Tome, June

Lay Summary This multicenter study evaluated clinical outcomes in pregnancy for women with ulcerative colitis and an ileal pouch-anal anastomosis. Close monitoring is needed with a multidisciplinary team for management of inflammatory complications of the pouch such as pouchitis in pregnancy and postpartum.

Lay Summary In this study we evaluated the effectiveness of vedolizumab (anti-integrin) vs ustekinumab/risankizumab (anti-interleukin) therapy for isolated small-bowel Crohn’s disease using a real-world, multicenter national database. We found that anti-interleukin therapy was more effective for inducing steroid-free remission and reducing hospitalizations.

ABSTRACT Introduction Chronic pouchitis is a major therapeutic challenge in patients with ulcerative colitis following ileal pouch‐anal anastomosis. Methods We conducted a real‐world, propensity‐matched cohort study of 856 patients from a healthcare database to compare ustekinumab and vedolizumab. Results Ustekinumab was associated with significantly lower relapse rates (aHR = 0.69; p < 0.001), longer time to relapse, reduced hospitalisation and decreased need for steroids or antibiotics. No differences were observed in surgery rates or therapy switching. Conclusion Our findings suggest that ustekinumab may offer advantages over vedolizumab in the management of chronic pouchitis.

Abstract Background The term “incomplete microscopic colitis” (MCi) has been suggested to define patients with chronic watery diarrhea not fulfilling the complete histologic criteria for MC. There are inconsistent data on the epidemiology of MCi and the optimal management of these patients. Methods A systematic search of randomized control trials (RCTs) and observational studies of adults with biopsy-proven MCi (incomplete lymphocytic colitis and collagenous colitis) was conducted using Cochrane, Medline, Scopus, and Embase from inception to May 6, 2025. Data were extracted on (1) incidence and prevalence of MCi, (2) patient features and risk factors, (3) clinical response with treatment, and (4) relapse after treatment cessation. Data were pooled using the random-effects model to calculate weighted pooled estimates and 95% confidence intervals (CIs). Results Of 136 potentially relevant publications identified, 49 passed abstract screening, and 17 studies (1 RCT and 16 observational) were included, with a total of 1370 patients with MCi (median age of 62 years and 69.6% women). The incidence rate of MCi ranged from 0.96 to 5.0 cases per 100 000 person-years. The pooled proportion of concurrent autoimmune disease with MCi was 18% (95% confidence interval [CI], 0.07-0.28; I2 = 95%), and 46% (95% CI, 0.28-0.64; I2 = 95%) were on medications associated with microscopic colitis (MC). The pooled clinical remission rate with any induction therapy was 78% (95% CI, 0.68-0.89; I2 = 81%) and 85% (95% CI, 0.72-0.98; I2 = 88%) with budesonide. Conclusions Patients with MCi share similar characteristics with full MC including demographics, risk factors, and response to therapy, indicating that the histologic criteria for MC should potentially be broadened.

INTRODUCTION: Bile acid sequestrants (BAS) are an option for microscopic colitis (MC) refractory or intolerant to budesonide. There are inconsistent data on the prevalence of bile acid malabsorption (BAM) and utility of bile acid testing in MC. The aim of this systematic review and meta-analysis was to evaluate these outcomes. METHODS: A systematic search of randomized control trials and observational studies of adults with MC treated with BAS was conducted using MEDLINE, Embase, Cochrane, and Scopus from inception to January 22, 2024. Data were extracted on (i) prevalence of BAM, (ii) clinical response and adverse events, and (iii) recurrence after BAS discontinuation. Data were pooled using random-effects models to determine weighted pooled estimates and 95% confidence intervals (CIs). RESULTS: We included 23 studies (1 randomized control trial, 22 observational), with 1,011 patients with MC assessed for BAM and 771 treated with BAS. The pooled prevalence of BAM was 34% (95% CI 0.26–0.42, I 2 = 81%). The pooled response rate with BAS induction for all patients with MC, irrespective of BAM, was 62% (95% CI 0.55–0.70, I 2 = 71%). There was a higher pooled response rate in patients with BAM compared with those without BAM ( P < 0.0001). The pooled rate of BAS-related adverse effects was 9% (95% CI 0.05–0.14, I 2 = 58%). DISCUSSION: One-third of patients with MC had BAM, and almost two-thirds of all patients responded to BAS with limited side effects. Patients with MC and BAM were more likely to respond to therapy, supporting the value of bile acid testing.

Teamwork in graduate medical education (GME) is often hindered in clinical learning environments where discontinuity among residents, supervisors, and other health care professionals is typical. Teaming is a conceptual approach to teamwork in dynamic environments with constantly changing team members and goals. Teaming is built on principles of project management and team leadership, which together provide an attractive strategy for addressing teamwork challenges in GME. Indeed, teaming is now a requirement of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program. However, many clinician-educators and leaders may be unfamiliar with teaming and how to integrate it into their GME programs. In this article, the teaming framework is described with a specific example of how it can be applied to improve hospital ward rounds, a common setting of teamwork breakdown. The goal of this article is to educate and encourage GME leaders as they learn new ways to implement teaming to improve patient care and education in their programs.

SummaryBackgroundPredictive models for eosinophilic oesophagitis (EoE) may not fully rule in the diagnosis.AimTo develop a reverse model that predicts against EoE to eliminate the need for oesophageal biopsies.MethodsIn this two‐centre study, a predictive model was developed (Mayo Clinic) and validated (University of North Carolina [UNC]). Cross‐sectional data from consecutive adult patients without prior EoE who underwent upper enoscopy with oesophageal biopsies were used. EoE cases had ≥15 eosinophils/high‐power field while controls had no eosinophils. Data were collected on patient clinical and endoscopic features. Multiple variable logistic regression was used to identify predictors of non‐EoE status while maintaining specificity ≥95%. A secondary model was developed to predict against the need for endoscopy in patients suspected of having EoE without alarm symptoms.ResultsThe Mayo and UNC cohorts consisted of 345 (EoE = 94, non‐EoE = 251) and 297 patients (EoE = 84, non‐EoE = 213), respectively. A primary model based on clinical and endoscopic features predicted against EoE with c‐statistic 0.92 (95% CI: 0.88–0.96), specificity 95%, and sensitivity 65%. This model was validated (UNC) with c‐statistic 0.87 (95% CI: 0.82–0.92). A simplified scoring system was created and a threshold of ≥12 points excluded EoE with 95% specificity and 50% sensitivity. A secondary model based on clinical characteristics alone predicted against EoE with c‐statistic 0.86 (95% CI: 0.82–0.90), specificity 95% and sensitivity 39% and validated (UNC) with c‐statistic 0.78 (95% CI: 0.71–0.85).ConclusionA simplified scoring system accurately identified a group of patients with a low likelihood of EoE where unnecessary oesophageal biopsies can be avoided, potentially resulting in resource and cost savings.

Abstract Background Microscopic colitis (MC) is a common cause of chronic diarrhea. Randomized controlled trials (RCTs) have demonstrated the efficacy of budesonide treatment for MC. However, relapse is frequent after discontinuation of budesonide, and data on maintenance therapy are limited. We performed a systematic review and meta-analysis evaluating these outcomes in clinical trials and real-world settings. Methods A systematic search was performed on October 31, 2022, of Medline, Embase, Cochrane, and Scopus. Case series, case-control, cohort studies, and RCTs of adults with MC were included. Data were pooled using random effects models to calculate weighted pooled estimates and 95% confidence intervals. Heterogeneity was assessed using the I2 statistic. Results We included 35 studies (11 RCTs, 24 observational studies) with 1657 MC patients treated with budesonide induction and 146 for maintenance. The overall pooled clinical remission rate with budesonide treatment was similar between RCTs and observational studies. The pooled remission rate with budesonide maintenance therapy was 84% (95% CI, 0.60-1.00; I2 = 91%). After budesonide discontinuation, the pooled relapse rate was 53% (95% CI, 0.42-0.63; I2 = 76%). On maintenance therapy, no differences were noted in adverse events (eg, metabolic bone disease, hypertension, hyperglycemia, cataracts/glaucoma) in those on budesonide vs placebo or other noncorticosteroid medications for MC (P = .9). Conclusions Budesonide is an effective maintenance treatment for MC. There is a high risk of recurrence after budesonide discontinuation, but long-term use at the lowest effective dose appears to be relatively safe and have limited adverse effects.

Background: Microscopic colitis (MC) causes chronic diarrhea. It has two histologic subtypes: lymphocytic colitis (LC) and collagenous colitis (CC). Little is known about the natural progression of disease with time and with treatment. Objectives: We aimed to assess histological changes over time. Design: We designed a retrospective study including adults diagnosed with MC from January 1992 to January 2020 at Mayo Clinic. Methods: Pathology reports were reviewed until 31 October 2020. Histological assessments at least 8 weeks apart were considered as adequate follow-up. Histological change from one subtype to the other and resolution were tracked with univariate and multivariable Cox proportional hazards models. Results: Overall, 416 patients with a median age at diagnosis of 63.9 years with >1 histopathological assessment were identified. Histology at initial diagnosis was CC in 218 (52.4%) patients and LC in 198 (47.6%). No medications were associated with a histological change. However, histological resolution was more likely with the use of aspirin [hazard ratio (HR): 2.10, 95% confidence interval (CI): 1.34–3.31, p = 0.001) and proton-pump inhibitors (PPIs; HR: 2.01, 95% CI: 1.34–3.02, p = 0.001). Histological resolution was more likely with budesonide treatment (HR: 1.86, 95% CI: 1.16–3.00, p = 0.010) and less likely with mesalamine (HR: 0.40, 95% CI: 0.19–0.83, p = 0.014), compared to medications such as prednisone, loperamide, and bismuth. Patients with CC were less likely to change their histology compared to patients with LC (HR: 0.24, 95% CI: 0.14–0.42, p < 0.001). There was no difference in histological resolution between the two subtypes (HR: 0.70, 95% CI: 0.47–1.05, p = 0.084). Conclusion: Patients with LC have a higher chance of changing their histology as compared to CC. However, histological resolution was associated with the use of PPIs and aspirin, and treatment with budesonide.