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C rohn's disease (CD) is a chronic inflammatory bowel disease with substantial morbidity when not adequately controlled. 1 Historically, approximately 20% of patients with CD were hospitalized every year, and the risk of surgery within 1 year of diagnosis was 24%, 36% by 5 years, and 47% by 10 years. 2 In recent years, outcomes have improved, likely because of earlier diagnosis, increasing use of biologics, escalation or alteration of therapy based on disease severity, and endoscopic management of colorectal cancer. CD includes multiple different phenotypes. The Montreal Classification categorizes CD as stricturing, penetrating, inflammatory (nonstricturing and nonpenetrating), and perianal disease. [3][4][5] Each of these phenotypes can present with a range in severity from mild to severe disease. 6 This guideline addresses the medical management of moderate to severe luminal and fistulizing CD. The International Organization for the Study of Inflammatory Bowel Diseases characterizes severe disease as having a high risk for adverse disease-related complications, including surgery, hospitalization, and disability, based on a combination of structural damage, inflammatory burden, and impact of quality of life. Contributors to severe disease include large or deep mucosal lesions on endoscopy or imaging, presence of fistula and/or perianal abscess, presence of strictures, prior intestinal resections, particularly of segments >40 cm, presence of a stoma, extensive disease (ileal involvement >40 cm, or pancolitis), anemia, elevated C-reactive protein, and low albumin. With respect to symptoms, patients with severe disease may have at least 10 loose stools per day, daily abdominal pain, presence of anorectal symptoms (eg, anorectal pain, bowel urgency, incontinence, discharge, and tenesmus), systemic corticosteroid use within the prior year, lack of symptomatic improvement despite prior exposure to biologics and/or immunosuppressive agents, or significant impact of the disease on activities of daily living. 7 Moderate to severe disease can also be defined using the Crohn's Disease Activity Index. This standardized disease assessment score categorizes severity of disease as: remission <150, mild to moderate as 150-220, moderate to severe as 220-450 and severe >450. 8 For this guideline, moderate to severe disease was considered a Crohn's Disease Activity Index score of 220 or higher.There are a number of different drug classes available for the management of moderate to severe CD, including tumor necrosis factor (TNF)-a antagonists (ie, infliximab, adalimumab, certolizumab pegol), anti-integrin agents (natalizumab, vedolizumab), interleukin 12/23 antagonist (ustekinumab), immunomodulators (thiopurines, methotrexate), and corticosteroids (prednisone, budesonide). 1 In general, most drugs, with the exception of corticosteroids, that are initiated for induction of remission are continued as maintenance therapy. Unless otherwise specified, we do not present separate recommendations for induction and maintenance of remission...

Background Long-term colorectal cancer incidence and mortality after colorectal polyp removal remains unclear. We aimed to assess colorectal cancer incidence and mortality in individuals with removal of different histological subtypes of polyps relative to the general population. MethodsWe did a matched cohort study through prospective record linkage in Sweden in patients aged at least 18 years with a first diagnosis of colorectal polyps in the nationwide gastrointestinal ESPRESSO histopathology cohort . For each polyp case, we identified up to five matched reference individuals from the Total Population Register on the basis of birth year, age, sex, calendar year of biopsy, and county of residence. We excluded patients and reference individuals with a diagnosis of colorectal cancer either before or within the first 6 months after diagnosis of the index polyp. Polyps were classified by morphology codes into hyperplastic polyps, sessile serrated polyps, tubular adenomas, tubulovillous adenomas, and villous adenomas. Colorectal cancer cases were identified from the Swedish Cancer Registry, and cause-of-death data were retrieved from the Cause of Death Register. We collected information about the use of endoscopic examination before and after the index biopsy from the Swedish National Patient Registry, and counted the number of endoscopies done before and after the index biopsies. We calculated cumulative risk of colorectal cancer incidence and mortality at 3, 5, 10, and 15 years, and computed hazard ratios (HRs) and 95% CIs for colorectal cancer incidence and mortality using a stratified Cox proportional hazards model within each of the matched pairs. Findings 178 377 patients with colorectal polyps and 864 831 matched reference individuals from the general population were included in our study. The mean age of patients at polyp diagnosis was 58•6 (SD 13•9) years for hyperplastic polyps, 59•7 (14•2) years for sessile serrated polyps, 63•9 (12•9) years for tubular adenomas, 67•1 (12•1) years for tubulovillous adenomas, and 68•9 (11•8) years for villous adenomas. During a median of 6•6 years (IQR 3•0-11•6) of follow-up, we documented 4278 incident colorectal cancers and 1269 colorectal cancer-related deaths in patients with a polyp, and 14 350 incident colorectal cancers and 5242 colorectal cancer deaths in general reference individuals. The 10-year cumulative incidence of colorectal cancer was 1•6% (95% CI 1•5-1•7) for hyperplastic polyps, 2•5% (1•9-3•3) for sessile serrated polyps, 2•7% (2•5-2•9) for tubular adenomas, 5•1% (4•8-5•4) for tubulovillous adenomas, and 8•6% (7•4-10•1) for villous adenomas compared with 2•1% (2•0-2•1) in reference individuals. Compared with reference individuals, patients with any polyps had an increased risk of colorectal cancer, withmultivariable HR of 1•11 (95% CI 1•02-1•22) for hyperplastic polyps, 1•77 (1•34-2•34) for sessile serrated polyps, 1•41 (1•30-1•52) for tubular adenomas, 2•56 (2•36-2•78) for tubulovillous adenomas, and 3•82 (3•07-4•76) for villous adenomas (p<0•05 for all ...

Objective Little research exists on Rome IV disorders of gut–brain interaction (DGBI; formerly called functional gastrointestinal disorders) in outpatients with eating disorders (EDs). These data are particularly lacking for avoidant/restrictive food intake disorder (ARFID), which shares core features with DGBI. We aimed to identify the frequency and nature of DGBI symptoms among outpatients with EDs. Method Consecutively referred pediatric and adult patients diagnosed with an ED (n = 168, 71% female, ages 8–76 years) in our tertiary care ED program between March 2017 and July 2019 completed a modified Rome IV Questionnaire for DGBI and psychopathology measure battery. Results The majority (n = 122, 72%) of participants reported at least one bothersome gastrointestinal symptom. Sixty‐six (39%) met criteria for a DBGI, most frequently functional dyspepsia—post‐prandial distress syndrome subtype (31%). DGBI were surprisingly less frequent among patients with ARFID (30%) versus EDs that are associated with shape or weight concerns (45%; X2[1] = 3.61, p = .058, Cramer's V = .147). Among those with ARFID, DGBI presence was associated with the fear of aversive consequences prototype and multiple comorbid prototype presence. Discussion We demonstrated notable overlap between DGBI and EDs, particularly post‐prandial distress symptoms. Further research is needed to examine if gastrointestinal symptoms predict or are a result of greater ED pathology, including ARFID prototypes.

We extend previous studies on the impact of masks on COVID-19 outcomes by investigating an unprecedented breadth and depth of health outcomes, geographical resolutions, types of mask mandates, early versus later waves and controlling for other government interventions, mobility testing rate and weather. We show that mask mandates are associated with a statistically significant decrease in new cases (-3.55 per 100K), deaths (-0.13 per 100K), and the proportion of hospital admissions (-2.38 percentage points) up to 40 days after the introduction of mask mandates both at the state and county level. These effects are large, corresponding to 14% of the highest recorded number of cases, 13% of deaths, and 7% of admission proportion. We also find that mask mandates are linked to a 23.4 percentage point increase in mask adherence in four diverse states. Given the recent lifting of mandates, we estimate that the ending of mask mandates in these states is associated with a decrease of -3.19 percentage points in mask adherence and 12 per 100K (13% of the highest recorded number) of daily new cases with no significant effect on hospitalizations and deaths. Lastly, using a large novel survey dataset of 847 thousand responses in 69 countries, we introduce the novel results that community mask adherence and community attitudes towards masks are associated with a reduction in COVID-19 cases and deaths. Our results have policy implications for reinforcing the need to maintain and encourage mask-wearing by the public, especially in light of some states starting to remove their mask mandates.