Managing Ulcerative Colitis and Crohn's Disease: Should the Target Be Endoscopy, Histology, or Both?

In inflammatory bowel disease (IBD), mucosal healing is the primary long-term treatment goal, encompassing both endoscopic and histological outcomes. This paper aims to overview the ability of new treatment options to promote endoscopic and histological healing and to discuss the prognostic significance of endoscopic and histological outcomes. The analysis included randomized-controlled trials (published since 2020) focused on the impact of pharmacological interventions on endoscopic and histological remission in IBD. Even though the Mayo endoscopic subscore is routinely used, the application of validated scoring systems for ulcerative colitis is uncommon. In Crohn's disease (CD), the application of endoscopic scores remains limited to clinical studies. The standardized evaluation of histological features has been performed in several recent ulcerative colitis trials, resorting mostly to the Geboes score and the Nancy histological index. Still, the use of histological scores for CD remains elusive. Current evidence underscores that histological remission conveys the best long-term prognosis, supporting the inclusion of histology as a treatment guide in ulcerative colitis. In CD, data are promising but originated from a few retrospective studies. Further efforts are warranted to: (1) use validated histological indexes for ulcerative colitis, aiming their adoption as treatment targets; (2) promote the validation and utilization of histological scores for CD, at least in clinical studies; (3) confirm the prognostic impact of histological remission in CD; (4) integrate artificial intelligence assets to support grading, particularly in the setting of histology; (5) prospectively define the monitoring frequency of IBD patients who achieved histological remission.

Risk and determinant factors for obstructive sleep apnea in patients with epilepsy / Risco e determinantes para apneia obstrutiva do sono em pacientes com epilepsia

OBJECTIVE: To evaluate the prevalence of risk of having obstructive sleep apnea (OSA) and its determinants in patients with epilepsy (PE). METHOD: 98 adult PE were prospectively screened for risk of OSA by Berlin questionnaire. Data was also collected about excessive daytime sleepiness, depression, anxiety, clinical and socio-demographic characteristics. RESULTS: The PE main characteristics: 59-men/39-women, mean age=39.97, SD=12.3, range 18-66. The prevalence of the risk of OSA was 55.1 percent (CI 95 percent, 0.45-0.65). The high risk for OSA was related with body mass index (BMI) (p=0.000), neck circumference (NC) (p=0.000), arterial hypertension (AH) (p=0.000), and anxiety (p=0.006), without relationship with number of seizures, number of antiepileptic drugs, age or depression. The NC was statistically significant regarding risk of OSA, mainly in men. CONCLUSION: We found a high risk of OSA in this sample. The main implicated measures were the large NC, high BMI and anxiety. The anthropometric variables were more relevant than those related to epilepsy itself and similar to those of the general population.

OBJETIVO: Avaliar riscos e fatores determinantes para síndrome da apneia obstrutiva do sono (SAOS) em pacientes com epilepsia (PCE). MÉTODO: 98 PCE adultos foram avaliados prospectivamente para risco de SAOS pelo questionário Clínico de Berlim, e também para sonolência excessiva diurna, depressão, ansiedade, características socioeconômico e demográficas. RESULTADOS: 98 PCE foram estudados (59-homens / 39-mulheres, idade média=39,97, DP=12,3, 18-66 anos). A prevalência de risco para SAOS foi de 55,1 por cento (CI 95 por cento, 0,45-0,65). O alto risco de SAOS estava relacionado com índice de massa corporal (IMC) (p=0,000), circunferência do pescoço (CP) (p=0,000), hipertensão arterial (p=0,000) e ansiedade (p=0,006), sem relação com número de crises, drogas antiepiléptica, idade ou depressão. A CP foi estatisticamente significativa na relação com SAOS, principalmente em homens. CONCLUSÃO: Encontrou-se alta prevalência de risco de SAOS nesta população. As medidas mais relevantes foram CP principalmente em homens, IMC e ansiedade. As variáveis antropométricas foram mais importantes que aquelas relacionadas à própria epilepsia, o que foi similar à população em geral.

Excessive daytime sleepiness in patients with epilepsy: a subjective evaluation.

OBJECTIVE: The main objective of the study was to evaluate excessive daytime sleepiness (EDS) in patients with epilepsy from a tertiary outpatient clinic in Rio de Janeiro, Brazil. METHODS: Ninety-nine unselected patients from the epilepsy outpatient clinic were invited and their sleep-wake habits were assessed by means of a clinical interview and four validated instruments: Epworth Sleepiness Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Basic Nordic Sleep Questionnaire. Sociodemographic information and characteristics of the epilepsy syndrome were collected. RESULTS: Complaints about EDS (Epworth Sleepiness Scale score >10) were reported by 47.5% (95% CI: 37.3-57.7) of the patients. In the sample, 52.6% (95% CI: 0.41-0.60) were overweight or obese, and 53.1% (95% CI: 0.43-0.62) had less than 8 years of formal education. Mainly anxiety, but also neck circumference, was correlated with EDS. Our patients did not exhibit quantitative sleep deprivation. No other epilepsy-related variable showed relationship with EDS. The prevalence of EDS in our population was higher than in similar studies performed in other countries. This finding does not seem to be related to epilepsy itself, but rather to other clinical factors, such as neck circumference, and mainly psychiatric factors, such as anxiety. CONCLUSIONS: Psychiatric comorbidities such as anxiety are linked to EDS and should be recognized and treated. More studies based on objective sleep quality analysis are needed to help elucidate these relationships in the Brazilian population.

Risk and determinant factors for obstructive sleep apnea in patients with epilepsy.

OBJECTIVE: To evaluate the prevalence of risk of having obstructive sleep apnea (OSA) and its determinants in patients with epilepsy (PE). METHOD: 98 adult PE were prospectively screened for risk of OSA by Berlin questionnaire. Data was also collected about excessive daytime sleepiness, depression, anxiety, clinical and socio-demographic characteristics. RESULTS: The PE main characteristics: 59-men/39-women, mean age=39.97, SD=12.3, range 18-66. The prevalence of the risk of OSA was 55.1% (CI 95%, 0.45-0.65). The high risk for OSA was related with body mass index (BMI) (p=0.000), neck circumference (NC) (p=0.000), arterial hypertension (AH) (p=0.000), and anxiety (p=0.006), without relationship with number of seizures, number of antiepileptic drugs, age or depression. The NC was statistically significant regarding risk of OSA, mainly in men. CONCLUSION: We found a high risk of OSA in this sample. The main implicated measures were the large NC, high BMI and anxiety. The anthropometric variables were more relevant than those related to epilepsy itself and similar to those of the general population.

Relação da epilepsia com a síndrome de apneia obstrutiva do sono: revisão / The relation between epilepsy and obstructive sleep apnea syndrome: review

OBJETIVOS: Avaliar principalmente a relação entre síndrome da apneia obstrutiva do sono (SAOS) e crises epilépticas (CE). MÉTODOS: Pesquisa no Pubmed com publicações de 2000 até 23.11.2009 a partir dos descritores “Sleep Apnea, Obstructive” [Mesh Major Topic] e epilepsy[title/abstract]. Acrescentado também artigo referente à Classificação Internacional de Transtornos do Sono-2005. RESULTADOS: Obtidos 19 artigos (um em alemão, excluído) sendo 1 artigo de revisão, 2 editoriais, 5 relatos de caso, 1 série de casos, 4 transversais, 1 ensaio clínico piloto, 2 longitudinais experimentais sem controle, 1 longitudinal/avaliação polissonográfica em dois momentos, 1 de acurácia. CONCLUSÃO: A SAOS é subnotificada na população epiléptica farmacorresistente e nos pacientes com sonolência excessiva diurna (pode ser consequência da SAOS) bem como nos que serão submetidos a estimulação do nervo vago (pode exacerbar SAOS em pacientes com SAOS pré-existente) para fim de controle de CE. Os dados dessa revisão levantam a hipótese da relação importante entre SAOS e CE, pois alguns estudos sugerem a relação mútua entre os dois fatores, apesar de não haver significância estatística. Existe uma relação inversa em um relato de caso de lobectomia frontal esquerda com resolução de CE e da apneia, levando a sugestão de que descargas epilépticas interictais extensas bem como a CE em si no sono pudessem alterar o controle das vias aéreas superiores. A revisão estabelece também a necessidade da realização de novos estudos com análise multivariada e, idealmente, prospectivos e com controles, com amostra maior, observacionais ou de intervenção, com continuous positive airway pressure (CPAP) para a conclusão mais fundamentada metodologicamente.

OBJECTIVES: Mainly to evaluate the relationship between obstructive sleep apnea (OSA) and seizure. METHODS: Search in the Pubmed from 2000 up to November 11, 2009, using the terms “Sleep Apnea, Obstructive” [Mesh Major Topic] and epilepsy [title/abstract]. Included too the International Classification of Sleep Disorders-2005. RESULTS: It was obtained 19 articles (one in German, excluded) being 1 review, 2 editorials, 5 case reports, 1 case series, 4 cross-sectional, 1 clinical pilot study, 2 longitudinal experimental without control, 1 longitudinal study with two polysomnographic estimations, 1 accuracy. CONCLUSION: The OSA is underreported in the pharmacoresistent epilepsy population and in daily excessive sleepiness patients (that can be consequence of the OSA) such as in that who will be submitted to the vagus nerve stimulation (may enhance OSA in patients with preexisting OSA) with the aim of seizure control. The data of this review raises the hypothesis that there is a important relationship between OSA and seizure, because some studies suggest the mutual relationship between the two factors in spite of not being statistically significant. In other hand, in a case report was hypothesized that the pathophysiology of OSA in patients with epilepsy may be impacted by frequent,extensive interictal epileptiform discharges or seizures altering upper airway control during sleep. This review also establishes the need of carrying out new studies with multivariate analysis and, ideally, prospective and with controls, with bigger sample size (observational/with intervention such as with CPAP) to define the studied relationship in better methodological basis.