Phantom of the inflammasome in the gut: Cytomegalovirus

Cytomegalovirus (CMV) is frequently detected in inflammatory bowel tissue, especially in corticosteroid-refractory patients, and it has been blamed for adverse outcomes. However, the first acquisition of CMV does not involve the colon. In particular in the colonic mucosa, which evolved due to the gut microbial relationship, CMV promotes inflammation via recruited monocytes and not through replication in resident macrophages. Whether CMV is the last straw in the process of mucosal inflammation, a doomed agent, or an innocent bystander is a difficult question that remains elusive. With this work, we will try to review the relationship between intestinal mucosa and CMV in the framework of basic virological principles.

Asymptomatic bacteriuria among hospitalized diabetic patients: Should they be treated?

Diabetes Mellitus is a significant health care challenge in the United States. The Center for Disease Control and Prevention estimates approximately 9.4% of patients in the United States are afflicted by diabetes. The Infectious Disease Society of America asymptomatic bacteriuria in women as two consecutive clean-catch voided urine specimens with isolation of the same bacterial strain in counts ≥ 10⁵ cfu/mL It is understood that diabetic patients tend to be at higher risk for infections than non-diabetics. Urinary tract infections (UTIs) tend to be the most common infection contracted by this population. UTIs are not only a significant cause of morbidity and mortality, they are also a significant financial burden. The data are conflicting, in regard to treating asymptomatic bacteriuria in diabetic patients to avoid hospital complications and ultimately decrease healthcare costs associated with these complications. However, clinicians continue to prescribe antibiotics empirically. Further randomized controlled study looking into the specific population as immunocompromised diabetic patients, patient with diabetic ketoacidosis and patient in intensive care unit needs to be undertaken.

Artificial intelligence for endoscopy

In recent times, there has been progressive development in artificial intelligence (AI) following the introduction of deep learning in the medical field including gastroenterology and endoscopy. Most of the reported studies were based on retrospective data. Several prospective studies of real-time diagnosis of moving images using the AI system are expected to match the real clinical situation and to aid the endoscopists in the detection and diagnosis of neoplasms without missing any lesion. AI can read a large number of endoscopic images in a few minutes and make a diagnosis; therefore, it is expected to cover the lack of support for the screening esophagogastroduodenoscopy in the health check-up and a large number of capsule images, thereby freeing the endoscopists from this burden. AI can help make the diagnosis during the endoscopic procedure and thereby prevent an unnecessary biopsy for patients taking antithrombotic drugs. AI can also be useful for education and training in endoscopy. Trainees can learn to perform endoscopy and the detection and diagnosis of lesions by the support of AI. In the near future, real-time endoscopic diagnosis using AI is expected to lessen the burden of endoscopists, to enhance the quality level of endoscopists, to overcome the miss of lesions and to make optimal diagnosis.

Single strain probiotics for dyslipidemia, fatty liver, and obesity: A systematic review and meta-analysis

BACKGROUND

A number of non-systematic reviews on the effects or mechanisms of probiotics on improving dyslipidemia, fatty liver, and obesity have been available but inconclusive to determine the independent effects of probiotics on each of the three conditions.

AIM

To perform a systematic review and meta-analysis on potential benefits of probiotics among individuals with fatty liver or obesity or hyperlipidemia.

METHODS

A systematic literature search was performed using PubMed and Embase. Adult participants of any gender without major comorbidities who received probiotics were considered following these criteria: (1) Studies on a single genus of probiotics with or without prebiotics; (2) Studies specifying the probiotic dosage into colony-forming units (CFUs); and (3) Studies on food-based probiotics were excluded. The primary outcome measures for fatty liver, obesity, and dyslipidemia were fibrosis score (kPa), body mass index (BMI; kg/m²), and serum lipid profiles (mg/dL), respectively. The secondary outcome measures for fatty liver and obesity were liver enzymes (U/L) and subcutaneous fat area (cm²).

RESULTS

A total of 13 articles, published between 1997 and 2018, fulfilled the selection criteria. Three probiotics were included, of which Lactobacillus was the most commonly studied (10 studies), followed by Bifidobacterium (two studies) and Pediococcus (one study). Probiotics significantly reduced BMI (P = 0.013), total cholesterol (P = 0.011), and low-density lipoprotein (P = 0.006) while increased high-density lipoprotein (P = 0.028); high heterogeneities were observed. Only Lactobacillus could decrease triglyceride level (P = 0.005) with low heterogeneity. No included studies reported fibrosis score, liver functions, subcutaneous fat outcomes.

CONCLUSION

Single probiotics, especially Lactobacillus, have a potentially beneficial effect on improving obesity and dyslipidemia. Evidence on the fatty liver is limited.

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length

Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.

Relationship between perioperative anaemia and outcomes in older people with hip fractures: A systematic review and meta-analysis protocol

BACKGROUND

Hip fractures are common with increasing age and is associated with decline in mobility. Both the fracture and the surgery can lead to blood loss, resulting in anaemia. However, it is uncertain at which time point haemoglobin is most strongly associated with different clinical outcomes after hip fracture. Our hypothesis is perioperative anaemia (admission, postoperative and discharge) during hip fracture surgery is associated with poor clinical outcomes.

AIM

To determine the effects of perioperative anaemia during hip fracture surgery on mortality, functional status and other clinical outcomes.

METHODS

Electronic databases will be searched to identify studies evaluating perioperative anaemia and outcomes of hip fracture surgery. Reference lists of included studies will also be searched to identify additional published studies. Eligibility criteria are as follows: Population: People who underwent hip fracture surgery; Exposure: Perioperative anaemia; Comparison: No anaemia before or after hip fracture surgery; Outcome: Mortality, hospital length of stay, postoperative complications, hospital readmission, change of discharge destination, quality of life and functional status. Risk of bias assessment will be assessed using the Cochrane Collaboration’s tool for randomized controlled trials and the modified version of the Epidemiological Appraisal Instrument for observational studies. Data will be pooled for meta-analysis if deemed appropriate.

CONCLUSION

This review seeks to clarify outcomes associated with perioperative anaemia at various time-points around hip fracture surgery. These findings will potentially inform evidence-based clinical practice on interventions in those with anaemia.

Treatment options for rumination syndrome: A systematic review

BACKGROUND

Rumination syndrome (RS) is characterized by recurrent effortless postprandial regurgitation of recently ingested food from the stomach to the oral cavity and has been associated with quality of life impairment and malnutrition. There is a general lack of consensus on the most appropriate treatment options for RS.

AIM

To summarize the literature on treatment options for RS.

METHODS

We conducted a systematic review according to PRISMA guidelines. We searched Medline (1946 to February 2019), EMBASE (1947 to February 2019), PsycINFO (1806 to February 2019) and Cochrane central register of controlled trials for articles discussing treatment options for adult patients (> 18 years) with RS. All relevant articles were accessed in full text. We extracted data on study designs, patient profiles, duration of symptoms, follow up periods, date, diagnostic criteria, interventions and outcomes. Risk of bias assessment was carried out independently by 3 reviewers via Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized controlled trials and Cohort studies respectively.

RESULTS

Twelve articles were identified. A total of 254 patients were included in the analysis, with a mean age of 36.1 (range 18-89). 185 patients (72.8%) were females. 5 studies looked into behavioral therapies, primarily diaphragmatic breathing (DB) 2 studies looked at baclofen, 1 fundoplication and 1 supportive lifestyle changes. 3 studies looked at a combination of therapies involving pharmacological, behavioral and psychotherapies.

CONCLUSION

Although evidence for treatment options is still limited, the strongest evidence point towards the use of DB and Baclofen, and both should be considered depending on their availabilities.

Surgery with adjuvant or neoadjuvant treatment vs surgery alone for resectable pancreatic cancer: A network meta-analysis

BACKGROUND

Pancreatic cancer is one of the most common and lethal malignancies worldwide. The common treatment options for resectable pancreatic cancer include surgery alone, neoadjuvant chemotherapy (CT), neoadjuvant chemoradiotherapy (CRT), adjuvant CT, and adjuvant CRT. However, the optimal treatment is still controversial.

AIM

To identify the most effective approach for pancreatic cancer using network meta-analysis.

METHODS

Eligible studies were searched from PubMed, MEDLINE, EMBASE, Cochrane database, and Google scholar. We searched and included randomized controlled trials reporting on neoadjuvant and adjuvant therapies. For direct comparisons, standard pairwise meta-analysis was performed using the inverse variance DerSimonian-Laird random-effects model. For indirect comparisons, Bayesian network meta-analysis was used to combine direct and indirect evidence. We used relative hazard ratios (HRs) to estimate death difference of different treatments, and relative odds ratios (ORs) for toxic effects. Treatment effects were ranked based on their efficacy for improving survival or reducing toxicity using rankogram. The quality of evidence of estimates from direct comparison and network meta-analysis was evaluated following the GRADE approach.

RESULTS

We included 13 high quality trials with 1591 participants in this network meta-analysis. Compared with surgery alone [pooled HR = 0.7, 95% confidence interval (CI): 0.62-0.79] and surgery with adjuvant CRT (pooled HR = 0.6, 95%CI: 0.54-0.72), surgery with adjuvant CT had a higher rate of overall survival. In contrast, standard pairwise meta-analysis showed a statistically significant survival advantage of surgery with adjuvant CT compared with surgery alone (pooled HR = 0.75, 95%CI: 0.63-0.89; P < 0.001). Rankogram showed that surgery with adjuvant CT was most likely to rank the best in terms of overall survival (probability: 94.2%), followed by surgery alone (probability: 5.8%). No significant differences in overall toxicity or haematological toxicity were found between all the therapies. High quality evidence supported surgery with adjuvant CT over surgery alone for increasing overall survival. Moderate quality evidence supported surgery with adjuvant CT over surgery with adjuvant CRT for increasing overall survival.

CONCLUSION

Surgery with adjuvant CT prolongs overall survival compared with surgery alone and surgery with adjuvant CRT, suggesting surgery with adjuvant CT is the optimal treatment for resectable pancreatic cancer.

Significance of multivisceral resections in oncologic surgery: A systematic review of the literature

BACKGROUND

Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.

AIM

To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.

METHODS

PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.

RESULTS

Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.

Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.

CONCLUSION

MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.

Hepatitis B reactivation in patients with hepatitis B core antibody positive and surface antigen negative on immunosuppressants

Hepatitis B viral (HBV) reactivation in the immunosuppressed is a significant problem even in patients who have achieved serological clearance due to the persistence of HBV as cccDNA. HBV reactivation will continue to pose a significant healthcare burden given the high prevalence of HBV and increasing use of immunosuppressants. Screening of hepatitis B surface antigen, antibody to Hepatitis B core antigen antibody and HBV DNA levels should be done routinely in all patients planned for significant immunosuppressant use. We aimed to examine the factors affecting reactivation risk. This depended on HBV disease status, the underlying disease requiring immunosuppression, and the specific immunosuppressive regime. While antiviral prophylaxis can prevent reactivation, it increases cost and still has risk of delayed reactivation after stopping antivirals and close follow-up and on-demand treatment is a good alternative for patients at risk of reactivation.

Scoring criteria for determining the safety of liver resection for malignant liver tumors

BACKGROUND

Liver resection has become safer as it has become less invasive. However, the minimum residual liver volume (RLV) required to maintain homeostasis is unclear. Furthermore, the formulae used to calculate standard liver volume (SLV) are complex.

AIM

To review previously reported SLV formulae and the methods used to evaluate the minimum RLV, and explore the association between liver volume and mortality.

METHODS

A systematic review of Medline, PubMed, and grey literature was performed. References in the retrieved articles were cross-checked manually to obtain further studies. The last search was conducted on January 20, 2019. We developed an SLV formula using data for 86 consecutive patients who underwent hepatectomy at our institution between July 2009 and August 2011.

RESULTS

Linear regression analysis revealed the following formula: SLV (mL) = 822.7 × body surface area (BSA) − 183.2 (R² = 0.419 and R = 0.644, P < 0.001). We retrieved 25 studies relating to SLV formulae and 12 studies about the RLV required for safe liver resection. Although the previously reported formulae included various coefficient and constant values, a simplified version of the SLV, the common SLV (cSLV), can be calculated as follows: cSLV (mL) = 710 or 770 × BSA. The minimum RLV for normal and damaged livers ranged from 20%-40% and 30%-50%, respectively. The Sapporo score indicated that the minimum RLV ranges from 35%-95% depending on liver function.

CONCLUSION

We reviewed SLV formulae and the minimum RLV required for safe liver resection. The Sapporo score is the only liver function-based method for determining the minimum RLV.

Present state of endoscopic ultrasonography-guided fine needle aspiration for the diagnosis of autoimmune pancreatitis type 1

Autoimmune pancreatitis (AIP) is defined as pancreatitis caused by irregular narrowing of the pancreatic duct accompanied by pancreatic swelling, fibrosis and lymphocyte infiltration, events that are related to autoimmune mechanisms. The 2010 International Consensus Diagnostic Criteria for AIP defined pancreatitis as “type 1” when increased levels of serum IgG4 were present and other organs were involved; lymphoplasmacytic sclerosing pancreatitis was the main histological characteristic. Apart from surgery, endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is the only method for the histological diagnosis of AIP; however, this method is difficult. The use of larger-diameter FNA needles and trucut biopsy did not improve the diagnostic performance of EUS-FNA, but it has improved gradually. In this review, we look back at past efforts to improve the diagnostic performance of EUS-FNA and reveal the present state of EUS-FNA for the histological diagnosis of AIP type 1.

Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the investigation and treatment of pancreaticobiliary diseases. However, post-ERCP pancreatitis (PEP) is a severe adverse effect. Prior meta-analyses have shown that prophylactic PS was useful for preventing PEP. However, abstract reports and patients who underwent endoscopic ampullectomy were included in the previous analyses. In addition, two meta-analyses involved non-randomized controlled trials (RCTs). The efficacy of PS for preventing severe PEP was different in each meta-analysis. Therefore, we performed the current meta-analysis, which included only full-text articles, and added new findings.

AIM

To reveal the efficacy of prophylactic pancreatic stent (PS) placement for preventing PEP.

METHODS

We searched the MEDLINE, Cochrane Library and PubMed databases for related RCTs. Among the reports retrieved, 11 studies were included in this meta-analysis. All full-text articles were published between 1993 and 2016. A total of 1475 patients were enrolled in the included studies; of these patients, 734 had a PS inserted, and 741 did not have a PS inserted. PEP and severe PEP occurrence were evaluated in this meta-analysis.

RESULTS

PEP was observed in all studies and occurred in 39 (5.3%) patients who received a PS. On the other hand, PEP occurred in 141 (19%) patients who did not receive a PS. The occurrence of PEP was significantly lower in the patients who underwent PS placement than in the patients who did not receive a PS (OR = 0.32; 95%CI: 0.23-0.45; P < 0.001). In addition, the occurrence of severe PEP was evaluated. Notably, the occurrence of severe PEP was not observed in the stent group; however, the occurrence of severe PEP was observed in 8 (1.3%) patients who did not have a PS inserted. Severe PEP occurred significantly less often in the stent group than in the no stent group (OR = 0.24; 95%CI: 0.06-0.94; P = 0.04).

CONCLUSION

In conclusion, prophylactic PS placement is useful for preventing PEP and severe PEP.

Current state and future direction of screening tool for colorectal cancer

As the second-most-common cause of cancer death, colorectal cancer (CRC) has been recognized as one of the biggest health concerns in advanced countries. The 5-year survival rate for patients with early-stage CRC is significantly better than that for patients with CRC detected at a late stage. The primary target for CRC screening and prevention is advanced neoplasia, which includes both CRC itself, as well as benign but histologically advanced adenomas that are at increased risk for progression to malignancy. Prevention of CRC through detection of advanced adenomas is important. It is, therefore, necessary to develop more efficient detection methods to enable earlier detection and therefore better prognosis. Although a number of CRC diagnostic methods are currently used for early detection, including stool-based tests, traditional colonoscopy, etc., they have not shown optimal results due to several limitations. Hence, development of more reliable screening methods is required in order to detect the disease at an early stage. New screening tools also need to be able to accurately diagnose CRC and advanced adenoma, help guide treatment, and predict the prognosis along with being relatively simple and non-invasive. As part of such efforts, many proposals for the early detection of colorectal neoplasms have been introduced. For example, metabolomics, referring to the scientific study of the metabolism of living organisms, has been shown to be a possible approach for discovering CRC-related biomarkers. In addition, a growing number of high-performance screening methodologies could facilitate biomarker identification. In the present, evidence-based review, the authors summarize the current state as recognized by the recent guideline recommendation from the American Cancer Society, US Preventive Services Task Force and the United States Multi-Society Task Force and discuss future direction of screening tools for colorectal cancer. Further, we highlight the most interesting publications on new screening tools, like molecular biomarkers and metabolomics, and discuss these in detail.

Hepatic gastrointestinal stromal tumor: Systematic review of an exceptional location

BACKGROUND

A minor subset of primary gastrointestinal stromal tumors (GIST) can also arise outside the gastrointestinal tract, which is known as an extra-GIST (E-GIST). Primary GIST of the liver is an exceptional location.

AIM

To characterize epidemiological, clinical and pathological features and options of treatments.

METHODS

We performed a systematic review to search for articles on primary hepatic GIST.

RESULTS

This review shows that right hepatic lobe was the most frequent location. Regarding pathological and immunohistochemical features, mitotic count was ≥ 5/50 High Power Fields in more than 50%; and CD117 was negative in only 1 patient. More than 70% of patients had a lesion with high risk of malignancy.

CONCLUSION

The diagnosis of E-GIST must be considered in a liver mass. Rendering an accurate diagnosis is a challenge, as well as the confirmation of their primary or metastatic nature.

Safety and efficacy of percutaneous transhepatic balloon dilation in removing common bile duct stones: A systematic review

BACKGROUND

Endoscopic sphincterotomy (EST) is widely regarded as the first choice in the management of common bile duct (CBD) stones. However, for some patients, this treatment is not possible. The percutaneous transhepatic balloon dilation (PTBD) technique has been suggested as an alternative but has yet to gain wide acceptance.

AIM

To review cases of PTBD for removing CBD stones and explore the safety and efficacy of this treatment.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched EMBASE, PubMed, and Web of Science for cases of PTBD that underwent CBD stone removal from 1981 to January 2019. We analyzed all relevant articles available in full text. We extracted data on patient’s age, gender, overall technique success rate, reasons for technique failure, and the presence and type of major and minor complications. We analyzed the data and reported the results in a table and text. Altogether, we retrieved 12 case series and 6 case reports, for a total of 1347 patients. Thirty cases were excluded due to a lack of patient data.

RESULTS

The overall technique success rate for removing a CBD stone was 98.5% (1327/1347) and 98.1% (109/111) for removing concurrent CBD and gallbladder stones. Based on available data (n = 1312), mean age of all patients (687 males and 625 females) was 68.9 years. The total number of procedures in the remaining 1317 patients (after exclusion) was 3237 (average 2.4 procedures per patient). The total number of failures for eliminating a CBD stone was 20, and the reasons for failure included: Stone impaction (n = 10), intrahepatic bile duct stricture (n = 5), large stone (n = 2), severe CBD dilation (n = 1), multiple stones (n = 1), and duodenal perforation (n = 1). Various major complications related to the procedure were reported, but the incidence rate was low (1.4%). No pancreatitis or procedure related mortality was reported. Minor complications including transient hyperamylasemia, nausea, vomiting, abdominal pain, fever, and mild hemobilia were reported. For 218 patients (88 patients with unsuccessful endoscopic removal due to anatomical change and large or impacted stone and 130 cases who refused endoscopic procedure due to poor general condition or other additional disease), the CBD stones were successfully pushed into the duodenum by performing the PTBD procedure.

CONCLUSION

PTBD is a safe and effective approach in the nonoperative management of CBD stones. PTBD provides an alternative treatment when endoscopic procedures fail or are unsuitable for the patient.

Effectiveness of taxanes over anthracyclines in neoadjuvant setting: A systematic-review and meta-analysis

BACKGROUND

Anthracyclines and taxanes are more active group of chemotherapy regimen. Randomized controlled trials (RCTs) reported variable evidences regarding efficacy of taxanes over anthracyclines for tumor response and survival outcomes. The present study compares the relative efficacy of taxanes over anthracyclines using pathological complete response (pCR), clinical responses, breast-conserving surgeries and survival outcomes in female breast cancer patients by systematic review and meta-analysis of available RCTs.

AIM

To assess the effectiveness of taxanes over anthracyclines in neoadjuvant setting in terms of tumor response and survival outcomes.

METHODS

All RCTs assessing efficacy of taxanes over anthracyclines in neoadjuvant setting for management of breast cancer searched through PubMed and Cochrane register of controlled trials on 28 April 2017 and published in English language were considered. Following PRISMA guideline, retrieved records were screened and data were extracted by two independent reviewers. Meta-analysis was performed using fixed effect or random effect method depending on heterogeneity assessed using I² statistic. Subgroup meta-analyses on the basis of taxane alone or taxane along with anthracycline in comparison to anthracycline alone were also performed for each considered outcomes.

RESULTS

A total of 16 RCTs involving 6752 breast cancer patients were found eligible. Taxanes based chemotherapy significantly improved pCR (n = 7, RR = 1.48, 95%CI: 1.04-2.12), disease free survival [n = 6, RR = 0.89 (0.80-0.99)] and loco-regional recurrence free survival [n = 4, RR = 0.74 (0.59-0.94)]. Interestingly in subgroup analysis, addition of taxane to anthracyclines showed better effectiveness regarding these survivals over anthracyclines than taxane alone over anthracycline.

CONCLUSION

Addition of taxanes to anthracyclines based chemotherapy significantly improves pCR, disease free survival and loco-regional recurrence free survival but with no significant impact on breast conservation rates.

Anti-inflammatory properties of antidiabetic agents

The reciprocal relationship between hyperglycemia and inflammation in the setting of diabetes mellitus has been the subject of extensive research. Insulin resistance, the hallmark of diabetic metabolic dysregulation, has been linked to the inflammatory cascade occurring mainly in adipose tissue. The main pathophysiologic processes facilitating the aforementioned interplay, is a phenotype switch of macrophages to the M1 class following gluco- and lipotoxicity and gut microbial remodeling. Given the correlation between inflammation and metabolic abnormalities, the elucidation of the exact mechanisms linking the two along with exploring the possible role of modulation of one in order to alter the other, could open up the possibility of novel therapeutic approaches for diabetes mellitus and its complications. Therefore, the aim of this review is to summarize the growing body of evidence concerning the molecular basis and results of pro-inflammatory processes in diabetic subjects along with the effect of current antidiabetic treatment options on tissue inflammation.

Drug interactions of dipeptidyl peptidase 4 inhibitors involving CYP enzymes and P-gp efflux pump

Dipeptidyl peptidase 4 (DPP4) inhibitors are oral antidiabetic drugs approved to manage type 2 diabetes mellitus. Saxagliptin is a substrate of CYP3A4/5 enzymes while other DPP4 inhibitors such as sitagliptin, linagliptin, gemigliptin and teneligliptin are weak substrates of CYP3A4. DPP4 inhibitors have also been identified as substrates of P-gp. Hence, the drugs inhibiting or inducing CYP3A4/5 enzymes and/or P-gp can alter the pharmacokinetics of DPP4 inhibitors. This review is aimed to identify the drugs interacting with DPP4 inhibitors. The plasma concentrations of saxagliptin have been reported to be increased significantly by the concomitant administration of ketoconazole or diltiazem while no significant interactions between various DPP4 inhibitors and drugs like warfarin, digoxin or cyclosporine have been identified.

Endoscopic management of biliary strictures post-liver transplantation

Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.

Subcellular expression of maspin – from normal tissue to tumor cells

Maspin or SerpinB5, a member of the serine protease inhibitor family, was shown to function as a tumor suppressor, especially in carcinomas. It seems to inhibit invasion, tumor cells motility and angiogenesis, and promotes apoptosis. Maspin can also induce epigenetic changes such as cytosine methylation, de-acetylation, chromatin condensation, and histone modulation. In this review, a comprehensive synthesis of the literature was done to present maspin function from normal tissues to pathologic conditions. Data was sourced from MEDLINE and PubMed. Study eligibility criteria included: Published in English, between 1994 and 2019, specific to humans, and with full-text availability. Most of the 118 studies included in the present review focused on maspin immunostaining and mRNA levels. It was shown that maspin function is organ-related and depends on its subcellular localization. In malignant tumors, it might be downregulated or negative (e.g., carcinoma of prostate, stomach, and breast) or upregulated (e.g., colorectal and pancreatic tumors). Its subcellular localization (nuclear vs cytoplasm), which can be proved using immunohistochemical methods, was shown to influence both tumor behavior and response to chemotherapy. Although the number of maspin-related papers increased, the exact role of this protein remains unknown, and its interpretation should be done with extremely high caution.

Higher dose of simethicone decreases colonic bubbles and increases prep tolerance and quality of bowel prep: Meta-analysis of randomized controlled trials

BACKGROUND

Antifoaming agents, such as simethicone, may facilitate mucosal inspection during colonoscopy. However, conflicting results have been reported with regard to the impact of simethicone on quality of bowel preparation and adenoma detection rate (ADR).

AIM

To perform a meta-analysis of trials that have compared simethicone vs placebo during colonoscopy.

METHODS

A reproducible literature search of multiple medical databases yielded eleven studies (n = 2605) for inclusion. Studies were compared for quality of bowel preparation, bubbles quality, ADR, and tolerability. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted by both fixed-effects and random-effects models. Relative risk (RR) estimates with a 95% confidence interval (CI) were calculated. Heterogeneity was assessed by I-squared index (I²) statistics.

RESULTS

Patients’ demographic characteristics were comparable in all studies. Of the 2605 patients, 1300 were in the simethicone group, whereas 1305 were in the placebo group. Inadequate bowel preparation was much lower in the simethicone group than in the placebo group [13% vs 24.6%; RR = 0.51 (0.31-0.82); P < 0.0001]. The placebo group was more likely to have significant colonic bubbles than was the simethicone group [35% vs 8%; RR = 1.49 (1.25-1.76); P = 0.0001]. Use of simethicone resulted in a slight, statistically significant increase in ADR compared with the placebo group [26.6% vs 21.6%, RR = 1.07 (1.01-1.13); P = 0.02]. Higher doses of simethicone (> 478 mg) were more likely to result in significant reduction of inadequate bowel preparation, colonic bubbles, and to improve ADR.

CONCLUSION

Adding simethicone improved the quality of bowel preparation, visualization, tolerability, and, eventually, ADR.

Gastrointestinal stress ulcer prophylaxis in the intensive care unit, where is the data?

Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. Several strategies for SUP have been suggested over the past four decades, with acid suppressive therapies being the most commonly used in the ICU. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and provision of a simple answer is not feasible at the present time. Recently, a large phase IV, multicenter, randomized clinical trial (SUP-ICU), negated the benefits (and harms) of proton pump inhibitors as SUP. This article reviews some of these controversies.

PD-1/PD-L1 antagonists in gastric cancer: Current studies and perspectives

Immune checkpoints release suppressive signals for T cells, which enable the tumors to escape from immune destruction and provide a new concept that uses the capabilities of the immune system as a therapeutic target for tumors. At present, programmed death receptor 1 (PD-1)/programmed death ligand-1 (PD-L1) has become the most promising therapeutic target. PD-1/PD-L1 blockades exhibit long-lasting antitumor efficacy and safety in patients with various cancers, such as melanoma and non-small-cell lung cancer. Moreover, PD-L1 is highly expressed in the peripheral blood and tumor specimens of patients with cancer, and the expression of PD-L1 is positively correlated with various pathological features and may serve as a predictor of poor prognosis or a diagnostic tool. Clinical trials have verified that PD-1/PD-L1 blockade therapy benefits patients with advanced gastric cancer or gastroesophageal junction cancer. Furthermore, there are many molecules involved in the regulation of PD-1/PD-L1 expression, and the modification of these molecules via drugs and combinations with PD-1/PD-L1 inhibitors may further improve the efficacy of immunotherapy for gastric cancer. In this review, the efficacy, safety, and possible combination treatment options of PD-1/PD-L1 in gastric cancer are reviewed in experimental and clinical settings.

Early immune response in post endoscopic retrograde cholangiopancreatography pancreatitis as a model for acute pancreatitis

This opinion review summarizes comparison of clinical presentation and immunology of post-endoscopic pancreatitis and acute pancreatitis (AP) of other etiology. The rationale for this topic was found in studies that mention differences in clinical presentation between these entities, stating that severe form of AP after endoscopic retrograde cholangiopancreatography was more severe than AP of other etiology. Found difference in clinical presentation may have a background in different immunology that needs to be further investigated.