Impact of difficult biliary cannulation on post-ERCP pancreatitis: secondary analysis of the stent versus indomethacin trial dataset

BACKGROUND AND AIMS

Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors.

METHODS

This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP.

RESULTS

In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages.

CONCLUSIONS

DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages.

Results of Endoscopic Treatment of Recurrent Malignant Biliary Obstruction in Patients with Self-Expanding Metal Stents

BACKGROUND AND AIM

Endoscopic biliary drainage with placement of a self-expanding metal stent (SEMS) is the preferred palliative treatment of malignant biliary obstruction. Recent advances in the treatment have prolonged survival, thus, increasing the chance of recurrent biliary obstruction (RBO) after SEMS placement. The aim of this study was to compare different endoscopic approaches in patients with a SEMS and RBO, regarding clinical success and time to RBO.

METHODS

This retrospective study included all patients with a SEMS placed because of malignant biliary strictures who underwent endoscopic retrograde cholangiopancreatography between January 2011 and December 2018. We evaluated the results of different endoscopic interventions to RBO, including insertion of a new SEMS, stent cleaning, and insertion of a plastic stent (PS).

RESULTS

From January 2011 to December 2018, 70 (22.4%) patients developed RBO requiring endoscopic reintervention (n = 105 sessions). From the 105 ERCPs, technical success, clinical success, and adverse events rates were 91,4%, 71,8%, and 7,8%, respectively. Younger age (OR = 1.11 95%CI: 1.03-1.19) and the finding of a patent SEMS (OR = 0.17 95%CI: 0.04-0.08) were predictors of clinical failure (P = 0.006 and P = 0.024, respectively). The mean patency time (in days) after endoscopic reintervention was greater for SEMSs than for PSs (417.2 [95% CI: 250.0-584.4] vs 175.2 [95% CI: 124.0-226.5], P = 0.002).

CONCLUSIONS

Correct identification and treatment of the causal factor of RBO typically lead to technical and clinical success. Placement of a second SEMS provides longer patency compared to a plastic stent if ingrowth (overgrowth) occurs.

Survey of the endoscopy workforce’s perception of sustainability

Objective

The National Health Service is a significant contributor to greenhouse gas emissions, with endoscopy ranking as the third highest contributor of waste in healthcare. We aimed to ascertain the endoscopy workforce attitudes towards sustainable practices, barriers to change and potential solutions towards achieving a more sustainable endoscopy practice.

Methods

A prospective cross-sectional online survey was distributed to endoscopy staff through the Joint Advisory Group on Gastrointestinal Endoscopy, the British Society of Gastroenterology (BSG), the Green Endoscopy Centre for Sustainable Healthcare Network and trainee research networks. The survey used a 5-point Likert scale to include:

(1) perceived importance of sustainability in endoscopy, (2) factors contributing to waste generation in endoscopy, (3) barriers to sustainability in endoscopy and (4) strategies for sustainable change

Results

Of 202 participants, 83% were highly concerned about climate change and 71% recognised the significant carbon footprint generation within endoscopy. Lack of environmental consideration (77%), personal protective equipment and decontamination (76%), and packaging of single-use items (74%) were considered the most significant factors impacting waste generation in endoscopy. Participants ranked poor access to recyclable equipment (55%), poor awareness (52%) and poor attitudes (47%) as the main barriers to sustainable change. Concerningly, only a third would inform others if they noticed the wasting of resources.

An overwhelming majority agreed with the BSG prioritising sustainability highly (84%), with 88.6% supporting policy and guideline development on sustainable endoscopy practice.

Conclusion

We identified a strong consensus supporting the BSG’s prioritisation of activities relating to sustainability and climate change, with endoscopy being a key area of focus for improvement.

Efficacy of hemostatic powder monotherapy versus conventional endoscopic treatment for nonvariceal GI bleeding: a meta-analysis and trial sequential analysis

BACKGROUND AND AIMS

Hemostatic powder (HP) is a novel hemostasis modality for nonvariceal GI bleeding. This meta-analysis was performed to evaluate the efficacy of HP monotherapy versus conventional endoscopic treatment (CET) for nonvariceal GI bleeding.

METHODS

PubMed, EMBASE, and Cochrane Library databases were systematically searched from inception to October 16, 2023. The primary outcomes were the initial hemostatic rate and the 30-day recurrent bleeding rate. After the meta-analysis, a trial sequential analysis (TSA) was also conducted to decrease the risk of random errors and validate the result.

RESULTS

The meta-analysis included 8 studies, incorporating 653 patients in total. Given significant heterogeneity, all analyses were segregated into malignancy-related and nonmalignancy-related GI bleeding lesions. For the former, HP monotherapy significantly improved the initial hemostasis rate and 30-day recurrent bleeding rate compared with CET (relative risk [RR], 1.50; 95% confidence interval [CI], 1.28-1.75; P < .001; RR, .32; 95% CI, .12-.86; P = .02, respectively), and TSA supported the results. For nonmalignancy-related GI bleeding, HP monotherapy and CET have similar initial hemostasis and 30-day recurrent bleeding rates (RR, 1.08; 95% CI, .98-1.19; P = .11; RR, 1.15; 95% CI, .46-2.90; P = .76, respectively), but the TSA failed to confirm the results.

CONCLUSIONS

HP monotherapy surpassed CET in terms of the initial hemostasis rate and 30-day recurrent bleeding rate for patients with malignancy-related GI bleeding. However, their relative efficacy for nonmalignancy-related GI bleeding remains unresolved.

Trial sequential analysis involving same-year studies requires careful temporal ordering

Trial sequential analysis (TSA) is an increasingly used tool in systematic reviews to monitor synthesized evidence. However, the current practice of TSAs often overlooks the order of same-year studies, which are typically ordered alphabetically based on the last names of the studies' authors by default in the widely used TSA software application. This practice is inappropriate and contrary to the TSA's definition. This issue is particularly concerning in systematic reviews on time-sensitive topics, such as COVID-19, where reviews include many studies within a short period. In this article, we use a case study to illustrate the impact of the order of same-year studies on TSA conclusions. It shows dramatically different patterns of evidence accumulation when same-year studies are ordered alphabetically vs in their actual temporal order. This article offers suggestions for authors to pay attention to study ordering in future TSAs.

Results of AIPO Italian survey on sustainability in Interventional Pulmonology

BACKGROUND

Sustainability in medicine is gaining increasing importance. In interventional pulmonology only few studies demonstrated the impact of mechanisms involved in CO2 equivalent production; moreover, operators' sensitivity to sustainability and each center's recycling processes are highly variable. We conducted a national survey among interventional pulmonologists on perception of sustainability resulting from their work, and how endoscopic activity impacts the production of recyclable material.

METHODS

A 26-item questionnaire was sent to each AIPO member registered in the interventional pulmonology study group. Items were divided in four topics: demographic data, perception of the problem, measures in place to improve sustainability and potentially feasible measure to improve the problem.

RESULTS

We obtained a 16.2% response rate and majority of participants work in high volume centers. Climate change was perceived as an important problem but responders though that physicians are few involved mainly due to lack of awareness of the problem. Recycling programs are widely available with differentiation between recyclable and potentially contaminated material. The disposable bronchoscopes use was perceived to increase carbon footprint. Most critical interventions to improve sustainability suggested were: optimization of separate waste collection, instrument reprocessing procedures, adherence to guidelines to reduce unnecessary procedures and improving staff awareness. Most participants believed that scientific societies should establish a working group on climate change.

CONCLUSIONS

The sustainability of daily activity in interventional pulmonology is a cause for concern among interventional pulmonologists while the lack of awareness remains the main reason for the poor perception of the problem; sustainability represents a need and an opportunity for interventional pulmonologists to align with other disciplines, but this concept can also be extended to all areas of pneumology.

Understanding the learning curve of intestinal ultrasound in inflammatory bowel disease: A comparative study between novice, regular and expert

BACKGROUND

Intestinal ultrasound (IUS) has emerged as a valuable tool for monitoring inflammatory bowel disease (IBD), but its reliability depends on the technical skills of the operator.

AIMS

This study aimed to assess the IUS learning curve of a novice briefly trained to get him familiarized with the ultrasound machine and normal/abnormal IUS images, and a gastroenterologist with formal general ultrasound training and regular IUS experience (> 200 exams), using an expert radiologist as the gold standard.

METHODS

The ULTRA-IBD study was a single-center, prospective study involving 50 consecutive IBD patients. Three successive IUS examinations were performed on each patient by the 3 operators. Inter-rater agreement on IUS disease activity was calculated using the intraclass correlation coefficient.

RESULTS

The experienced gastroenterologist demonstrated consistently good agreement with the radiologist throughout the study, while the novice failed to go beyond poor agreement after 50 examinations, although a faster learning curve was observed in patients without history of IBD surgery.

CONCLUSION

These findings highlight the difficulty of the technical performance of IUS rather than its interpretation. Comprehensive ultrasound training beforehand and between 50 and 200 examinations of experience are necessary before embarking on IUS.

Impact of simulated animated video education on patients' disease uncertainty, anxiety, and sleep quality in digestive endoscopy examination

BACKGROUND

Gastrointestinal endoscopy examinations were commonly associated with patient uncertainty, anxiety, and sleep disturbances. Simulated animated video education has emerged as a potential intervention to address these psychosocial aspects in the healthcare setting. This study explores the impact of simulated animated video education on patients' disease uncertainty, anxiety, and sleep quality in the context of digestive endoscopy examinations.

METHODS

A total 166 patients who underwent digestive endoscopy examinations were conducted and divided into the conventional education group (n = 77) and the simulated animated video education group (n = 89). Disease uncertainty was assessed using the Mishel's Uncertainty in Illness Scale (MUIS), anxiety was evaluated using the Hamilton Anxiety Rating Scale (HAMA), and sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Both conventional and simulated animated video education interventions led to a reduction in disease uncertainty, anxiety levels, and improvement in sleep quality post-education and at the one-month follow-up. However, the simulated animated video education group exhibited greater reductions in disease uncertainty (post-education: 86.69 ± 2.65 vs. 85.65 ± 3.46, P = 0.031; follow-up: 82.57 ± 4.57 vs. 81.21 ± 3.69, P = 0.038), anxiety (post-education: 19.88 ± 3.78 vs.18.75 ± 3.42, P = 0.046; follow-up: 18.59 ± 3.4 vs. 17.54 ± 3.25, P = 0.046), and improvement in sleep quality (post-education: 5.57 ± 1.25 vs. 5.15 ± 1.1, P = 0.023; follow-up: 5.22 ± 1.13 vs. 4.89 ± 0.86, P = 0.038) compared to the conventional education group.

CONCLUSION

The study findings suggest that simulated animated video education was associated with reduced disease uncertainty, alleviated anxiety, and improved sleep quality among patients undergoing gastrointestinal endoscopy.

New machine-learning models outperform conventional risk assessment tools in Gastrointestinal bleeding

Rapid and accurate identification of high-risk acute gastrointestinal bleeding (GIB) patients is essential. We developed two machine-learning (ML) models to calculate the risk of in-hospital mortality in patients admitted due to overt GIB. We analyzed the prospective, multicenter Hungarian GIB Registry's data. The predictive performance of XGBoost and CatBoost machine-learning algorithms with the Glasgow-Blatchford (GBS), pre-endoscopic Rockall and ABC scores were compared. We evaluated our models using five-fold cross-validation, and performance was measured by area under receiver operating characteristic curve (AUC) analysis with 95% confidence intervals (CI). Overall, we included 1,021 patients in the analysis. In-hospital death occurred in 108 cases. The XGBoost and the CatBoost model identified patients who died with an AUC of 0.84 (CI:0.76-0.90; 0.77-0.90; respectively) in the internal validation set, whereas the GBS and pre-endoscopic Rockall clinical scoring system's performance was significantly lower, AUC values of 0.68 (CI:0.62-0.74) and 0.62 (CI:0.56-0.67), respectively. ABC score had an AUC of 0.77 (CI:0.71-0.83). The XGBoost model had a specificity of 0.96 (CI:0.92-0.98) at a sensitivity of 0.25 (CI:0.10-0.43) compared with the CatBoost model, which had a specificity of 0.74 (CI:0.66-0.83) at a sensitivity of 0.78 (CI:0.57-0.95). XGBoost and the CatBoost models evaluate the mortality risk of acute GI bleeding better, than the conventional risk assessment tools.

Splenic Artery Embolization for Upper Gastrointestinal Bleeding Caused by Hemosuccus Pancreaticus

Hemosuccus pancreaticus (HP) is a rare but potentially life-threatening condition, characterized by upper gastrointestinal bleeding from the ampulla of Vater, often originating from a ruptured pseudoaneurysm of the peripancreatic arteries. Despite its rarity, HP presents a diagnostic and therapeutic challenge due to its elusive clinical presentation and complex underlying pathophysiology. In this case report, we presented a compelling instance of HP, diagnosed in a 48-year-old man, complicated with gastrointestinal bleeding and severe anemia successfully managed with urgent endovascular intervention. We highlighted the importance of early recognition, prompt intervention, and interdisciplinary collaboration in achieving favorable outcomes in patients afflicted by this distinctly unusual condition.

Pharmacogenetics in Response to Biological Agents in Inflammatory Bowel Disease: A Systematic Review

Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders influenced by microbial, environmental, genetic, and immune factors. The introduction of biological agents has transformed IBD therapy, improving symptoms, reducing complications, and enhancing patients' quality of life. However, approximately 30% of patients exhibit primary non-response, and 50% experience a loss of response over time. Genetic and non-genetic factors contribute to variability in treatment outcomes. This systematic review aims to thoroughly analyze and assess existing studies exploring the relationships between genetic variations and individual responses to biologic drugs, in order to identify genetic markers that are predictive of treatment efficacy, risk of adverse effects, or drug toxicity, thereby informing clinical practice and guiding future research. PubMed and EMBASE papers were reviewed by three independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. Of the 883 records screened, 99 met the inclusion criteria. The findings of this review represent an initial step toward personalized medicine in IBD, with the potential to improve clinical outcomes in biological therapy.

Laboratory Tests in Inflammatory Bowel Disease: An Evidence-Based Approach to Daily Practice

Inflammatory bowel diseases (IBDs) comprise a group of chronic gastrointestinal disorders characterized by periods of relapse and remission. The mainstay of treatment is medical, involving medications such as steroids, immune modulators, monoclonal antibodies (categorized as biologics), and small molecules. These medications can provide profound therapeutic benefits, but they can also cause severe and irreversible toxicities. Clinicians may utilize laboratory tests in the diagnosis and management of IBD including assessment of disease activity, monitoring medication response or toxicity, surveillance of infectious complications, and detection of nutritional deficiencies. Routine use of laboratory tests may help clinicians avoid reactivation of life-threatening infections such as tuberculosis or hepatitis B virus upon initiation of immune suppressive therapy. They can also be used to detect vitamin deficiencies such as B12 deficiency, which has the potential to cause irreversible neurologic damage. While some laboratory tests constitute established practices, the utility of newer tests such therapeutic drug monitoring (TDM) in the era of biologics is an evolving topic. Although clinical assessment with imaging, endoscopic, and histopathological examination is standard practice, laboratory tests serve as valuable adjuncts. We aim to explore the broad range of laboratory tests available to clinicians and to summarize their application in the current management of IBD in daily clinical practice, with special attention to updates in therapeutic drug monitoring.

Predictors of Short and Long-term Rebleeding in Patients With Overt Gastrointestinal Bleeding: A Prospective Study

BACKGROUND

We aimed to identify predictors of rebleeding in patients with overt gastrointestinal bleeding (GIB) and to develop a rebleeding index.

METHODS

This was a prospective study of patients admitted with GIB from 2013 to 2023 at a tertiary care center. Rebleeding was defined as the recurrence of visible bleeding after initial stabilization, endoscopic evaluation, and/or hemostatic therapy, accompanied by a change in vital signs or a hemoglobin (Hgb) decrease of ≥2 g/dL. Independent predictors were determined after adjusting for confounders.

RESULTS

Seven hundred ninety-seven patients with GIB were recruited between 2013 and 2023 and were followed up until death or January 2023. In-hospital, 1-month, 1-year, and end of follow-up rebleeding rates were: 5.3%, 8.9%, 16.2%, and 21.8%, respectively. Sources of rebleeding were different from the original sources in 36% of patients. Predictors of 1-month rebleeding included need for ≥3 packed red blood cell (PRBC) units (HR=1.86; p=0.041), endoscopic stigmata of recent hemorrhage (SRH) (HR=1.99; p=0.007), and Hgb level (HR=0.82; p=0.018; lower Hgb predicts higher rebleeding risk). A rebleeding index based on SRH, Hgb level, and ≥3 PRBC units showed modest performance (AUC=0.68), with higher scores indicating increased rebleeding risk. At the end of follow-up, SRH remained a predictor (HR=1.61; p=0.003), whereas antiplatelets on admission or discharge appeared protective against rebleeding (HR=0.66; p=0.021; HR=0.63; p=0.026).

CONCLUSION

Predictors of rebleeding after GIB were SRH, PRBC transfusion, and lowest Hgb. The novel index based on these predictors performed favorably compared with the GBS, Rockall systems for UGUB and ABC scores. These data will help guide management and risk stratification of patients with GIB.

Comparative Outcomes of Adalimumab and Infliximab Dose Escalation in Inflammatory Bowel Disease Patients Failing First-Line Biologic Treatment

Background/Objectives: Dose escalation has been commonly used to achieve and maintain response. We aimed to compare the outcomes of adalimumab or infliximab dose escalation in inflammatory bowel disease (IBD) patients. Methods: Treatment persistence (TP) and predictive factors for remission-free treatment discontinuation (r-fTD) were evaluated in patients treated with adalimumab or infliximab dose escalation between 2019 and 2024. Results: Dose escalation was identified in 142 patients treated with adalimumab (UC: 23.9%; CD: 76.1%) and in 126 patients treated with infliximab (UC: 23.8%; CD: 76.2%). The TP rate was significantly lower in the adalimumab group (35.2%) than the infliximab group (53.2%) (p = 0.003). The survival analysis showed that drug persistence was lower in the adalimumab group compared with the infliximab group (mean time: 74.3 vs. 99.5 months, p < 0.001). TP rates showed no significant differences between UC and CD for both adalimumab (mean time UC: 64.7 months vs. CD: 76.2 months, p = 0.403) and infliximab (mean time UC: 80.3 months and CD: 102.6 months, p = 0.151). The r-fTD rates were significantly higher in the adalimumab group (62.7%) than the infliximab group (39.7%) (p < 0.001). Primary lack of response and secondary loss of response (sLOR) rates were both higher in the adalimumab group (7.7% and 51.4%) than the infliximab group (1.6% and 28.6%). However, serious adverse events were lower in the adalimumab group (2.1%) than the infliximab group (7.9%) (p = 0.027). Conclusions: Infliximab dose escalation was more effective than adalimumab in both UC and CD patients. Regarding the side effect profile, adalimumab dose escalation was found to be safer compared with infliximab.

Age as a Predictor of Serum Tumor Necrosis Factor Antagonist Drug and Antidrug Antibody Concentrations in Inflammatory Bowel Disease-A Nationwide Cohort Study

Background/Objectives: Tumor necrosis factor antagonists (anti-TNFs) have been shown to be an effective treatment for inflammatory bowel disease (IBD). Several factors are associated with anti-TNF treatment failure. This study aims to explore the impact of age on serum concentrations of anti-TNF drugs and antidrug antibodies (ADAbs). Methods: We retrospectively reviewed patients' charts from July 2018 until September 2024 across seven medical centers. Patients with an established diagnosis of IBD receiving infliximab or adalimumab were included. The primary outcome of this study was the effect of age on the anti-TNFs serum drug concentration and ADAb levels. Linear regression was performed to explore the relationship between age and serum anti-TNF drug and ADAb levels. Results: 1093 patients were included in our cohort. In patients receiving infliximab, there was a significant association between older age and increasing ADAbs levels (p = 0.036), whereas in patients treated with adalimumab, there was no significant relationship between older age and ADAb levels (p = 0.771). There was no significant relationship between age and adalimumab serum concentration (p = 0.54). When stratified by age, patients taking infliximab who were >30 years of age developed more ADAbs compared to those aged ≤30 (p = 0.003). Conclusions: Patients older than 30 years of age receiving infliximab monotherapy have higher ADAbs and lower serum drug concentrations than younger patients. There was no statistically significant difference in ADAbs and serum drug concentrations among patients receiving infliximab combination therapy or adalimumab monotherapy.

Carbon footprinting and environmental impact of gastrointestinal endoscopy procedures at a tertiary care institution: a prospective multi-dimensional assessment

BACKGROUND

Given the imperative to combat climate change, reducing the healthcare sector's implications on the environment is crucial.

OBJECTIVE

This study aims to offer a comprehensive assessment of the environmental impact of gastrointestinal endoscopy (GIE) procedures, specifically focusing on greenhouse gas (GHG) emissions and waste generation.

DESIGN

A prospective study was conducted at the Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India, from 29 May to 10 June 2023, including all consecutive GIE procedures. Carbon emissions for various variables involved were calculated with specific emission factors using 'The GHG Protocol'.

RESULTS

Based on data from 3244 consecutive patients undergoing 3873 procedures, the study revealed a total carbon footprint of 148 947.32 kg CO2e or 38.45 kg CO2e per procedure. Excluding patient travel, the emissions were 6.50 kg CO2e per procedure. The total waste generated was 1952.50 kg, averaging 0.504 kg per procedure, far less than 2-3 kg per procedure in the West. The waste disposal breakdown was 9.5% direct landfilling, 64.8% incineration, then landfilling and 25.7% recycling, which saved 380 kg CO2e. India effectively recycles 25.7% of hospital-related waste, which undergoes landfilling in the West. The primary contributors to GHG emissions were patient travel (83.09%), electricity consumption (10.42%), medical gas transport and usage (3.63%) and water consumption (1.86%). Diagnostic procedures generate less waste and lower carbon footprint than therapeutic procedures.

CONCLUSION

This study highlights the significant environmental footprint of GIE procedures, emphasising the importance of optimising practices to reduce patient travel and repeat procedures, alongside improving electricity and water management for sustainable healthcare.

Lipid-Rapamycin Nanovaccines Overcome the Antidrug Antibody Barrier in Biologic Therapies

Antidrug antibodies (ADAs) against biologics present a major challenge for sustained biotherapy, including enzyme replacement therapies and adeno-associated virus (AAV) gene therapies. These antibodies arise from undesirable immune responses, leading to altered pharmacokinetics, reduced efficacy, and adverse reactions. In this study, we introduced a rationally designed lipid-rapamycin (Rapa)-based nanovaccine to restore immune tolerance to biologics and overcome drug resistance. The nanovaccine significantly decreased ADA responses when used in a tolerogenic regimen with keyhole limpet hemocyanin (KLH), uricase, pegylated uricase, and AAV8 vector gene therapy. This approach facilitated three rechallenges with pegylated uricase after a 5 week rest from the nanovaccine, thereby enhancing its urate-lowering efficacy. Furthermore, the nanovaccine allowed for the successful intravenous readministration of AAV8 vector expressing secreted embryonic alkaline phosphatase (AAV8-SEAP), achieving sustained viral DNA and transcript levels in target tissues. The nanovaccine prompted antigen-presenting cells (APCs) in the liver to exhibit dynamic changes in CD80, CD86, MHCII, and PD-L1, which promoted the development of immunoregulatory T cells in response to biologic challenges. Notably, the nanovaccine exerted a minimal impact on CD8+ T cells, natural killer (NK) cells, and NK T cells, preserving the body's normal immune response to pathogens and tumors. Overall, the universal nanovaccine addressed biologic resistance by mitigating ADA-related issues, thereby enabling a prolonged therapeutic efficacy for antibodies, proteins, and gene therapies.

Oakland score to identify low-risk patients with lower gastrointestinal bleeding performs well among emergency department patients

BACKGROUND

The Oakland Score predicts risk of 30-day adverse events among hospitalized patients with lower gastrointestinal bleeding (LGIB) possibly identifying patients who may be safe for discharge. The Oakland Score has not been studied among emergency department (ED) patients with LGIB. The Oakland Score composite outcome includes re-bleeding, defined as additional blood transfusion requirements and/or a further decrease in hematocrit (Hct) >/= 20% after 24 h in clinical stability; red blood cell transfusion; therapeutic intervention to control bleeding, including surgery, mesenteric embolization, or endoscopic hemostasis; in-hospital death, all cause; and re-admission with further LGIB within 28 days. Prediction variables include age, sex, previous LGIB admission, systolic blood pressure, heart rate, and hemoglobin concentration, and scores range from 0 to 35 points, with higher scores indicating greater risk.

METHODS

Retrospective cohort study of adult (≥ 18 years old) patients with a primary ED diagnosis of LGIB across 21 EDs from March 1st, 2018, through March 1st, 2020. We excluded patients who were more likely to have upper gastrointestinal bleeding (esophago-gastroduodenoscopy without LGIB evaluation), patients who left against medical advice or prior to ED provider evaluation, ED patients without active health plan membership, and patients with incomplete Oakland Score variables. We assessed predictive accuracy by reporting the area under the receiver operator curve (AUROC) and sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios at multiple clinically relevant thresholds.

RESULTS

We identified 8,283 patients with LGIB, 52% were female, mean age was 68, 49% were non-White, and 27% had an adverse event. The AUROC for predicting an adverse event was 0.85 (95% CI 0.84-0.86). There were 1,358 patients with an Oakland Score of

CONCLUSION

The Oakland Score had high predictive accuracy among ED patients with LGIB. Prospective evaluation is needed to understand if the risk score could augment ED decision-making and improve outcomes and resource utilization.

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Key Words

• Emergency medicine
• Lower gastrointestinal bleeding
• Risk stratification

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MESH Headings Collapse

Grants

• Kaiser Permanente Northern California Community Health

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Affiliation(s)

Daniel D DiLena Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA.
Sean C Bouvet Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
Madeline J Somers Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Maqdooda A Merchant Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Theodore R Levin Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA Department of Gastroenterology, Kaiser Permanente Antioch Medical Center, Antioch, CA, USA
Adina S Rauchwerger Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Dana R Sax Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA

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Collaborators Collapse

Difficult cannulation during endoscopic retrograde cholangiopancreatography-needle-knife precut versus transpancreatic sphincterotomy on the basis of successful cannulation and adverse events

BACKGROUND

When cannulation is challenging during endoscopic retrograde cholangiopancreatography (ERCP), and the standard guidewire technique with sphincterotomy is unsuccessful, alternative cannulation techniques can be used to access the biliary tree. The purpose of this study was to compare the incidence of adverse events and cannulation success rates between transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS).

METHODS

Data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), collected from 2011 to 2022, were analyzed. A total of 105,303 ERCP procedures were recorded in GallRiks during the study period. After exclusions, the study population consisted of 47,486 ERCP procedures. Of these, 4547 received PCS and 3273 received TPS. The remaining 39,666 ERCP procedures with conventional sphincterotomy served as the control group. The primary endpoints were successful cannulation and adverse events within 30 days.

RESULTS

Successful cannulation was more frequent with the TPS technique than with the PCS technique (86.5% vs. 69.7%), but both groups had a lower cannulation rate than the control group (92.4%; OR-PCS 0.20, 95% CI 0.18-0.21; OR-TPS 0.58, 95% CI 0.52-0.64). The TPS group had a higher incidence of adverse events than the PCS group (24.1% vs. 18.8%) and both groups had a higher incidence of adverse events than the control group (15.5%; OR-PCS 1.25, 95% CI 1.15-1.36; OR-TPS 1.71, 95% CI 1.57-1.87). Adverse events for TPS were driven by a higher incidence of pancreatitis (10.5% vs. 6.4% vs. 4.5%; OR 2.53, 95% CI 2.23-2.86) and perforation (1.6% vs. 0.8% vs. 0.5%; OR 2.99, 95% CI 2.20-4.06) compared to both PCS and control.

CONCLUSION

TPS is more successful at cannulation than PCS; however, this success comes at a higher cost in terms of adverse events, particularly pancreatitis and perforation.

The timing of surgical interventions following the implantation of coronary drug-eluting stents in patients undergoing gastrointestinal cancer surgery: a multicenter retrospective cohort study

AIM

We aim to investigate the optimal timing for surgical interventions to maximize patient benefit.

BACKGROUND

The guidelines recommending a minimum deferral of 6 months for non-cardiac surgeries following drug-eluting stent percutaneous coronary intervention (DES-PCI) do not adequately address the requirements for individuals undergoing gastrointestinal cancer surgery (GCS).

METHODS

The study encompassed 2501 patients treated from January 2017 to December 2021, all of whom underwent GCS within 1 year after DES-PCI. We conducted an analysis by comparing the occurrence of major adverse cardiovascular events (MACEs) within 30 days post-surgery at different time points.

RESULTS

This study enrolled a total of 2501 participants with meticulously recorded data who underwent DES-PCI and subsequently underwent GCS within 1 year post-implantation. The incidence rate of MACEs is 14.2%, including MI (5.1%), HF (5.8%), IS (3.2%), and cardiac death (0.2%), across all patients in this study. The threshold probability was determined using the Youden Index, resulting in a value of 0.320, corresponding to a "time-to-surgery value" of 87. Significant statistical differences were observed in the occurrence rates of MACEs for adjacent time intervals at 30 days ( P < 0.001), 90 days ( P < 0.009), and 180 days ( P < 0.001).

CONCLUSIONS

The timing of surgical intervention following DES-PCI significantly influences the occurrence of MACEs at 1, 3, and 6 months. GCS may be appropriately advanced within the 6-month timeframe, but with the exception of emergency, efforts should be made to defer them beyond the initial month.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

Impact of long-term trends on outcomes in the management of colonic diverticular bleeding: mediation analyses in a large multicenter study

BACKGROUND

Despite accumulating evidence and recommendations for management of colonic diverticular bleeding (CDB), the changes in its clinical management and outcomes remain unknown.

METHODS

We performed a retrospective tendency analysis on a biennial basis, a propensity score-matched cohort study between the first and latter half groups, and mediation analyses to compare the diagnostic and treatment methods between January 2010 and December 2019 (CODE BLUE-J Study).

RESULTS

A total of 6575 patients with CDB were included. While the use of colonoscopy as the initial diagnostic procedure declined, the use of computed tomography (CT) increased in both the trend test and before-and-after comparisons. In hemostasis therapy, the use of endoscopic clips declined and band ligation increased. Interventional radiology remained unchanged; however, the number of surgeries decreased over time. The stigmata of recent hemorrhage (SRH) detection rate and length of hospital stay (LOS) improved significantly. Mediation analyses showed that use of a distal attachment and water-jet scope contributed to an improved SRH detection rate, and use of band ligation contributed to preventing rebleeding within 30 days.

CONCLUSIONS

Management strategies for CDB have changed in the past decade, particularly regarding the increased use of CT and decreased need for surgery. However, the main outcomes, except for the SRH detection rate and LOS, did not improve. The widespread use of distal attachment, water-jet scope, and band ligation could improve outcomes in CDB management.

Qualitative Insights Into Non-attendance for Scheduled Radiology Appointments at a Specialist Hospital in Saudi Arabia

BACKGROUND

Patient non-attendance for radiology appointments is an international problem with significant implications for healthcare recipients and healthcare efficiency. Non-attendance impacts patient health, waiting lists, and other hospital departments while increasing staff stress, anxiety, and fatigue. Understanding the reasons behind patient non-attendance is crucial for developing effective strategies to help improve attendance rates.

OBJECTIVE

This study explored the reasons for patient non-attendance for scheduled radiology appointments and identified potential strategies to enhance attendance at a specialist hospital in Saudi Arabia.

METHODS

Using semi-structured interviews, nine men and eight women who were purposively sampled and had missed scheduled radiology appointments at the research site were interviewed. Thematic analysis was employed to identify the key themes represented by the data.

FINDINGS

This qualitative study revealed the multifaceted nature of patient non-attendance for scheduled radiology appointments at the specialist hospital in Saudi Arabia. Five themes underlying non-attendance were identified. First, scheduling conflicts were a significant barrier. Second, a lack of adequate knowledge about health conditions was evident. Third, physician-patient miscommunication was a critical issue. Fourth, transportation difficulties, especially for those living far from the hospital or without personal transportation, were a key factor in non-attendance. Finally, personal reasons, such as fear of medical procedures and the patient's health status, also contributed. The study identified two main areas for improvement: implementing an effective appointment reminder system and enhancing the radiology department by extending hours and addressing non-attendance more effectively. These strategies underscore the need for a patient-centered approach to reduce barriers to attendance.

CONCLUSION

The findings suggest that patient non-attendance is multifactorial, involving personal and hospital-specific reasons. Strategies to improve attendance should thus be multifaceted, including better scheduling systems, enhanced patient education and communication, and reminder systems. These insights can inform targeted interventions to reduce non-attendance rates, ultimately improving healthcare delivery and resource utilization.

Modified Delphi Procedure to Achieve Consensus for the Concept of a National Curriculum for Minimally Invasive and Robot-assisted Surgery in Germany (GeRMIQ)

The rapid development of minimally invasive surgery (MIS) and robot-assisted surgery (RAS) requires standardized training to ensure high-quality patient care. In Germany, there is currently a lack of a standardized curriculum that teaches these specialized skills. The aim of this study is to find a consensus for the development of a nationwide curriculum for MIS and RAS with the subsequent implementation of the consented content.A modified Delphi process was used to reach consensus among national experts in MIS and RAS. The process included a literature review, an online survey and an expert conference.All 12 invited experts participated in the survey. They primarily achieved consensus on 73% and secondarily within the expert conference on 95 out of 122 questions (77.9%). The preference for a basic curriculum as a foundation on which specialized modules can build on was particularly clear. The results support the development of an integrated curriculum for MIS and RAS that includes step-by-step training from theoretical knowledge via e-learning modules to practical skills in dry lab simulations and in the OR. Emphasis was placed on the need to promote clinical judgment and decision making through targeted assessment during the learning curve to ensure effective application of learned skills in clinical practice. There was also a consensus that training content must be aligned with learners' skill acquisition using objective performance assessments in line with the principle of proficiency-based progression (PBP). The continuous updating of the curriculum to keep it up to date with the latest technology was considered essential.The study underlines the urgent need for a standardized training curriculum for MIS and RAS in Germany in order to increase patient safety and improve the quality of surgical care. There is broad expert consensus for the implementation of such a curriculum. It aims to ensure a contemporary and internationally competitive uniform quality of training and to increase the attractiveness of surgical training.

Small Molecules, Big Results: How JAK Inhibitors Have Transformed the Treatment of Patients with IBD

Small molecule Janus kinase (JAK) inhibitors have revolutionized the management of ulcerative colitis (UC) and Crohn's disease (CD) through their low immunogenicity, safety, and consistent pharmacologic response that are superior to existing therapeutic options. In this perspective, we highlight existing evidence supporting the use of currently approved JAK inhibitors (upadacitinib, tofacitinib, and filgotinib) for UC or CD, additionally emphasizing the evidence for their use in related autoimmune conditions such as rheumatoid arthritis and spondyloarthropathies. Our perspective concludes with a review of the existing comparative effectiveness literature, which positions JAK inhibitors, particularly upadacitinib, favorably compared with other biologic therapies. This perspective is paired with a companion publication highlighting the origins and development of JAK inhibitors and a more in-depth review of their pathophysiologic mechanisms.

Endoscopic Papillary Large Balloon Dilatation With or Without Endoscopic Sphincterotomy in the Treatment of Common Bile Duct Stones

PURPOSE OF REVIEW

Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS.

FINDINGS

EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.

Transpancreatic precut sphincterotomy: Can nonexperts match the outcomes of experts?

BACKGROUND

Nonexpert endoscopists cannot achieve high-quality performance during difficult biliary cannulation, representing a significant challenge; precutting is an effective approach for managing these cases. Transpancreatic biliary sphincterotomy (TPBS) is considered more effective than needle-knife precutting owing to its wire-guided technique, which may be suitable for nonexpert endoscopists; however, comparisons between nonexpert and expert endoscopists performing TPBS are not well documented.

METHODS

Consecutive patients who underwent TPBS between January 2010 and April 2024 were evaluated. Rates of successful biliary duct cannulation, time to TPBS and bile duct cannulation, and adverse events were compared between both groups. Logistic regression analysis was conducted to identify factors associated with successful bile duct cannulation using TBPS.

RESULTS

The study included 140 patients (77 and 63 in the nonexpert and expert groups, respectively). The rates of successful biliary cannulation and overall adverse events (including pancreatitis, 9.1% vs. 9.5%) were 88.3% and 93.7% (p = .38) and 15.6% and 9.5% (p = .32) in the nonexpert and expert groups, respectively. Multivariate analysis revealed that early TPBS (<22 min) was a significant predictive factor for successful bile duct cannulation.

CONCLUSIONS

TBPS may be an effective technique for nonexpert endoscopists; additionally, early TPBS is a significant predictive factor for successful bile duct cannulation.

Comparative diagnostic utility of Rockall and Glasgow-Blatchford scores in non-variceal upper gastrointestinal bleeding: a systematic review and meta-analysis

INTRODUCTION

The Rockall score and Glasgow-Blatchford score (GBS) are two scoring systems validated in the evaluation of upper gastrointestinal bleeding (UGIB). However, no meta-analysis exists to summarize the current data and clarify the use of Rockall score and GBS focusing on non-variceal UGIB. We aimed to evaluate and compare the utility of the Rockall score and GBS in predicting clinical outcomes in non-variceal UGIB.

METHODS

We conducted a systematic review and meta-analysis, searching the MEDLINE and EMBASE databases for all peer-reviewed articles using the terms including 'Glasgow-Blatchford', 'Rockall', and 'gastrointestinal bleed' from their inception to 22 March 2023. Outcomes included mortality, rebleeding, need for blood transfusion, and need for surgical intervention.

RESULTS

Seven studies with 755 participants with non-variceal bleeding were included in the analysis. Pooled analysis demonstrated no difference in the area under the receiver operating characteristic (AUROC) between GBS and Rockall score to predict mortality [weighted mean difference (WMD) = 0.01, 95% CI: -0.06 to 0.08] or rebleeding (WMD = 0.04, 95% CI: -0.03 to 0.11). GBS had a higher AUROC to predict the outcomes compared to Rockall score for the needs for transfusion (WMD = 0.09, 95% CI: 0.01-0.16) and surgical intervention (WMD = 0.21, 95% CI: 0.14-0.29).

CONCLUSION

The GBS could be superior to the Rockall score in predicting the needs for transfusion and surgical intervention in non-variceal UGIB. However, both scores demonstrate low performance for predicting mortality or rebleeding.

Risk of metachronous peritoneal metastases after surgery for obstructive colon cancer: Multivariate analysis from a series of 1,085 patients

BACKGROUND

Data in the literature suggest that obstruction is an independent predictor of poor prognosis in colon cancer. Of all possible sites of recurrence, peritoneal metastases are associated with worse survival. Our aim was to report the incidence of metachronous peritoneal metastases from a cohort of patients undergoing resection of obstructive colon cancer with curative intent and to identify predictive factors for metachronous peritoneal metastases.

METHODS

From 2000 to 2015, a total of 2,325 patients were treated for obstructive colon cancer in French surgical centers, members of the French National Surgical Association (AFC). Patients with palliative management, synchronous metastatic disease, and with postoperative mortality were excluded. A multivariate analysis was performed to determine independent predictive factors of metachronous peritoneal metastases.

RESULTS

The cohort included 1,085 patients. The median follow-up was 21.5 months. Metachronous peritoneal metastases occurred in 12% of patients and were diagnosed after a median interval of 13.5 months. The cumulative 3-year metachronous peritoneal metastasis rate was 10.9%. Three-year overall survival was 85% for patients who did not develop recurrence, 71% for those who develop recurrence without peritoneal metastases, and 56% for those with metachronous peritoneal metastases (P < .0001). In multivariate analysis, 3 variables were identified as independent risk factors for metachronous peritoneal metastases: pT4 stage (odds ratio: 1.98; 95% confidence interval: 1.17-3.36; P = .011), pN2 stage (odds ratio: 2.57; 95% confidence interval: 1.89-4.45; P = .0007), and fewer than 12 lymph nodes examined (odds ratio: 2.01; 95% confidence interval: 1.08-3.74; P = .028).

CONCLUSION

This study showed a significant risk of metachronous peritoneal metastases after curative-intent resection of obstructive colon cancer. The awareness of factors predisposing to metachronous peritoneal metastases could improve the treatment strategy of these patients.

Environmental footprint and material composition comparison of single-use and reusable duodenoscopes

BACKGROUND

Infection outbreaks associated with contaminated reusable duodenoscopes (RUDs) have induced the development of novel single-use duodenoscopes (SUDs). This study aimed to analyze the material composition and life cycle assessment (LCA) of RUDs and SUDs to assess the sustainability of global and partial SUD implementation.

METHODS

A single-center study evaluated material composition analysis and LCA of one RUD and two SUDs from different manufacturers (A/B). Material composition analysis was performed to evaluate the thermochemical properties of the duodenoscope components. The carbon footprint was calculated using environmental software. We compared the sustainability strategies of universal use of RUDs, frequent use of RUDs with occasional SUDs, and universal use of SUDs over the lifetime of one RUD.

RESULTS

RUDs were substantially heavier (3489 g) than both SUD-A (943 g) and SUD-B (716 g). RUDs were mainly metal alloys (95%), whereas SUDs were mainly plastic polymers and resins (70%-81%). The LCA demonstrated the sustainability of RUDs, with a life cycle carbon footprint 62-82 times lower than universal use of SUDs (152 vs. 10 512-12 640 kg CO2eq) and 10 times lower than occasional use of SUDs (152 vs. 1417-1677 kg CO2eq). Differences were observed between SUD-A and SUD-B (7.9 vs. 6.6 kg CO2eq per endoscope). End-of-life incineration emissions for SUDs were the greatest environmental contributors.

CONCLUSIONS

Widespread adoption of SUDs has greater environmental challenges; it requires a balance between infection control and environmental responsibility. Carbon footprint labelling can help healthcare institutions make sustainable choices and promote environmentally responsible healthcare practices.

Understanding the therapeutic toolkit for inflammatory bowel disease

Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is a group of chronic, immune-mediated disorders of the gastrointestinal tract that present substantial clinical challenges owing to their complex pathophysiology and tendency to relapse. A treat-to-target approach is recommended, involving iterative treatment adjustments to achieve clinical response, reduce inflammatory markers and achieve long-term goals such as mucosal healing. Lifelong medication is often necessary to manage the disease, maintain remission and prevent complications. The therapeutic landscape for IBD has evolved substantially; however, a ceiling on therapeutic efficacy remains and surgery is sometimes required (owing to uncontrolled disease activity or complications). Effective IBD management involves comprehensive care, including medication adherence and a collaborative clinician-patient relationship. This Review discusses current therapeutic options for IBD, detailing mechanisms of action, efficacy, safety profiles and guidelines for use of each drug class. We also explore emerging therapies and the role of surgery. Additionally, the importance of a multidisciplinary team and personalized care in managing IBD is emphasized, advocating for patient empowerment and involvement in treatment decisions. By synthesizing current knowledge and emerging trends, this Review aims to equip healthcare professionals with a thorough understanding of therapeutic options for IBD, enhancing informed, evidence-based decisions in clinical practice.

Use of the mini-forceps traction-assisted cannulation technique when standard ERCP methods fail: Single-center retrospective study

Background and study aims

There are few salvage techniques for achieving biliary cannulation when no duct can be accessed.

Patients and methods

We retrospectively reviewed 10 consecutive cases in which the mini-forceps traction-assisted cannulation technique (MFTAC) was used after failure of any duct access during endoscopic retrograde cholangiopancreatography (ERCP). Outcomes included technical success, use of adjunct techniques; time to biliary access; and adverse events (AEs).

Results

Most patients had a native papilla (n = 9) of peri-diverticular location (n = 5) and a benign indication (n = 6). Standard cannulation was unsuccessful over 8:23 mm:ss (interquartile range [IQR] 6:04-19:43). MFTAC had 100% technical success, achieved biliary access after 17:38 mm:ss (IQR 8:52-20:31), and had a 10% incidence of AEs (post-ERCP pancreatitis). MFTAC was sufficient to allow biliary cannulation in three cases and allowed pancreatic duct access in seven cases, which then allowed biliary cannulation with double-wire technique (5/10) and transpancreatic septotomy (2/10).

Conclusions

MFTAC is a feasible salvage approach for biliary access when standard cannulation methods fail.

Therapeutic drug monitoring and neutralizing anti-drug antibody detection to optimize TNF-alpha inhibitor treatment for uveitis

Background

Adalimumab taken every other week is an effective treatment in patients with chronic refractory uveitis. Patients who have a suboptimal response to this treatment may suffer from recurrent inflammation and vision loss. Here, we investigated the use of therapeutic drug monitoring and neutralizing anti-drug antibody detection as a strategy to optimize tumor necrosis factor (TNF)-alpha inhibitor treatment in patients who have a suboptimal response to the initial dosing of adalimumab.

Method

Retrospective cohort study performed in two tertiary referral uveitis services in the United States between 2015 to 2023. Patients with non-infectious uveitis who had a suboptimal response to every two-week dosing of adalimumab and underwent serum adalimumab level with reflex to anti-drug antibody testing were followed. Patients were considered to have neutralizing drug antibodies when serum drug levels were low (less than or equal to 6 mcg/mL) and anti-adalimumab antibodies were present on reflex testing. Treatment adjustment was made by clinicians with the knowledge of serum adalimumab level and the presence or absence of neutralizing drug antibodies. Every two-week dosing of adalimumab was either escalated to weekly dosing or switched to infliximab, an alternate TNF-alpha inhibitor, based on these findings. The primary outcome was success or failure at 12 months, as determined by disease inactivity on steroid-sparing therapy.

Results

32 patients with suboptimal response to the initial dosing of adalimumab were included. 31.2% (n=10) of patients were found to have neutralizing drug antibodies. All patients with neutralizing drug antibodies underwent a medication switch to infliximab with a remission rate of 40% at 12 months. Patients without neutralizing drug antibodies (n=22) underwent dose escalation (77.3%; n=17) or medication switch (22.7%; n=5) and achieved a remission rate of 68.2% at 12 months. Altogether, treatment adjustment based on therapeutic drug monitoring and neutralizing drug antibody detection, in our cohort, resulted in a remission rate of 62.5%.

Conclusions

For patients with uveitis experiencing suboptimal therapeutic response to adalimumab dosed every two weeks, therapeutic drug monitoring and neutralizing drug antibody detection may help clinicians optimize TNF-alpha inhibitor treatment.

Comprehensive care of ulcerative colitis: new treatment strategies

INTRODUCTION

Ulcerative colitis is a chronic inflammatory condition of the colon driven by aberrant immune activation. Although advanced medical therapies form the cornerstone of ulcerative colitis management, unmet needs include failure to induce and sustain remission in a substantial proportion of patients and in managing acute severe ulcerative colitis. We review new treatment strategies that might improve patient outcomes in the management of moderate-to-severe ulcerative colitis.

AREAS COVERED

A literature search was conducted using the PubMed database, including studies published from inception to October 2024, selected for their relevance. Recognizing current limitations, this article reviews strategies to improve treatment outcomes in ulcerative colitis using advanced therapies. These approaches include early treatment initiation, dose optimization, positioning newer agents as first-line therapies, combination therapy, targeting novel therapeutic endpoints, and the management of acute severe ulcerative colitis.

EXPERT OPINION

The strategies discussed may contribute to establishing new standards of care aimed at achieving long-term remission and enhancing patient outcomes. Personalized therapy, which tailors treatment based on individual disease characteristics and risk factors, is anticipated to become a critical aspect of delivering more effective care in the future.

Ripple Effect: Safety, Cost, and Environmental Concerns of Using Sterile Water in Endoscopy

The gastroenterology societies are committed to reducing the carbon footprint of endoscopies and hence, re-examining waste-generating practices. One such practice is the recommendation to use sterile water during endoscopy for endoscopy lens cleaning and colon irrigation. We critically reviewed all published medical literature and guidelines on the safety of the type of water used in endoscopy. We calculated the cradle-to-grave carbon footprint of a 1-L sterile water bottle and compared it to published studies on bottled drinking water. Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions. Referenced studies utilize care protocols that are not practiced. There is also considerable cross-referencing of review articles and guidelines. Two clinical studies directly comparing tap and sterile water in gastrointestinal endoscopy found tap water to be a safe and practical cost-saving alternative to sterile water. The calculated carbon footprint of bottled sterile water is 575 g CO2 equivalent. No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endoscopy procedures. It contributes to health-care waste and climate change and is costly. We recommend tap water be used to fill sterile water bottles until evidence shows the need for alternative practice. It would be prudent to re-evaluate guidelines and write new ones that consider harm to the environment and society in the provision of care to patients, especially when the intervention may be more harmful than the risk it aims to address.

Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients' differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED.

Sabry S, Mansour SMG, El-Nahas HM, Ayoub MM. Experimental Investigation into the Design, Optimization, Toxicity, and Anti-Viral Efficacy of Proliposomes Loaded with Ivermectin Against Infectious Bronchitis Virus Using an Embryonated Chicken Egg Model

Background: Infectious bronchitis virus (IBV) causes a significant illness in birds, making it a leading source of financial loss in the poultry business. The objective of this study was to assess the effectiveness of proliposomes (PLs) containing ivermectin (IVM) against IBV using embryonated chicken eggs (ECEs). Methods: A three-factor, two-level (23) full factorial design was employed; carrier/lipid phase ratio (A), stearyl glycyrrhetinate amount (B), and phospholipid type (C) were studied as independent variables, while product yield (PY), entrapment efficiency (EE), particle size (PS), polydispersity index (PDI), zeta potential (ZP), and cumulative percentage of drug released after 6 h (Q6h) were characterized. The selected formulations (PL2 and PL6) were subjected to further characterizations, including IVM toxicity and anti-viral activity. Results: The PY% ranged from 88.6 ± 2.19% to 98.8 ± 0.45%, EE% was from 71.8 ± 2.01% to 96.1 ± 0.51%, PS was from 330.1 ± 55.65 nm to 1801.6 ± 45.61 nm, PDI was from 0.205 ± 0.06 to 0.603 ± 0.03, ZP was from -18.2 ± 0.60 mV to -50.1 ± 1.80 mV, and Q6h was from 80.95 ± 1.36% to 88.79 ± 2.03%. IVM-loaded PLs had lower toxicity in ECEs than pure IVM; the mortality rate was substantially reduced in IBV-infected ECEs injected with PL2 rather than pure IVM. As further evidence of IVM's anti-viral action against IBV, quantitative real-time polymerase chain reaction (qRT-PCR) revealed that the PL2-treated group exhibited further reduction in IBV's copies in comparison with the pure IVM-treated group. Conclusions: PLs loaded with IVM are an innovative and potentially effective way to inhibit IBV.

A Treat-to-Target Approach in IBD: Contemporary Real-World Perspectives from an International Survey

Background/Objectives: The management of inflammatory bowel disease (IBD) varies due to differences in healthcare systems, treatment costs, access to diagnostics, and diverse clinical practices between specialists. Despite the frequent advocacy of a treat-to-target (T2T) approach, there is insufficient clarity on how clinicians implement T2T in real-world settings. We aim to conduct a large, global survey among IBD experts to identify current practices in management. Methods: A prospective, cross-sectional study was conducted using a 16-item survey divided into two sections-for ulcerative colitis (UC) and Crohn's disease (CD)-and distributed to practicing IBD clinicians. Results: A total of 261 respondents from 88 countries participated in the survey, with the majority (253/261) being physicians and eight being IBD nurse specialists. Despite global guidance, only a quarter of the respondents routinely perform an endoscopy to assess the response after starting an advanced therapy (28.4% in UC vs. 23.5% in CD). Moreover, despite an increasing academic focus on intestinal ultrasound (IUS), 171 (66%) of respondents in UC and 132 (51%) in CD reported that they do not routinely undertake IUS to guide treatment decisions. Faecal calprotectin for monitoring treatment response was routinely used by 87% (90% in UC and 84% in CD) of the respondents. Forty-five percent reported use of therapeutic drug monitoring (TDM) both proactively and reactively and 35% reported only using TDM reactively. Conclusions: Our study shows considerable variation in IBD management across different countries and interpretation of the T2T approach. This highlights the need for standardised and pragmatic guidelines to help improve outcomes for patients with IBD globally.

Detection of antibodies to infliximab in routine care: a 4-year French retrospective study

Despite its wide use to treat various inflammatory diseases, infliximab becomes ineffective in some patients due to inadequate drug levels and production of anti-drug antibodies (ADA). The aim of this study was to compare the prevalence and ADA levels in a large cohort of patients. ADA and infliximab (IFX) through levels measured by enzyme-linked immunosorbent assay were collected from 505 patients within a period of 4 years. The results indicate that (i) 13.5% of patients produce ADA, (ii) male patients were more likely to produce ADA at levels above 10 000 ng/ml than female patients, (iii) ADA levels were lower when associated with immunosuppressant drugs, (iv) there was an inverse relationship between ADA presence and IFX detection, and (v) no correlation was observed between ADA levels and number of injections or brand of IFX administered. This study improves our understanding of the factors promoting IFX immunogenicity and highlights the need to develop personalized treatment strategies.

Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk.

OBJECTIVE

To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement.

DESIGN

This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up.

RESULTS

Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality.

CONCLUSION

This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement.

TRIAL REGISTRATION NUMBER

NL5130.

A new preprocedural predictive risk model for post-endoscopic retrograde cholangiopancreatography pancreatitis: The SuPER model

Background

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a severe and deadly adverse event following ERCP. The ideal method for predicting PEP risk before ERCP has yet to be identified. We aimed to establish a simple PEP risk score model (SuPER model: Support for PEP Reduction) that can be applied before ERCP.

Methods

This multicenter study enrolled 2074 patients who underwent ERCP. Among them, 1037 patients each were randomly assigned to the development and validation cohorts. In the development cohort, the risk score model for predicting PEP was established via logistic regression analysis. In the validation cohort, the performance of the model was assessed.

Results

In the development cohort, five PEP risk factors that could be identified before ERCP were extracted and assigned weights according to their respective regression coefficients: -2 points for pancreatic calcification, 1 point for female sex, and 2 points for intraductal papillary mucinous neoplasm, a native papilla of Vater, or the pancreatic duct procedures (treated as 'planned pancreatic duct procedures' for calculating the score before ERCP). The PEP occurrence rate was 0% among low-risk patients (≤0 points), 5.5% among moderate-risk patients (1-3 points), and 20.2% among high-risk patients (4-7 points). In the validation cohort, the C statistic of the risk score model was 0.71 (95% CI 0.64-0.78), which was considered acceptable. The PEP risk classification (low, moderate, and high) was a significant predictive factor for PEP that was independent of intraprocedural PEP risk factors (precut sphincterotomy and inadvertent pancreatic duct cannulation) (OR 4.2, 95% CI 2.8-6.3; p<0.01).

Conclusions

The PEP risk score allows an estimation of the risk of PEP prior to ERCP, regardless of whether the patient has undergone pancreatic duct procedures. This simple risk model, consisting of only five items, may aid in predicting and explaining the risk of PEP before ERCP and in preventing PEP by allowing selection of the appropriate expert endoscopist and useful PEP prophylaxes.

Funding

No external funding was received for this work.

Establishment and internal validation of a model to predict the efficacy of Adalimumab in Crohn's disease

BACKGROUND

Clinically, the ability to distinguish which Crohn's disease patients can benefit from Adalimumab is limited.

AIMS

This study aimed to develop a model for predicting clinical remission probability for Crohn's disease patients with Adalimumab at 12 weeks. The model assists clinicians in identifying which Crohn's disease patients are likely to benefit from Adalimumab treatment before starting therapy, thus optimizing individualized treatment strategies.

METHODS

Demographic and clinical characteristics of Crohn's disease patients were utilized to develop a model for clinical remission probability. LASSO regression was used to select predictive factors, and predictions were made using a logistic regression model. The model was internally validated using the bootstrap method (resampling 1000 times).

RESULTS

68 patients with Crohn's disease were enrolled in this study. Clinical remission was observed in 55.9% at 12 weeks. Three variables were selected through the least absolute shrinkage and selection operator regression method, including Adalimumab-positive cell count, disease duration, and neutrophil count of Crohn's disease patients. A predictive model was constructed by multivariate logistic regression (Adalimumab-positive cell count (OR, 1.143; 95%CI, 1.056-1.261), disease duration (OR, 0.967; 95%CI, 0.937-0.986), and neutrophil count (×109/L) (OR, 1.274; 95%CI,1.014-1.734)). The predictive model yielded an area under the curve of 0.866 (95%CI, 0.776-0.956), and in the internal validation, the area under the curve was 0.870 (95%CI, 0.770-0.940).

CONCLUSIONS

This model provides a convenient tool to assess the likelihood of patient remission prior to Adalimumab treatment, thereby supporting the development of personalized treatment plans.

Measuring Medical Waste from Gastrointestinal Endoscopies in South Korea to Estimate Their Carbon Footprint

Background/Aims

Although gastrointestinal endoscopy (GIE) is a major contributor to the carbon footprint of national healthcare, the amount of medical waste generated by GIE procedures is not reported in South Korea. This study aimed to measure the amount of medical waste generated from GIE procedures in South Korea.

Methods

We conducted a 5-day audit of medical waste generated during GIEs at seven hospitals. During the study period, medical waste in the endoscopy examination rooms was measured twice daily and documented as mass (kg). To calculate the mean mass of disposable waste generated during one esophagogastroduodenoscopy (EGD) and one colonoscopy, the mean mass of medical waste generated from seven examinations was calculated. The mean mass of medical waste generated during GIEs was calculated by dividing the total mass of medical waste generated by the number of GIE procedures.

Results

Overall, 3,922 endoscopies were performed and 4,558 kg of waste was generated. The mean weight of medical waste generated per endoscopy was 1.34 kg. Each EGD and colonoscopy generated a mean of 0.24 kg and 0.43 kg of disposable waste, respectively. Applying the mean waste estimates from this study to annual GIE procedures performed in South Korea in 2022 showed that the total medical waste produced from GIE was 13,704,453 kg. In addition, the total masses of medical waste produced during EGD and colonoscopy procedures were 819,766 kg and 2,889,478 kg, respectively.

Conclusions

Our quantitative measurement showed that a large amount of medical waste is generated from GIE procedures. However, further research is warranted to reduce medical waste generated during GIE, which is an urgent unmet need.

Effectiveness and Safety of Adalimumab in Patients With Very Early-Onset Inflammatory Bowel Disease: A Retrospective Study on Behalf of the Porto Inflammatory Bowel Disease Working Group of European Society for Pediatric Gastroenterology Hepatology and Nutrition

BACKGROUND AND AIMS

Patients with very early-onset inflammatory bowel disease (VEO-IBD), with an age of onset < 6 years, can present with severe manifestations and may require biologic therapy. Infliximab and adalimumab are approved for induction and maintenance in pediatric IBD patients but are licensed only above the age of 6 years. Effectiveness and safety data on adalimumab in this patient population are lacking. We assessed the therapeutic response to help close this gap.

METHODS

This retrospective study involved 30 sites worldwide. Demographic, clinical, and laboratory data were collected from patients with VEO-IBD who commenced adalimumab therapy before the age of 6 years.

RESULTS

Seventy-eight patients (37 Crohn's disease, 26 ulcerative colitis, and 15 with IBD-unclassified) were included. Median age of IBD onset was 2.6 (1.3-4.1) years, with 30 (38.5%) patients diagnosed at age <2 years. Median age at adalimumab initiation was 4.2 (2.8-5.1) years. Adalimumab was used as second-line biologic therapy in 45 (57.7%) patients after infliximab. The median time to last follow-up was 63 (22-124) weeks. Significant improvement in clinical scores, CRP, fecal calprotectin, and weight Z-score were observed by Week 52. Adalimumab durability rates were 61.9%, 48.1%, and 35.6% after 1, 2, and 3 years, respectively. Drug discontinuation rates were not dependent on IBD type, age, prior anti-TNF exposure, or concomitant immunomodulatory treatment. Four (5.1%) patients developed serious infections, including 1 patient with TTC7A deficiency who died following adenovirus sepsis.

CONCLUSION

Adalimumab therapy is a viable therapeutic option in patients with VEO-IBD with an acceptable safety profile.