Impact of antitumour necrosis factor therapy on surgery in inflammatory bowel disease: a population-based study.

OBJECTIVE: It is unclear whether widespread use of biologics is reducing inflammatory bowel disease (IBD) surgical resection rates. We designed a population-based study evaluating the impact of early antitumour necrosis factor (TNF) on surgical resection rates up to 5 years from diagnosis. DESIGN: We evaluated all patients with IBD diagnosed in Cardiff, Wales 2005-2016. The primary measure was the impact of early (within 1 year of diagnosis) sustained (at least 3 months) anti-TNF compared with no therapy on surgical resection rates. Baseline factors were used to balance groups by propensity scores, with inverse probability of treatment weighting (IPTW) methodology and removing immortal time bias. Crohn's disease (CD) and ulcerative colitis (UC) with IBD unclassified (IBD-U) (excluding those with proctitis) were analysed. RESULTS: 1250 patients were studied. For CD, early sustained anti-TNF therapy was associated with a reduced likelihood of resection compared with no treatment (IPTW HR 0.29 (95% CI 0.13 to 0.65), p=0.003). In UC including IBD-U (excluding proctitis), there was an increase in the risk of colectomy for the early sustained anti-TNF group compared with no treatment (IPTW HR 4.6 (95% CI 1.9 to 10), p=0.001). CONCLUSIONS: Early sustained use of anti-TNF therapy is associated with reduced surgical resection rates in CD, but not in UC where there was a paradoxical increased surgery rate. This was because baseline clinical factors were less predictive of colectomy than anti-TNF usage. These data support the use of early introduction of anti-TNF therapy in CD whereas benefit in UC cannot be assessed by this methodology.

Changes in incidence and clinical features of inflammatory bowel disease in Cardiff, UK over 50 years: an update for 2005-2016.

INTRODUCTION: Population-based studies of inflammatory bowel disease (IBD) in Cardiff have recorded data back to 1930 for Crohn's disease (CD) and 1968 for ulcerative colitis (UC). This study compares incidence and phenotype for 2005-2016 with past data. METHODS: All new IBD cases resident in the Cardiff at diagnosis were collected retrospectively for the 12-year period 2005-2016, and compared with previous Cardiff data for trends in incidence and phenotype. Overall incidence was age/sex corrected to the UK population. RESULTS: There were 991 new patients: 34% had CD, 5.4% IBD unclassified (IBD-U) and 60.5% had UC. The corrected incidence of CD was 7.7 per 100,000 person years [95% CI 6.9-8.6]. CD incidence is significantly higher than previous Cardiff studies, but the annual percentage change (APC) for 1980-2016 of 0.06; [95%CI -0.02 to 0.14] is not significant, with a previous higher APC for 1953-1980 of 0.18, [95%CI 0.13 to 0.23]. Uncorrected IBD-U incidence was 1.3 per 100,000 person years [95% CI 1.0-1.7]. UC corrected incidence was 14.4 per 100,000 person years [95% CI 13.3-15.6]. Incidence of UC is greater than in previous studies but did not increase during the current 12-year period. CD distribution at diagnosis continues to change as in previous Cardiff studies, with further increase in colonic disease and ileocolonic, (42% L2, 28% L3) and reduction in isolated terminal ileal disease (29% L1). CONCLUSIONS: Incidence of both CD and UC are no longer rising significantly, but the location of CD at diagnosis continues to change with an increase in colonic location.Key messagesWhat is already known? It is unclear whether the incidence of IBD has now plateaued in urbanised nations. Changes in Crohn's disease location are often not reported in incidence studies and terminal ileal disease has usually been reported as the commonest site of diseaseWhat is new here? The incidence of UC and Crohn's is no longer rising in Cardiff UK, but the phenotype has changed progressively over time with a continuing increase in colonic disease location and decrease in isolated terminal ileal diseaseHow can this study help patient care? Understanding that Crohn's colitis is the predominant location has implications for diagnostic tests and implications for treatment optionsIMPACT STATEMENTThis work shows that although IBD incidence is no longer rising, the pattern of Crohn's disease is changing with more colonic disease and less isolated terminal ileal disease.PRACTITIONER RELEVANCE STATEMENTThe changing pattern of Crohn's disease location has implications for diagnostic assessment and treatment of this disease.

Comparison of two ophthalmoscopes for direct ophthalmoscopy.

BACKGROUND: To measure the ease of use and performance of the Optyse lens-free ophthalmoscope compared with the standard Keeler pocket ophthalmoscope, and to assess its suitability as an inexpensive ophthalmoscope for medical students. DESIGN: Randomized cross-over study. PARTICIPANTS: Twenty second-year medical students, 10 as ophthalmoscopists ('observers') and 10 as 'patients'. METHODS: Students used both ophthalmoscopes to examine the optic disc in each eye of 10 'patients'. They were randomized as to the order in which they were used. A Consultant ophthalmologist was used as the gold standard. MAIN OUTCOME MEASURES: Main outcome measures were accuracy in estimating vertical cup:disc ratio (VCDR), ease of use (EOU) for each examination, and overall ease of use (OEOU). RESULTS: Of 400 attempted eye examinations, sufficient visualization was achieved in 220 cases to allow a VCDR estimation: 107/200 VCDR estimates with the Optyse and 113/200 with the Keeler. Accuracy of VCDR estimates was better with the Optyse by the equivalent of 0.05 VCDR (P = 0.002). There was no significant difference in EOU or OEOU between the two ophthalmoscopes. EOU for 400 examinations: median (IQR) of 6 (3-8) for Optyse versus 6 (3-8) for Keeler (P = 0.648). OEOU for 20 scores: median (IQR) of 6.5 (2-9) for Optyse versus 5.5 (3-8) for Keeler (P = 0.21). CONCLUSION: Medical students found the Optyse and Keeler pocket ophthalmoscopes to be of similar ease of use and performed slightly better with the Optyse when estimating VCDR. The lens-free Optyse ophthalmoscope is a reasonable alternative to the standard Keeler pocket ophthalmoscope.