) patients with Crohn’s disease received 5-aminosalicylate period during follow-up for a median duration of 28 months (interquartile range 6–60). Of these, 78 (16%) patients received 5-aminosalicylate monotherapy during the first year following diagnosis. Patients who received monotherapy with 5-aminosalicylate experienced a mild disease course with only nine (12%) who required hospitalization, surgery, or developed stricturing or penetrating disease, and most never needed more intensive therapy. The remaining 214 patients were treated with 5-aminosalicylate as the first maintenance drug although most eventually needed to step up to other treatments including immunomodulators (75 (35%)), biological therapy (49 (23%)) or surgery (38 (18%)). In this European community-based inception cohort of unselected Crohn’s disease patients, 5-aminosalicylate was commonly used. A substantial group of these patients experienced a quiescent disease course without need of additional treatment during follow-up. Therefore, despite the controversy regarding the efficacy of 5-aminosalicylate in Crohn’s disease, its use seems to result in a satisfying disease course for both patients and physicians.

Inflammatory bowel disease (IBD) places a significant burden on health-care systems because of its chronicity and need for expensive therapies and surgery. With increasing use of biological therapies, contemporary data on IBD health-care costs are important for those responsible for allocating resources in Europe. To our knowledge, no prospective long-term analysis of the health-care costs of patients with IBD in the era of biologicals has been done in Europe. We aimed to investigate cost profiles of a pan-European, community-based inception cohort during 5 years of follow-up.

ObjectiveThe Epi-IBD cohort is a prospective population-based inception cohort of unselected patients with inflammatory bowel disease from 29 European centres covering a background population of almost 10 million people. The aim of this study was to assess the 5-year outcome and disease course of patients with Crohn’s disease (CD).DesignPatients were followed up prospectively from the time of diagnosis, including collection of their clinical data, demographics, disease activity, medical therapy, surgery, cancers and deaths. Associations between outcomes and multiple covariates were analysed by Cox regression analysis.ResultsIn total, 488 patients were included in the study. During follow-up, 107 (22%) patients received surgery, while 176 (36%) patients were hospitalised because of CD. A total of 49 (14%) patients diagnosed with non-stricturing, non-penetrating disease progressed to either stricturing and/or penetrating disease. These rates did not differ between patients from Western and Eastern Europe. However, significant geographic differences were noted regarding treatment: more patients in Western Europe received biological therapy (33%) and immunomodulators (66%) than did those in Eastern Europe (14% and 54%, respectively, P<0.01), while more Eastern European patients received 5-aminosalicylates (90% vs 56%, P<0.05). Treatment with immunomodulators reduced the risk of surgery (HR: 0.4, 95% CI 0.2 to 0.6) and hospitalisation (HR: 0.3, 95% CI 0.2 to 0.5).ConclusionDespite patients being treated early and frequently with immunomodulators and biological therapy in Western Europe, 5-year outcomes including surgery and phenotype progression in this cohort were comparable across Western and Eastern Europe. Differences in treatment strategies between Western and Eastern European centres did not affect the disease course. Treatment with immunomodulators reduced the risk of surgery and hospitalisation.

Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts. These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts). A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults. These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.

The aim of this study was to assess the role of known risk factors and specifically evaluate the role of pancreatitis potentially associated drugs as potential risk factors for post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

In the present study, the changes in circulating IGF-1 and its binding protein IGFBP-3 were determined in adult patients with active inflammatory bowel disease (IBD) in order to assess the effect of this inflammatory condition on the IGF system. IGF-1 and IGFBP-3, as well as interleukin-6 (IL-6) were measured in serum obtained from 22 consecutive newly diagnosed patients (mean age 41.3 years) with active IBD, including 10 patients with Crohn's disease (CD), and 12 with ulcerative colitis (UC). For comparison the same parameters were determined in 30 healthy volunteers matched for age, sex and Body Mass Index (BMI).

OBJECT:It is well established that during ERCP pancreas is undergoing a multifactorial attack by the whole endoscopic procedure (catheters, liquids used and mechanical pressure) despite of the fact that it might have already been inflamed at the day of admission. The purpose of this study was the biochemical assessment of this pancreatic damage using both routine and sophisticated markers of pancreatic inflammation and the correlation of the derived values with patients clinical parameters and disease outcome. It should be noticed that patients need always a 3 days hospital admission for the whole ERCP procedure.MATERIALS AND METHODS:In 31 consecutive patients with no renal insufficiency or severe hepatic inflammation (15 males and 16 females, mean age 61 years) undergoing diagnostic or therapeutically ERCP we assessed 24 hours before, 2 hours and 18 hours after ERCP the following parameters; AST, ALT, g-GT, ALP, AMS(serum and urine), LDH(routine methods) and elastase-1(ELISA, normal values 0.1-4 ng/ml).Meanwhile a full registry was performed with the patients epidemiological profile, clinical symptoms, initial and final diagnosis, days of hospital admission and disease outcome. Statistical correlation was performed using all the above mentioned values emphasizing more on elastase-1. RESULTS: Elastase was elevated in 7/38(18%)patients after ERCP and correlated statistically with serum amylase(p<0,05) with a ratio elastase/amylase=1/376.It also correlated with pathology (lithiasis or stenosis) of the pancreatic and lower part of the common bile duct. Clinically diagnosed post -ERCP pancreatitis was evident in 2/38(5%)of patients with elastase >3,5 ng/ml and 6-fold AMS increase while biochemical pancreatitis was diagnosed in another 5 (12%) free of symptoms patients. DISCUSSION:In ERCP the routine use of elastase may be of great importance because of its ability not only to reveal pancreatic damage but also to offer early prediction of the post- ERCP outcome(earlier than serum or urine amylase) when levels are>3.5 ng/ml.We further propose the routine use of elastase in other pancreatic diseases in order to assess early relapse or disease outcome.