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PubMed2002

Metabolic bone disease is present at diagnosis in patients with inflammatory bowel disease.

AIM: To establish whether bone disease is present at diagnosis in inflammatory bowel disease and to identify contributory metabolic abnormalities. METHODS: Newly diagnosed patients with inflammatory bowel disease (19 males, 15 females; mean age, 44 years; range, 17-79 years; 23 ulcerative colitis, 11 Crohn's disease) were compared against standard reference ranges and a control group with irritable bowel syndrome (eight males, 10 females; mean age, 40 years; range, 19-64 years). Bone mineral density (g/cm2, dual-energy X-ray absorptiometry: lumbar spine and femoral neck) and biochemical bone markers were measured. RESULTS: Femoral neck bone mineral density, T- and Z-scores (mean +/- s.d., respectively) were lower in inflammatory bowel disease patients than in irritable bowel syndrome controls (0.78 +/- 0.12 vs. 0.90 +/- 0.16, P = 0.0046; - 0.88 +/- 0.92 vs. 0.12 +/- 1.17, P = 0.0018; - 0.30 +/- 0.89 vs. 0.61 +/- 1.10, P = 0.0030). Lumbar spine bone mineral density and T-scores were also significantly lower in patients than controls (0.98 +/- 0.15 vs. 1.08 +/- 0.13, P = 0.0342; - 1.05 +/- 1.39 vs. - 0.14 +/- 1.19, P = 0.0304). Compared with controls, the urinary deoxypyridinoline : creatinine ratio was increased (7.66 vs. 5.70 nmol/mmol, P = 0.0163) and serum 25-hydroxy vitamin D was decreased (18.7 vs. 28.5 micro g/L, P = 0.0016); plasma osteocalcin and serum parathyroid hormone did not differ (P > 0.05). CONCLUSIONS: The bone mineral density is reduced at diagnosis, prior to corticosteroid treatment, in both Crohn's disease and ulcerative colitis. Our data suggest that this is attributable to increased resorption rather than decreased bone formation.

Adolescent↗

PubMed1998

Medical therapy of inflammatory bowel disease for the 21st century.

Inflammatory bowel disease therapy can be considered in several subcategories, and this review is designed to provide selective updates for some of the most important therapeutic entities currently marketed or soon to be available for the medical management of IBD. Although conventional corticosteroids have been a major component of acute inflammatory bowel disease management, steroids have many serious disadvantages; and toxicity is heightened with chronic steroid therapy. Newer corticosteroids, particularly budesonide, may be less toxic than older agents such as prednisone. Budesonide may be used as an enema in active distal ulcerative colitis (UC) or as delayed release tablets in Crohn's disease (CD). However, budesonide is not completely free from steroid side effects, and may share in some of the toxicity of older corticosteroids, particularly when high dose budesonide is administered. Topical and oral aminosalicylates are widely utilized for the treatment of mild to moderate active UC and mild active CD, and they also are efficacious for maintenance of IBD remission. Recent data continue to support the concept that higher doses and prolonged use of mesalamine-based drugs are therapeutically superior to lower doses and short term treatment. In addition, the combination of oral and rectal aminosalicylate formulations often succeeds in patients refractory to either used alone. The immunomodulatory drugs azathioprine and 6-mercaptopurine are particularly effective in treating both CD and UC, and methotrexate has also shown some promise in CD therapy. Immunosuppressive therapy for inflammatory bowel disease initially met with strong physician resistance. However, views have shifted in response to positive data on the utility of immunosuppressive agents in many cases of IBD. Although cyclosporine may be used as a 'rescue' medication in some severe IBD cases, it has been associated with severe toxic reactions. Possible candidates for cyclosporine treatment should be offered such therapy only in academic centers highly experienced with the nuances of this modality. Clinical trials of the newer entities IL-10, IL-11, tacrolimus, and anti-TNFalpha, have demonstrated variable efficacy in refractory IBD patients. Anti-TNFalpha has been very impressive, particularly in the presence of fistulizing Crohn's disease. Many physicians have utilized various antibiotics empirically as part of their 'general' management of IBD. Only metronidazole has been adequately studied in controlled CD trials, but other antibiotic studies are pending. Further exploration of antimicrobial treatment for IBD is clearly warranted. Many other investigational agents in disparate pharmaceutical categories have been employed in IBD therapy; and some of these also show varying degrees of promise, including the aloe vera derivative acemannan, several formulations of heparin, and both transdermal and intra-rectal nicotine. Despite the growing list of medications and formulations promoted for the treatment of IBD, no single drug or recognized combination has yet been confirmed as dependably clinically effective. Many additional investigations of IBD medical therapy are needed, including permutations of conventional medications, along with newer agents that may be more precisely targeted to specific aspects of IBD pathophysiology. All physicians who care for UC and CD patients enthusiastically await more optimal regimens for these challenging disorders.

Forecasting↗

PubMed1992

Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 expression in inflammatory bowel disease.

The etiology of ulcerative colitis (UC) and Crohn's disease (CD) remains enigmatic. Infiltrating intestinal macrophages are capable of producing the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), and interleukin-6 (IL-6). We investigated the presence of IL-6, TNF-alpha and IL-1 beta mRNA transcripts in inflammatory bowel disease (IBD), normal, and other inflammatory intestinal specimens utilizing the polymerase chain reaction (PCR). TNF-alpha mRNA levels did not very between inflammatory bowel disease and control specimens. IL-1 beta mRNA levels were highest in active UC and noninflammatory bowel disease inflammatory specimens while IL-6 mRNA levels were highest in active IBD specimens. Infiltrating T cells, macrophages, and B cells were identified as sources of IL-6 protein in inflammatory bowel disease specimens by immunofluorescent staining. IL-6 transcripts were elevated only in active inflammatory bowel disease specimens, suggesting that IL-6-mediated immune processes are ongoing in the inflammatory mucosal environment of CD and UC.

B-Lymphocytes↗

PubMed1992

Nutrition support in inflammatory bowel disease.

Many patients with the inflammatory bowel diseases, Crohn's disease, or ulcerative colitis have significant protein-calorie malnutrition and micronutrient deficiencies. Factors that contribute to these nutritional deficits include inadequate nutrient intake, malabsorption, excessive nutrient secretion across the diseased gastrointestinal tract, drug-nutrient interactions, and increased nutrient requirements. In this review, the use of enteral and parenteral nutrition support as primary therapy for active Crohn's disease and ulcerative colitis is discussed. Other roles for nutrition support in patients with inflammatory bowel disease, including preoperative nutrition support, nutritional treatment of intestinal fistulas and growth retardation, and home parenteral nutrition for gut failure, are also reviewed.

Deficiency Diseases↗

PubMed2006

Costs of inflammatory bowel disease in Germany.

INTRODUCTION: Inflammatory bowel disease (IBD) is a chronic condition that afflicts young adults in their economically productive years. The goal of this study was to determine the costs of IBD in Germany from a societal perspective, using cost diaries. METHODS: Members of the German Crohn's Disease and Ulcerative Colitis Association who had IBD were recruited by post, and those who agreed to participate documented their IBD-associated costs prospectively in a diary over 4 weeks. They documented their use of healthcare facilities, medications, sick leave and out-of-pocket expenditures, as well as general demographic information, the status and history of their IBD, and long-term disability. Item costs were calculated according to national sources. Cost data were calculated using non-parametric bootstrapping and presented as mean costs (year 2004) over 4 weeks. RESULTS: The cost diaries were returned by 483 subjects (Crohn's disease: n = 241, ulcerative colitis: n = 242) with a mean age of 42 years and an average disease duration of 13 years (SD +/- 8.09). The cost diaries were regarded as 'easy to complete' by 89% of participants. The mean 4-week costs per subject were 1,425 Euros(95% CI 1201, 1689) for Crohn's disease and 1,015 Euros(95% CI 832, 1258) for ulcerative colitis. Of the total costs for Crohn's disease, 64% were due to indirect costs such as early retirement or sick leave and 32% were due to direct medical costs. In contrast, of the total costs for ulcerative colitis, 41% were due to direct medical costs and 54% to indirect costs. CONCLUSIONS: This is the first comprehensive cost study for Crohn's disease and ulcerative colitis in Germany. The most important economic factors that influenced the cost profiles of both diseases were the long-term productivity losses due to an ongoing inability to work and the cost of medications. Results indicate significant cost differences between Crohn's disease and ulcerative colitis. This data provides initial cost estimates that can be analysed further with respect to cost determinants and disease-specific costs in the future.

Adult↗

PubMedDate not supplied

Immunomodulatory benefits of cyclosporine A in inflammatory bowel disease.

Etiopathogenesis of mucosal inflammation in inflammatory bowel disease remains a complex and enigmatic field; various factors (genetic, environmental and microbial) trigger an event that activates intestinal immune and nonimmune systems culminating in inflammation and tissue injury. Specifically, both innate and adaptive immune systems seem to play important roles in the pathophysiology of this disease. Cyclosporine A represents a macrolide immune modulator with primary inhibitory effects on T helper lymphocyte production of interleukin-2, and other cytokines leading to altered T-lymphocyte and B-lymphocyte function. The diversity of its therapeutic outcome reported in inflammatory bowel disease may be due to the intricate immuno-pathogenic profile of the disease and the variety of the applied dose-dependent courses of therapy. Cyclosporine A exerts additional actions on other components of the inflammatory infiltrate, including neutrophils and mast cells, thereby appearing to be a multi-dynamic therapeutic approach, although with potential drawbacks, that may be applied alone or combined with other immunomodulatory agents in inflammatory bowel disease patients. Because cyclosporine A induces apoptosis of T-lymphocytes responsible for perpetuation of the chronic inflammatory process in the disease with potential tumorigenic effect, it may exert a further inhibitory effect on cancer development in inflammatory bowel disease patients, and can be combined with other relative agents, such as rapamycin, which also promotes T-lymphocyte apoptosis. Therefore, recently established multifactorial action of cyclosporine A in relation to the pathogenesis of the disease can open new horizons for prospective, controlled trials in large cohorts, aiming to emphasize cyclosporine A's potential.

Colitis, Ulcerative↗

PubMedDate not supplied

New cytokine therapeutics for inflammatory bowel disease.

Conventional therapy for inflammatory bowel diseases rely on corticosteroids and 5-aminosalicylates combined with immunosuppressive agents for maintenance. These drugs are not always effective and may inflict serious side effects. Other therapies are therefore awaited. Infliximab, a monoclonal antibody against the pro-inflammatory cytokine TNF-alpha has been successfully applied as a treatment for Crohn's disease. The mechanism of action of this drug extends beyond the level of TNF-alpha scavenging and includes induction of apoptosis of effector cells. Numerous anti-TNF antibodies have been developed and are currently evaluated in clinical trials. Other targets for monoclonal antibodies include integrins and cytokines involved in T-cell differentiation and activation. Likewise recombinant proteins that moderate TNF bioactivity and lymphocyte function have been developed. The therapeutic effect of recombinant interleukin-10 seems to be dependent on local delivery of the protein. Antisense therapy targeting lymphocyte migration has also been tested in IBD. Finally, the conventional drug thalidomide and possibly MAP-kinase inhibitors may become novel treatment entities for IBD.

Cytokines↗

PubMedDate not supplied

Inflammatory bowel disease. 1: Aetiology and pathogenesis.

Inflammatory bowel disease, a chronic lifelong condition, affects between 15 and 30 people per 10,000 of the UK population. Despite the large number affected, there seems to be a paucity of information on this subject in the British nursing press. Hence, nurses have little or no understanding of the impact of this illness, and there is a danger that the distress and debilitation that inflammatory bowel disease can have on people's lives is underestimated. However, a healthcare professional, armed with the appropriate knowledge and attitude, can make a real difference to the quality of care that these patients receive. This article is the first in a series of three that shall review the aetiology, treatment and concept of patient participation in inflammatory bowel disease. The series aims to enhance nurses' understanding and stimulate further investigation into this chronic illness.

Diagnosis, Differential↗

PubMed2000

Resistance to activated protein C and low levels of free protein S in Greek patients with inflammatory bowel disease.

OBJECTIVE: Patients with inflammatory bowel disease (IBD) frequently suffer from thromboembolic events. A recently identified mechanism for thrombophilia, the poor anticoagulant response to activated protein C, has been suggested as one of the leading risk factors for thrombosis. The aim of this study was to evaluate the frequency of thrombophilic abnormalities, including activated protein C-resistance (APCR), in Greek patients with ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Forty-eight patients with UC, 36 with CD, and 61 matched healthy controls (HC) were studied. Cases with presence of lupus anticoagulant, use of anticoagulants or heparin, and pregnancy were excluded. Disease activity in CD was evaluated by use of the Crohns Disease Activity Index (CDAI) score and in UC by the Truelove-Witts grading system. Plasma levels of protein C, free protein S, antithrombin III (AT-III), activated protein C resistance (APCR), and fibrinogen were determined in IBD patients, as well as in HC. All the cases and controls with abnormal APCR were further studied by genetic testing for the factor V Leiden mutation. RESULTS: Mean fibrinogen levels in UC and CD patients were significantly elevated (p<0.0001), compared with HC. The mean values of free protein S, as well as mean APCR, were significantly lower in UC and CD patients than in the HC (p<0.0001). Seven (five UC and two CD) of 84 IBD patients (8.3%) and three of the HC (4.9%) had the factor V Leiden mutation. No significant difference was observed for the other thrombophilic parameters. Fibrinogen levels and profound free protein S deficiency were found related to disease activity. CONCLUSIONS: Thrombophilic defects are common in Greek patients with IBD and they could interfere either in the disease manifestation or in the thrombotic complications.

Activated Protein C Resistance↗

PubMed1993

Quality of Life--rationale and methods for developing a disease-specific instrument for inflammatory bowel disease.

Quality of Life (QOL) is a composite descriptor applied to an unlimited spectrum of tangible and intangible parameters of life satisfaction and capacity. Because of the breadth of determinants of QOL, most researchers prefer to focus on a specific segment of it, such as health-related quality of life (HRQOL). Generally, HRQOL indices incorporate physical, emotional and social aspects of both health perception and function. Most instruments are also subjective and quantitative. As in clinical trials, several elements are critical to the development of a HRQOL measure. Most importantly, the putative application of the instrument should be determined beforehand. The clinical setting and disease-specific population of interest must be identified. The questionnaire must be as simple as possible and easy to administer. The final instrument must be shown to be a valid measure of HRQOL, which is reproducible, with limited variability and observer bias on repeated administrations, when no clinical change has occurred. If applicable, the instrument should demonstrate responsiveness to important changes in clinical status. Finally, the value of the instrument in relevant clinical studies should be demonstrated. The critical phases of development of the McMaster IBDQ are outlined. The IBDQ is a quantitative index of HRQOL intended as a measure of therapeutic outcome for clinical trials in patients with inflammatory bowel disease.

Attitude to Health↗

PubMed1997

Dairy sensitivity, lactose malabsorption, and elimination diets in inflammatory bowel disease.

The ability of inflammatory bowel disease (IBD) patients to tolerate dairy products and the guidance they receive from physicians and nutritionists on this subject are important considerations in the management of their IBD. Although most affected persons are able to consume a glass of milk daily without discomfort, additional consideration must be given to specific factors that can be relevant to certain individuals. The declaration by patients that they are "dairy sensitive" may be related to lactose intolerance or malabsorption, the long-chain triacylglycerol content of milk, allergy to milk proteins, as well as psychologic factors and the misconception that dairy products can be detrimental to their health. The prevalence of lactose malabsorption is significantly greater in patients with Crohn disease involving the small bowel than it is in patients with Crohn disease involving the colon or ulcerative colitis. In the latter colonic conditions the prevalence of lactose malabsorption is mainly determined by ethnic risk, which is based on genetic factors. In addition, lactose malabsorption in Crohn disease of the small bowel may be determined by factors other than lactase enzyme activity, such as bacterial overgrowth and/or small bowel transit time. Physicians differ widely in the advice they give their patients: some dogmatically advise avoidance of dairy products when the diagnosis is made whereas others discount the possible role of dairy in the management of IBD. IBD patients avoid dairy products more than they would need to based on the prevalence of lactose malabsorption and/or milk intolerance, probably partly because of incorrect patient perceptions and arbitrary advice from physicians and authors of popular diet books. Adequate scientific and clinical information is now available to permit recommendations about the intake of dairy products for each IBD patient.

Humans↗

PubMed1998

Nutritional issues and therapy in inflammatory bowel disease.

Nutritional issues in inflammatory bowel disease (IBD) often receive inadequate attention both in regard to therapy and nutritionally related complications of IBD. This article reviews much of the research that has evaluated the role of diet in the causation, primary treatment, and adjunctive therapy of both ulcerative colitis (UC) and Crohn's disease (CD). Benefits have been demonstrated in the use of elemental diets or polymeric diets in CD in both acute flare up or maintenance of IBD. A careful team approach can overcome problems in implementing nutritional therapy. Nutrition also has a critical benefit in postoperative CD and perioperative UC. Numerous easily corrected, nutritional abnormalities are often overlooked in patients with IBD, which may have significant consequences. Nutritional therapy may have a central place in the hierarchy of treatment in IBD and further research is critical in this area to better define the benefits of nutrition in IBD.

Adult↗

PubMed2001

Pharmacotherapeutic options in inflammatory bowel disease: an update.

Chronic inflammatory bowel disease (IBD) refers to two diseases: Crohn's disease (CD) and ulcerative colitis (UC). The etiology of IBD remains unknown. The understanding of the pathogenesis has expanded greatly over the last decade. The combination of genetic risk factors, abnormalities in the immune system, vascular and neural factors, and random environmental factors may all play an important role. Most treatments currently in use have multiple action. The choice of appropriate medical treatment is determined by the status (inductive or maintenance therapy) and severity of the disease and the potential for toxicity. Despite the variety of medical therapies available for the treatment of IBD, none is ideal. Ongoing research into the well-established drugs, as well as novel agents with more precise targets, may contribute to an optimal therapy of IBD in the near future. In this paper the current (5-aminosalicylates, glucocorticosteroids, thioguanine derivatives, methotrexate, cyclosporin and infliximab) as well as some of the new (mycophenolate mofetil and thalidomide) therapeutic options are reviewed.

Animals↗

PubMed2002

Increased rectal nitric oxide in children with active inflammatory bowel disease.

BACKGROUND: Luminal nitric oxide increases in ulcerative colitis and Crohn disease. The authors have previously used a minimally invasive method to demonstrate increased luminal nitric oxide in ulcerative colitis and Crohn disease of the colon. The aim of the current study was to determine whether this method could be applied to identify inflammatory activity in ulcerative colitis and Crohn disease in children. METHODS: Thirty-six children (18 of whom had active disease) with inflammatory bowel disease localized to the colon were studied. The control group comprised 12 healthy children. To measure nitric oxide, a silicon catheter with an inflatable balloon was inserted into the rectum and inflated with 10 mL of nitric oxide-free air. After a 10-minute incubation time, the air was withdrawn and nitric oxide concentrations were immediately analyzed using a chemiluminescence technique. RESULTS: Children with active ulcerative colitis and Crohn disease of the colon had greatly increased luminal nitric oxide concentrations in the rectum (8,840 +/- 5,120 and 15,170 +/- 4,757 parts per billion [ppb], respectively) compared with controls (77 +/- 17 ppb) (P < 0.001). Children with nonactive ulcerative colitis or Crohn disease displayed low concentrations of rectal nitric oxide (356 +/- 110 and 188 +/- 55 ppb, respectively), which was not different from that of healthy controls. CONCLUSION: Rectal nitric oxide measurement is a feasible and useful method for monitoring disease activity in inflammatory bowel disease, especially in children.

Adolescent↗

PubMed2006

Cytomegalovirus colitis complicating inflammatory bowel disease.

When patients with inflammatory bowel disease (IBD) are admitted to the hospital with a flare of acute severe colitis, the possibility of a concurrent cytomegalovirus (CMV) infection causing or worsening the colitis is often considered. IBD patients are usually immunosuppressed, and therefore presumably at increased risk for active CMV infection and disease. Multiple techniques are used to diagnose CMV infection, including endoscopy, histology, serology, viral culture, CMV antigen testing, and CMV DNA testing. Immunohistochemistry (IHC) performed on colon biopsy specimens with monoclonal antibodies directed against CMV immediate early antigen is considered by most to be the current gold standard for diagnosis. The prevalence of CMV infection in acute severe colitis appears to be 21-34%, and the prevalence of CMV infection in the steroid refractory subgroup of these patients is 33-36%. After antiviral therapy, colitis remission rates in IBD patients with CMV infection range from 67% to 100%, though CMV histological infection or the presence of circulating virus alone is not always associated with steroid resistance, and may not require antiviral therapy.

Colitis↗

PubMed2007

5-Aminosalicylic acid therapy and the risk of colorectal cancer among patients with inflammatory bowel disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) affecting the colon are at increased risk of developing colorectal cancer (CRC). Published data are conflicting about whether 5-aminosalicylic acid (5-ASA) has chemopreventive properties against IBD-related carcinogenesis. The objective of this observational study was to determine if an association between 5-ASA therapy and CRC risk exists in IBD patients. METHODS: Adult patients with a new CRC diagnosis (n = 18,440) were identified from 2 large administrative claims databases. For each case, 20 control patients with no record of CRC diagnosis or bowel surgery (n = 368,800) were identified. RESULTS: An IBD diagnosis was associated with a 6- to 7-fold increased risk of CRC (ulcerative colitis, crude odds ratio [OR] = 6.72, 95% CI, 5.79-7.81; Crohn's disease, crude OR = 6.60, 95% CI, 5.56-7.82). Among patients with IBD (364 CRC cases, 1172 controls), exposure to 5-ASA therapy of any dose or duration during the 12 months before CRC diagnosis was not associated with a reduced risk of CRC (OR = 0.97; 95% CI, 0.77-1.23). However, there was a trend toward a decreased risk of CRC with increasing number of mesalamine prescriptions in the previous year, though statistical significance was not achieved (trend P = 0.08). CONCLUSIONS: Treating IBD patients with 5-ASA medications was not found to have a protective effect against colitis-related CRC when assessed over a short period of exposure.

Aged↗

PubMed1997

Clinical evaluation of hepatocyte growth factor in patients with gastrointestinal and pancreatic diseases with special reference to inflammatory bowel disease.

Hepatocyte growth factor (HGF) is widely expressed in the gastrointestinal tract and pancreas. However, the clinical significance of HGF in gastrointestinal and pancreatic diseases remains unclear. To clarify its clinical significance in these diseases, we determined serum HGF in patients with gastrointestinal and pancreatic diseases. Serum HGF was measured in 81 patients with gastrointestinal diseases, pancreatic diseases, and 150 healthy individuals, using a highly sensitive immunoradiometric assay (IRMA). The patients included 55 patients with colonic disorders, 20 with gastric disorders and 6 with pancreatic disorders. Serum HGF levels in patients with inflammatory bowel diseases and chronic pancreatitis were higher than those in normal individuals (p < 0.05, each). Symptomatic patients with inflammatory bowel diseases showed higher values of HGF than symptom-free patients (p < 0.05). Patients with moderately severe or severe ulcerative colitis showed higher values of HGF than patients with mild disease (p < 0.05). Serum HGF values were correlated with C-reactive protein (CRP) and serum HGF changed in parallel with clinical courses in patients with ulcerative colitis. The immunohistochemical study showed that HGF was present around the neutrophils infiltrating into the lamina propria, which was biopsied from endoscopically active colonic mucosa in patients with ulcerative colitis, while little HGF was observed in the inactive mucosa. The results of the present study suggest that serum HGF changes in gastrointestinal and pancreatic diseases, especially in inflammatory bowel diseases.

Adult↗

PubMed2001

Inflammatory bowel disease.

The pathogenesis of inflammatory bowel disease (IBD) continues to be explored, with the emphasis on genetically determined host immune dysregulation as it applies to interactions with luminal bacteria. The role of endoscopic ultrasound in the evaluation of IBD continues to be studied. Recent advances in the evaluation of enterocutaneous fistulas have been made through the use of hydrogen peroxide to enhance definition of the fistula course and characteristics of the neighboring bowel, as evaluated by transabdominal ultrasound. Refinements have been made in the use and interpretation of the results of surveillance colonoscopy for detection of colorectal cancer and dysplasia in IBD, but a consistent approach still needs to be applied by individual practitioners. New data exist on the usefulness of methotrexate for maintenance of remission, while a lack of efficacy has been demonstrated for mesalamine in the prevention of postoperative recurrence. The role of anti-tumor necrosis factor (TNF) antibody therapy in the treatment of IBD continues to be investigated.

Colonoscopy↗