Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Treatment outcomes for multidrug-resistant Mycobacterium Tuberculosis (MDRTB) are generally poor compared to drug sensitive disease. We sought to estimate treatment outcomes and identify risk factors associated with poor outcomes in patients with MDRTB.

METHODOLOGY/PRINCIPAL FINDINGS

We performed a systematic search (to December 2008) to identify trials describing outcomes of patients treated for MDRTB. We pooled appropriate data to estimate WHO-defined outcomes at the end of treatment and follow-up. Where appropriate, pooled covariates were analyzed to identify factors associated with worse outcomes. Among articles identified, 36 met our inclusion criteria, representing 31 treatment programmes from 21 countries. In a pooled analysis, 62% [95% CI 57-67] of patients had successful outcomes, while 13% [9]-[17] defaulted, 11% [9]-[13] died, and 2% [1]-[4] were transferred out. Factors associated with worse outcome included male gender 0.61 (OR for successful outcome) [0.46-0.82], alcohol abuse 0.49 [0.39-0.63], low BMI 0.41[0.23-0.72], smear positivity at diagnosis 0.53 [0.31-0.91], fluoroquinolone resistance 0.45 [0.22-0.91] and the presence of an XDR resistance pattern 0.57 [0.41-0.80]. Factors associated with successful outcome were surgical intervention 1.91 [1.44-2.53], no previous treatment 1.42 [1.05-1.94], and fluoroquinolone use 2.20 [1.19-4.09].

CONCLUSIONS/SIGNIFICANCE

We have identified several factors associated with poor outcomes where interventions may be targeted. In addition, we have identified high rates of default, which likely contributes to the development and spread of MDRTB.

Diagnostic accuracy of echocardiography for pulmonary hypertension: a systematic review and meta-analysis

CONTEXT

Right heart catheterisation is the gold standard for the diagnosis of pulmonary hypertension. However, echocardiography is frequently used to screen for this disease and monitor progression over time because it is non-invasive, widely available and relatively inexpensive.

OBJECTIVE

To perform a systematic review and quantitative meta-analysis to determine the correlation of pulmonary pressures obtained by echocardiography versus right heart catheterisation and to determine the diagnostic accuracy of echocardiography for pulmonary hypertension.

DATA SOURCES

MEDLINE, EMBASE, Papers First, the Cochrane collaboration and the Cochrane Register of controlled trials were searched and were inclusive as of February 2010.

STUDY SELECTION

Studies were only included if a correlation coefficient or the absolute number of true-positive, false-negative, true-negative and false-positive observations was available, and the 'reference standards' were described clearly.

DATA EXTRACTION

Two reviewers independently extracted the data from each study. Quality was assessed with the quality assessment for diagnostic accuracy studies. A random effects model was used to obtain a summary correlation coefficient and the bivariate model for diagnostic meta-analysis was used to obtain summary sensitivity and specificity values. Results 29 studies were included in the meta-analysis.The summary correlation coefficient between systolic pulmonary arterial pressure estimated from echocardiography versus measured by right heart catheterisation was 0.70 (95% CI 0.67 to 0.73; n=27).The summary sensitivity and specificity for echocardiography for diagnosing pulmonary hypertension was 83% (95% CI 73 to 90) and 72% (95% CI 53 to 85;n=12), respectively. The summary diagnostic OR was 13(95% CI 5 to 31).Conclusions Echocardiography is a useful and noninvasive modality for initial measurement of pulmonary pressures but due to limitations, right heart catheterisation should be used for diagnosing and monitoring pulmonary hypertension.

Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods

OBJECTIVE

Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known.

DESIGN

Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods.

RESULTS

A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively.

CONCLUSIONS

In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.

Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps

BACKGROUND & AIMS

Thermal ablation of the defect margin after endoscopic mucosal resection (EMR-T) for treating large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) has shown efficacy in a randomized trial, with a 4-fold reduction, in residual or recurrent adenoma (RRA) at first surveillance colonoscopy (SC1). The clinical effectiveness of this treatment, in the real world, remains unknown.

METHODS

We sought to evaluate the effectiveness of EMR-T in an international multicenter prospective trial (NCT02957058). The primary endpoint was the frequency of RRA at SC1. Detailed demographic, procedural, and outcome data were recorded. Exclusion criteria were LNPCPs involving the ileo-caecal valve, the appendiceal orifice, and circumferential LNPCPs.

RESULTS

During 51 months (May 2016-August 2020) 1049 LNPCPs in 1049 patients (median size, 35 mm; interquartile range, 25-45 mm; right colon location, 53.5%) were enrolled. Uniform completeness of EMR-T was achieved in 989 LNPCPs (95.4%). In this study, 755/803 (94.0%) eligible LNPCPs underwent SC1 (median time to SC1, 6 months; interquartile range, 5-7 months). For LNPCPs that underwent complete EMR-T, the frequency of RRA at SC1 was 1.4% (10/707).

CONCLUSIONS

In clinical practice, EMR-T is a simple, inexpensive, and highly effective auxiliary technique that is likely to significantly reduce RRA at first surveillance. It should be universally used for the management of LNPCPs after EMR. https://clinicaltrials.gov; Clinical Trial Number, NCT02957058.

When trainees reach competency in performing ERCP: a systematic review

BACKGROUND AND AIMS

ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP.

METHODS

Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency.

RESULTS

Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs.

CONCLUSIONS

Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.

Performance of interferon-gamma release assays in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Guidelines mandate screening for latent tuberculosis infection (LTBI) prior to anti-tumor necrosis factor (anti-TNF) therapy in patients with inflammatory bowel disease (IBD). However, many are already on immunosuppressive therapy (IST) that may affect the precision of the Tuberculin skin test (TST). Our aim was to assess the performance of the new interferon-gamma release assays (IGRAs) to detect LTBI in patients with IBD.

METHODS

MEDLINE and EMBASE were searched (up to June 2011) to identify studies evaluating the performance of IGRAs (QuantiFERON-TB Gold [QFT-2G], QuantiFERON-TB Gold In-Tube [QFT-3G] and T-SPOT.TB) in individuals with IBD. Forest plots and pooled estimates using random effects models were created where applicable.

RESULTS

Nine unique studies encompassing 1309 patients with IBD were included for analysis. The pooled concordance between the TST and QFT-2G/QFT-3G was 85% (95% confidence interval [CI] 77%-90%). The concordance of the TST and TSPOT.TB was 72% (95% CI 64%-78%). Studies assessing agreement reported more IGRA-/TST+ results versus IGRA+/TST- results. The pooled percentage of indeterminate results was 5% (95% CI 2%-9%) for QFT-2G/QFT-3G. TSPOT.TB showed similar results. Both positive QFT-2G/QFT-3G results (pooled odds ratio [OR] 0.37, 95% CI 0.16-0.87) and positive TST results (pooled OR 0.28, 95% CI 0.10-0.80) were significantly influenced by IST (both P = 0.02).

CONCLUSIONS

While it remains difficult to determine superiority between the IGRAs and the TST, both are negatively affected by IST. Therefore, screening prior to initiation of IST should be considered. Nevertheless, it is imperative that all patients receive screening prior to anti-TNF therapy.

Impact of asian ethnicity on colorectal cancer screening: a population-based analysis

OBJECTIVES

Although research shows that African Americans and Hispanics frequently receive less colorectal cancer screening (CRCS) than whites, few studies have focused on CRCS among Asians. The aims of this study were to compare CRCS between Asians and whites and to evaluate for clinical predictors of CRCS.

METHODS

From the 2007 California Health Interview Survey, we identified all Asian and white respondents who were eligible for CRCS. Logistic regression was performed to evaluate for differences in CRCS. We used stratified and interaction analyses to examine whether associations between race and CRCS were modified by insurance status, birthplace, or language skills, while controlling for other confounders.

RESULTS

Baseline characteristics were similar between Asians and whites. Only 58% of Asians and 66% of whites reported undergoing up-to-date CRCS (P < 0.01). In multivariate analyses, visiting a physician more than 5 times produced the highest odds of being up-to-date with screening. When compared with whites, Asians had decreased odds of being up-to-date with screening. Stratified analyses showed that this disparity existed mainly in the insured, but not in the uninsured, and it was not modified by place of birth or English language proficiency.

CONCLUSIONS

Despite its ability to reduce mortality, CRCS is suboptimal in our US population-based cohort of Asians when compared with whites. A contributing factor to this problem for the Chinese and Koreans may be a lack of awareness regarding CRCS, whereas the source of the problem in the Vietnamese seems to be related to healthcare access.

Proposal for the return to routine endoscopy during the COVID-19 pandemic

In response to the coronavirus disease 2019 (COVID-19) pandemic, many jurisdictions and gastroenterological societies around the world have suspended nonurgent endoscopy. Subject to country-specific variability, it is projected that with current mitigation measures in place, the peak incidence of active COVID-19 infections may be delayed by over 6 months. Although this aims to prevent the overburdening of healthcare systems, prolonged deferral of elective endoscopy will become unsustainable. Herein, we propose that by incorporating readily available point-of-care tests and conducting accurate clinical risk assessments, a safe and timely return to elective endoscopy is feasible. Our algorithm not only focuses on the safety of patients and healthcare workers, but also assists in rationalizing the use of invaluable resources such as personal protective equipment.

Factors associated with positive findings from capsule endoscopy in patients with obscure gastrointestinal bleeding

BACKGROUND & AIMS

Capsule endoscopy (CE) is used most frequently to identify causes of obscure gastrointestinal bleeding (OGIB). Identifying factors associated with the detection of lesions by CE could improve resource utilization and thereby improve patient selection for CE examination. We sought to identify clinical factors associated with positive findings from CE in patients with OGIB.

METHODS

We analyzed data from 698 CE procedures performed between December 2001 and April 2011 at St Paul's Hospital, Vancouver, Canada (50.3% of patients were female; mean age, 63.4 years). A positive finding was defined as a lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, or visible blood). Univariate and multivariate logistic regression analyses were used to correlate demographic and clinical parameters with positive findings.

RESULTS

A lesion believed to be the cause of bleeding was identified in 42% of cases. In univariate analysis, the number of esophagogastroduodenoscopies (EGDs), the presence of connective tissue disease or diabetes with end-organ damage, Charlson comorbidity index scores, and increasing transfusion requirements were significantly associated with identification of causative pathology from CE (all P < .027). In multivariate analysis, increasing number of EGDs (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.37), increasing transfusion requirements (3-9 units: OR, 1.70; 95% CI, 1.08-2.66, and ≥10 units: OR, 2.72; 95% CI, 1.69-4.37), and connective tissue disease (OR, 2.24; 95% CI, 1.14-4.41) were all significantly associated with identification of positive findings by using CE (all P < .045).

CONCLUSIONS

Patients with a higher number of precapsule EGDs or transfusions, or connective tissue disease, are superior candidates for analysis of OGIB by CE.

When trainees reach competency in performing endoscopic ultrasound: a systematic review

Background/Study aim The American Society for Gastrointestinal Endoscopy (ASGE) recommends that trainees complete 150 endoscopic ultrasound (EUS) procedures before assessing competency. However, this recommendation is largely based on limited evidence and expert opinion. With new evidence suggesting that this historical threshold is underestimating training requirements, we evaluated the learning curve for achieving competency in EUS. Patients/Materials and methods Two investigators independently searched MEDLINE for full-text citations assessing the learning curve for achieving competency in EUS in the period 1946 to 25 March 2016. A learning curve was defined as either a tabulated or graphic representation of competency as a function of increasing EUS experience. Results Eight studies assessing 28 trainees and 7051 EUS procedures were included. When stratifying studies based on procedural indication: three studies assessed competency in evaluating mucosal lesions, three studies assessed competency in EUS fine-needle aspiration (EUS-FNA), and two studies assessed comprehensive competency. Among studies assessing mucosal lesion T-staging accuracy, competency was achieved by 65 to 231 procedures. Among studies assessing EUS-FNA, competency was achieved by 30 to 40 procedures. Among the two studies assessing comprehensive competency in EUS, competency was not achieved in either study across all trainees. Only four of 17 trainees reached competency by 225 to 295 EUS procedures. Conclusion As EUS competency assessment has evolved to more closely reflect independent clinical practice, the number of procedures required to achieve competency has risen well above ASGE recommendations. Advanced endoscopy training programs and specialty societies need to re-assess the structure of EUS training.

Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction

OBJECTIVE

The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs.

DESIGN

EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC).

RESULTS

Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027).

CONCLUSION

EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.

Factors associated with suboptimal colorectal cancer screening in US immigrants

BACKGROUND

Our objectives were to: (1) compare colorectal cancer screening (CRCS) among US born citizens (USBs), naturalized citizens (NACs), and noncitizens (NOCs) and (2) evaluate clinical factors and potential barriers associated with CRCS in these populations.

METHODS

Screening-eligible patients were identified from the 2007 California Health Interview Survey. Up-to-date CRCS was defined as a fecal occult blood test within 1 year, a sigmoidoscopy within 5 years, or a colonoscopy within 10 years. Using logistic regression, we determined the effects of immigrant status on CRCS. Stratified analyses based on location of residence, health insurance status, and English proficiency were conducted.

RESULTS

A total of 30,434 average-risk adults aged 50 years or older completed the survey. Only 67% of USBs, 61% of NACs, and 46% of NOCs underwent CRCS. Advanced age, male sex, high-income earners, nonsmokers, and those who were married or visited their physicians frequently were more likely to receive CRCS (all P < 0.05). Compared with USBs, both NACs and NOCs showed decreased odds of CRCS (odds ratio 0.88, 95% confidence interval, 0.74-1.06 and odds ratio 0.68, 95% confidence interval, 0.53-0.88, respectively; P = 0.011). Stratified analyses revealed that the associations between immigrants and decreased CRCS were more prominent for those who lived in rural areas, lacked insurance, or were not English proficient.

CONCLUSIONS

CRCS remains suboptimal, especially in new US immigrants. Improving health care access and mitigating language barriers may minimize this disparity.

A statistical method was used for the meta-analysis of tests for latent TB in the absence of a gold standard, combining random-effect and latent-class methods to estimate test accuracy

OBJECTIVE

Because of the lack of a gold standard, the diagnostic performance of tests for the detection of latent tuberculosis infection (LTBI) is not known. However, statistical methods can be used to estimate the accuracy from the studies reporting the concordance among the tests.

STUDY DESIGN AND SETTING

We developed a random-effect latent-class model to estimate performance characteristics of three LTBI diagnostic tests: tuberculin skin test (TST, at 10-mm cutoff), QuantiFERON-TB gold (QFG), and TSPOT-TB from the studies evaluating agreement among the tests.

RESULTS

Nineteen studies were included. QFG had a sensitivity of 0.642 (95% confidence interval [CI]: 0.593-0.691) and specificity of 0.996 (95% CI: 0.989-1.000), TSPOT-TB had a sensitivity of 0.500 (95% CI: 0.334-0.666) and specificity of 0.906 (95% CI: 0.882-0.929), and TST had a sensitivity of 0.709 (95% CI: 0.658-0.761) and specificity of 0.683 (95% CI: 0.522-0.844). Results were not sensitive to the inclusion of any single study. When only the three studies that reported on TSPOT were removed, estimates for the other two tests varied minimally.

CONCLUSIONS

Statistical methods can help estimate the accuracy of LTBI tests. Although the specificities were close to their reported values in the literature, the estimates for sensitivities were low; a finding that should be carefully evaluated.

Effect of longer battery life on small bowel capsule endoscopy

AIM

To determine if longer battery life improves capsule endoscopy (CE) completion rates.

METHODS

A retrospective study was performed at a tertiary, university-affiliated hospital in Vancouver, Canada. Patients who underwent CE with either PillCam™ SB2 or SB2U between 01/2010 and 12/2013 were considered for inclusion. SB2 and SB2U share identical physical dimensions but differ in their battery lives (8 h vs 12 h). Exclusion criteria included history of gastric or small bowel surgery, endoscopic placement of CE, interrupted view of major landmarks due to technical difficulty or significant amount of debris, and repeat CE using same system. Basic demographics, comorbidities, medications, baseline bowel habits, and previous surgeries were reviewed. Timing of major landmarks in CE were recorded, and used to calculate gastric transit time, small bowel transit time, and total recording time. A complete CE study was defined as visualization of cecum. Transit times and completion rates were compared.

RESULTS

Four hundred and eight patients, including 208 (51.0%) males, were included for analysis. The mean age was 55.5 ± 19.3 years. The most common indication for CE was gastrointestinal bleeding (n = 254, 62.3%), followed by inflammatory bowel disease (n = 86, 21.1%). There was no difference in gastric transit times (group difference 0.90, 95%CI: 0.72-1.13, P = 0.352) and small bowel transit times (group difference 1.07, 95%CI: 0.95-1.19, P = 0.261) between SB2U and SB2, but total recording time was about 14% longer in the SB2U group (95%CI: 10%-18%, P < 0.001) and there was a corresponding trend toward higher completion rate (88.2% vs 93.2%, OR = 1.78, 95%CI 0.88-3.63, P = 0.111). There was no statistically significant difference in the rates of positive findings (OR = 0.98, 95%CI: 0.64-1.51, P = 0.918).

CONCLUSION

Extending the operating time of CE may be a simple method to improve completion rate although it does not affect the rate of positive findings.

Previously Attempted Large Nonpedunculated Colorectal Polyps Are Effectively Managed by Endoscopic Mucosal Resection

INTRODUCTION

Endoscopic mucosal resection (EMR) is an effective therapy for naive large nonpedunculated colorectal polyps (N-LNPCPs). The best approach for the treatment of previously attempted LNPCPs (PA-LNPCPs) is undetermined.

METHODS

EMR performance for PA-LNPCPs was evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by technical success (removal of all visible polypoid tissue during index EMR) and recurrence at first surveillance colonoscopy (SC1). Safety was assessed by clinically significant intraprocedural bleeding, deep mural injury types III-V, clinically significant post-EMR bleeding, and delayed perforation.

RESULTS

From January 2012 to October 2019, 158 PA-LNPCPs and 1,134 N-LNPCPs underwent EMR. Median PA-LNPCP size was 30 mm (interquartile range 25-46 mm). Technical success was 93.0% and increased to 95.6% after adjusting for 2-stage EMR. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) was required for nonlifting polypoid tissue in 73 (46.2%). Median time to SC1 was 6 months (interquartile range 5-7 months). Recurrence occurred in 9 (7.8%). No recurrence was identified among 65 PA-LNPCPs which underwent margin thermal ablation at SC1 vs 9 (18.0%; P < 0.001) which did not. There were significant differences in resection duration (35 vs 25 minutes; P < 0.001), technical success (93.0% vs 96.6%; P = 0.026), and use of CAST (46.2% vs 7.6%; P < 0.001), between PA-LNPCPs and N-LNPCPs. When adjusting for 2-stage EMR, no difference in technical success was identified (95.6% vs 97.8%; P = 0.100). No differences in adverse events or recurrence were identified.

DISCUSSION

EMR, using auxillary techniques where necessary, can achieve high technical success and low recurrence frequencies for PA-LNPCPs.

Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer

OBJECTIVE

Endoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach.

DESIGN

Retrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group.

RESULTS

Of 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2-4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4-6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6-105).

CONCLUSION

Following ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved.

TRIAL REGISTRATION NUMBER

NCT03987828.

Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial

BACKGROUND

Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon.

METHODS

We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed.

FINDINGS

Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported.

INTERPRETATION

Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding.

FUNDING

None.

Current recommendations for the treatment of mild asthma

Patients suffering from mild asthma are divided into intermittent or persistent classes based on frequency of symptoms and reliever medication usage. Although these terms are used as descriptors, it is important to recognize the approach of focusing on asthma control in managing asthma patients. Beta-agonists are considered first-line therapy for intermittent asthmatics. If frequent use of beta-agonists occurs more than twice a week, controller therapy should be considered. For persistent asthma, low-dose inhaled corticosteroids are recommended in addition to reliever medication. Compliance to regular therapy can pose problems for disease management, and while intermittent controller therapy regimens have been shown to be effective, it is imperative to stress the value of regular therapy especially if an exacerbation occurs. It is also important when such an approach is adopted that there is regular re-evaluations of asthma control. This is because regular anti-inflammatory therapy may become necessary if symptoms become more persistent. Other therapies are seldom needed. Antileukotrienes can be considered an option for mild asthma; however, studies have shown that they are not as effective as inhaled corticosteroids. Aside from therapy, patient education, which includes a written action plan, should be a component of the patient's strategy for disease management.

Optical Evaluation for Predicting Cancer in Large Nonpedunculated Colorectal Polyps Is Accurate for Flat Lesions

BACKGROUND AND AIMS

The ability of optical evaluation to diagnose submucosal invasive cancer (SMIC) prior to endoscopic resection of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) is critical to inform therapeutic decisions. Prior studies suggest that it is insufficiently accurate to detect SMIC. It is unknown whether lesion morphology influences optical evaluation performance.

METHODS

LNPCPs ≥20 mm referred for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Optical evaluation was performed prior to endoscopic resection with the optical prediction of SMIC based on established features (Kudo V pit pattern, depressed morphology, rigidity/fixation, ulceration). Optical evaluation performance outcomes were calculated. Outcomes were reported by dominant morphology: nodular (Paris 0-Is/0-IIa+Is) vs flat (Paris 0-IIa/0-IIb) morphology.

RESULTS

From July 2013 to July 2019, 1583 LNPCPs (median size 35 [interquartile range, 25-50] mm; 855 flat, 728 nodular) were assessed. SMIC was identified in 146 (9.2%; 95% confidence interval [CI], 7.9%-10.8%). Overall sensitivity and specificity were 67.1% (95% CI, 59.2%-74.2%) and 95.1% (95% CI, 93.9%-96.1%), respectively. The overall SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). Significant differences in sensitivity (90.9% vs 52.7%), specificity (96.3% vs 93.7%), and SMIC miss rate (0.6% vs 5.9%) between flat and nodular LNPCPs were identified (all P < .027). Multiple logistic regression identified size ≥40 mm (odds ratio [OR], 2.0; 95% CI, 1.0-3.8), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7), and nodular morphology (OR, 7.2; 95% CI, 2.8-18.9) as predictors of missed SMIC (all P < .039).

CONCLUSIONS

Optical evaluation performance is dependent on lesion morphology. In the absence of features suggestive of SMIC, flat lesions can be presumed benign and be managed accordingly.

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children

BACKGROUND

Written action plans providing guidance in the early treatment of asthma exacerbations have traditionally advocated doubling of inhaled corticosteroids (ICS) as one of the first steps in treatment.

OBJECTIVES

To compare the clinical effectiveness of increasing the dose of ICS versus keeping the usual maintenance dose as part of a patient-initiated action plan at the onset of asthma exacerbations.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (last search October 2009) which is derived from searches of CENTRAL, MEDLINE, EMBASE and CINAHL, as well as handsearched respiratory journals and meeting abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared the strategy of increasing the daily dose of ICS to continuing the same ICS dose in the home management of asthma exacerbations in children or adults with persistent asthma on daily maintenance ICS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information.

MAIN RESULTS

Five RCTs (four parallel-group and one cross-over) involving a total of 1250 patients (28 children and 1222 adults) with mild to moderate asthma were included. The mean daily baseline ICS dose was 555 mcg (range 200 mcg to 795 mcg) and the mean daily ICS dose achieved following increase was 1520 mcg (range 1000 mcg to 2075 mcg), in CFC beclomethasone dipropionate equivalents. Three parallel-group studies in adults (two doubling and one quadrupling; mean achieved daily dose of 1695 mcg with a range of 1420 to 2075 mcg), involving 1080 patients contributed data to the primary outcome. There was no significant reduction in the need for rescue oral corticosteroids when patients were randomised to the increased ICS compared to stable maintenance dose groups (OR 0.85, 95% CI 0.58 to 1.26). There was no significant difference in the overall risk of non-serious adverse events associated with the increased ICS dose strategy, but the wide confidence interval prevents a firm conclusion. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very little evidence from trials in children. In adults with asthma on daily maintenance ICS, a self-initiated ICS increase to 1000 to 2000 mcg/day at the onset of an exacerbation is not associated with a statistically significant reduction in the risk of exacerbations requiring rescue oral corticosteroids. More research is needed to assess the effectiveness of increased ICS doses at the onset of asthma exacerbations (particularly in children).

Achieving asthma control in patients with moderate disease

Patients with moderate asthma are symptomatic on an ongoing basis. They are usually treated initially with low-dose inhaled corticosteroids (ICSs) supplemented with a short-acting bronchodilator as a rescue medication. Most steroid-naive patients will achieve good control with this strategy. For patients in whom adherence, inhaler technique, environmental control, and comorbidities have been addressed but who still have uncontrolled symptoms, the addition of a long-acting beta-adrenergic agonist should be considered. Some patients might require a higher dose of ICS. Leukotriene receptor antagonists might be considered as alternate initial therapy or as an add-on to maintenance therapy with an ICS. All patients should receive a structured education program emphasizing the need for ongoing maintenance treatment, even when control is achieved. Patients should also be provided with a written action plan that clearly explains which additional anti-inflammatory therapy should be taken if asthma symptoms worsen. The most effective strategy in this situation has been shown to be the quadrupling of the maintenance dose of ICS.

The Utility of Infliximab Therapeutic Drug Monitoring among Patients with Inflammatory Bowel Disease and Concerns for Loss of Response: A Retrospective Analysis of a Real-World Experience

Background. Infliximab (IFX) therapeutic drug monitoring (TDM) allows for objective decision making in patients with inflammatory bowel disease (IBD) and loss of response. Questions remain about whether IFX TDM improves outcomes. Methods. Patients with IBD who had IFX TDM due to concerns for loss of response were considered for inclusion. Serum IFX trough concentration and anti-drug antibody (ADA) concentrations were measured. Patients were grouped by TDM results: group 1, low IFX/high ADA; group 2, low IFX/low ADA; group 3, therapeutic IFX. Changes in management were analyzed according to groupings; remission rates were assessed at 6 months. Results. 71 patients were included of whom 37% underwent an appropriate change in therapy. Groups 1 (67%) and 2 (83%) had high adherence compared to only 9% in group 3. At 6 months, 57% had achieved remission. More patients who underwent an appropriate change in therapy achieved remission, though this did not reach statistical significance (69% versus 49%; P = 0.098). Conclusions. A trend towards increased remission rates was associated with appropriate changes in management following TDM results. Many patients with therapeutic IFX concentrations did not undergo an appropriate change in management, potentially reflecting a lack of available out-of-class options at the time of TDM or due to uncertainty of the meaning of the reported therapeutic range.