Introduction

The evolution of inflammatory bowel disease (IBD) occurs across four epidemiological stages: emergence, acceleration in incidence, compounding prevalence and prevalence equilibrium; as put forward by Kaplan et al.¹ Newly industrialized countries are in the acceleration in incidence stage, which is associated with rapidly rising incidence and low prevalence, while the western world is in the compounding prevalence stage: stable incidence and rapidly increasing prevalence.
The Veszprém IBD cohort is one of the very few well-established prospective, population based inception cohorts worldwide, capable of delivering reliable epidemiological data.

Aims & Methods

Our aim was to analyze total, age and gender specific incidence and prevalence rates of Crohn’s disease (CD) patients over the past four decades (1977-2018).
Data of 946 CD patients were analyzed. Patient inclusion was between January 1, 1977 and December 31, 2018. All patients in Veszprem county, a well-defined administrational area of Hungary, was included. Both in-hospital and outpatient records were collected and comprehensively reviewed at diagnosis and during clinical follow-up. The source of age- and gender-specific demographic data for statistical analysis was derived from the results of a national population census in 1980, 1990, 2001 and 2011 (source: Hungarian Central Statistical Office). Prevalence rates were calculated in 1991, 2001, 2011 and 2015.

Results

Mean incidence rate of CD showed steady increase from 1.44 (CI95%: 0.64-3.27) /10⁵ person-years in 1977-1991 to 10.59 (CI95%: 7,70-14,57) /10⁵ in 2007-2011. Incidence showed no further elevation in 2012-2018 (9.46 (CI95%: 6.76-13.27) /10⁵ person-years). see Figure 1. Age specific mean incidence rates in the total cohort show a clear peak at the age of 20-29 years (18.13 /10⁵ person-years).
The total prevalence of CD patients increases steadily from 17.35 (CI95%: 13.62-22.18) /10⁵ persons in 1991 to 230.58 (CI95%: 215.31-246.94) /10⁵ in 2015. Age specific prevalence rates show highest prevalence among the 30-39 years old in 2015 (422.02 (CI95%: 371.19-479.79) /10⁵ persons). Prevalence rates are still significantly lower in the elderly (60-69y: 167.80 (CI95%: 133.07-211.59) /10⁵ persons). see Table 1.

Conclusion

Incidence rates of CD rose steadily until the 2010s and may start a plateau phase thereafter. Prevalence rates of CD show a steady increase over the study period, thus Hungary is probably entering the 3^rd epidemiological phase of compounding prevalence. Age specific prevalence rates peak at the age of 30-39 years and decrease in the elderly, as opposed to ulcerative colitis (UC), meaning that CD is probably in an earlier epidemiological stage compared to UC.

References

1. Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021 Jan;18(1):56-66.

Introduction

​​​​​Parenteral nutrition (PN) is necessary to overcome malnutrition in hospitalized patients with acute or chronic intestinal failure, but is associated with complications. Physicians often lack knowledge in clinical nutrition, which makes clinical decision support tools recommended for prescribing PN. ¹

Aims & Methods

This study evaluated the impact of the OLIVE TREE (Offering guidance and Learning to prescribers to Initiate parenteral nutrition using a Validated Electronic decision TREE), a decision tree integrated into the prescribing software at University Hospital Leuven, Belgium, on prescribing behavior and safety.² Two cohorts were compared: 63 patients who received OLIVE TREE-guided PN initiation and 63 who did not. The primary outcome, assessed in the first cohort, was the proportion of patients for whom the OLIVE TREE impacted prescribing behavior. An impact was defined as a different PN regimen that was prescribed after using the OLIVE TREE compared with before using the OLIVE TREE (i.e. for the first question of the OLIVE TREE, the prescriber had to indicate which PN regimen he/she would initiate). Secondary outcomes included changes in initial PN regimens, time to regimen change, mortality, PN-related complications (hyperglycemia, liver dysfunction, fluid overload, catheter-related thrombosis, central line associated bloodstream infection and PN-related intensive care transfer) and weight evolution between PN initiation and discontinuation and between PN initiation and discharge.

Results

An impact on prescribing behavior was observed in 33 of 63 patients (52.4%; 95% CI 39.4-65.1; p < 0.001), resulting in providing more calories (27.0%), less calories (9.5%) and more refeeding protocols (6.3%). Initial PN regimens were altered in 54.0% of both cohorts, with a median time to change of six days (p = 0.820). No significant differences were found in mortality (1.6% and 3.2%; p = 0.747), complications (31.9% and 48.1%; p = 0.284), weight change between PN initiation and discontinuation (-0.5kg [-3.2-0.5] and -0.6kg [-2.5-1.2]; p = 0.317) or weight evolution between PN initiation and discharge (-1.4kg [-3.6-0.2] and -1.3kg [-2.75-0.3]; p = 0.541) between the OLIVE TREE and non-OLIVE TREE cohort.

Conclusion

The OLIVE TREE significantly impacted prescribing behavior, without leading to earlier or more frequent PN regimen changes, increased complications or different weight evolutions.

References

1 1 Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014;38(3):296-333.
2 Van den Broucke E et al. Offering Guidance and Learning to Prescribers to Initiate Parenteral Nutrition using a Validated Electronic Decision TREE (OLIVE TREE). J Med Syst. 2022;46(8):56.

Introduction

Endoscopist performance may fluctuate throughout the day, potentially influencing adenoma detection during colonoscopy. Endoscopist fatigue has been proposed as contributing factor but few studies have rigorously examined its impact using precise quality metrics^1,2.

Aims & Methods

This study compared corrected withdrawal time (cWT) and lesion detection metrics between morning and afternoon procedures to assess the effect of procedural timing.
We conducted a prospective analysis of elective colonoscopies performed in adult patients (≥18 years) at the University of Montreal Hospital Center by 19 endoscopists. All procedures were video-recorded and annotated in real-time by trained research assistants. Procedures performed solely for polypectomy, those with incomplete examinations, technical failures, or performed by endoscopists with fewer than 10 colonoscopies were excluded. cWT was defined as the withdrawal time minus the duration of all therapeutic interventions. The primary outcome was the comparison of mean cWT between morning and afternoon colonoscopies. Secondary outcomes included the cWT required to reach ADR threshold ≥35%, adenoma detection rate (ADR), advanced ADR (AADR), sessile serrated lesion detection rate (SSLDR), adenomas per colonoscopy (APC), and the per-lesion intervention time, all stratified by time of day. The increase of all performance measures per additional cWT minute were further compared across time of day, adjusting for patient demographics, bowel preparation quality, indication for colonoscopy, computed-assisted detection use, and clustering by individual endoscopist using generalized estimated equations.

Results

A total of 1,437 colonoscopies were included, of which 665 were performed in the morning and 772 in the afternoon. Morning colonoscopies had significantly longer mean cWT than afternoon procedures (8'49'' vs. 8'11''; P=0.002), despite similar per-lesion intervention durations (1’32’’ vs 1’28’’, P=0.425). To achieve an ADR ≥35%, afternoon procedures required on average 1’42’’ more cWT than morning ones (10'02'' vs. 8'20''). Mean ADR and AADR were higher in the morning (ADR: 36.2% vs. 32.4%, P=0.138; AADR: 7.2% vs. 6.5%, P=0.652), although not statistically significant (Table 1). For each additional cWT minute, adenoma detection odds increased by 7.2% in the morning (P=0.003) and 5.9% in the afternoon (P=0.049), suggesting reduced detection efficiency later in the day despite comparable polyp intervention times. Also, the increases in the odds of detecting advanced adenoma dropped from 13.1% in the morning to 7.8% in the afternoon for each additional cWT minute. This reduction was not as steep for SSLDR and APC metrics.

Table 1. Metrics’ estimated summaries overall and by time of day.

Conclusion

Colonoscopy outcomes were influenced by procedural timing, with morning examinations associated with higher adenoma detection and more efficient use of WT. Afternoon procedures required longer cWT to achieve comparable detection benchmark of ≥35%, indicating potential performance fatigue. These findings suggest that optimizing endoscopy scheduling may enhance diagnostic yield and overall quality of care.

References

1. Sanaka MR, Deepinder F, Thota PN, Lopez R, Burke CA. Adenomas are detected more often in morning than in afternoon colonoscopy. Am J Gastroenterol. 2009;104(7):1659–1665. doi:10.1038/ajg.2009.188

2. Lee CK, Cha JM, Kim WJ, et al. Endoscopist fatigue may contribute to a decline in the effectiveness of screening colonoscopy. J Clin Gastroenterol. 2015;49(7):e51–e56. doi:10.1097/MCG.0000000000000300

Disclosure

Daniel von Renteln has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Fujifilm, and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, and Pendopharm. Roupen Djinbachian has received speaker fees from Fujifilm. The remaining authors declare that they have no conflict of interest.