Involvement of HLADQA1*05 in Patients with Inflammatory Bowel Disease Treated with Anti-TNF Drugs

Background: Over the past decade, TNF inhibitors such as Infliximab and Adalimumab have become central to Inflammatory Bowel Diseases treatment, greatly enhancing patient outcomes. However, immunogenicity-where anti-drug antibodies diminish effectiveness-remains an issue, often requiring dose changes or combination therapies. Pharmacogenomics is increasingly applied in IBD to personalise treatment, especially since genetic factors like the HLA-DQA1*05 variant heighten the immunogenicity risk with IFX. This study aims to examine the relationship between the HLA-DQA1*05 variant and response loss or antibody development in patients regularly monitored on IFX or ADA. Methods: Sixty-five paediatric IBD patients were enrolled, with therapeutic drug monitoring (TDM) of IFX and ADA, conducted using immunoenzymatic assays. The presence of the HLA-DQA1*05 T>C allele variant was also tested using a Biomole HLA-DQA1 Real-time PCR kit. Results: The HLA-DQA1*05 rs2097432 T>C allele was present in 54% of patients on IFX and 69% of those on ADA. No statistically significant differences were found between HLA carriers and non-carriers across any of the three analysed groups: IFX, ADA and the overall anti-TNFα. Conclusions: Our study suggests that the HLA-DQA1*05 allele does not increase the risk of secondary loss of response to anti-TNF therapy, likely because most patients were on a combination of anti-TNF agents and immunomodulators, which can lower anti-drug antibody production. Testing for HLA-DQA105 can aid in personalising treatment and optimising therapy to minimise immunogenicity risks.

HLA-DQA1*05 Associates With Anti-Tumor Necrosis Factor Immunogenicity and Low Adalimumab Trough Concentrations in Inflammatory Bowel Disease Patients From the SERENE Ulcerative Colitis and Crohn's Disease Studies

BACKGROUND AND AIMS

Anti-tumor necrosis factor (anti-TNF) therapies are commonly prescribed treatments for Crohn's disease (CD) and ulcerative colitis (UC). Many patients treated with anti-TNF therapy eventually develop anti-drug antibodies (ADAs). Understanding the factors associated with immunogenicity in anti-TNF-treated patients can help guide treatment. The Humira SERENE studies were Phase 3 trials investigating adalimumab induction regimens in CD and UC patients.

METHODS

We imputed alleles for 7 HLA genes in 1100 patients from the SERENE CD and SERENE UC trials. We then tested these alleles for association with time to immunogenicity. Subsequently, we tested loci significantly associated with immunogenicity for their association with patients who had consistently low drug serum concentrations.

RESULTS

This study replicated the association of HLA-DQA1*05 with time to immunogenicity (hazard ratio [HR] 1.42, p = 2.22E-06). Specifically, HLA-DQA1*05:05 was strongly associated (HR 1.76, p = 2.02E-10) and we detected a novel association represented by HLA-DRB1*01:02 (HR 3.16, p = 2.92E-07). Carriage of HLA-DQA1*05:05 and HLA-DRB1*01:02 was associated with patients who experienced consistently low adalimumab trough concentrations (HLA-DQA1*05:05: odds ratio [OR] 1.98, p = 0.0049; HLA DRB1*01:02: OR 7.06, p = 7.44E-05).

CONCLUSIONS

We found a significant association between alleles at genes in the human HLA locus and the formation of adalimumab immunogenicity and low adalimumab drug serum concentrations in large clinical studies of CD and UC patients. This work extends previous findings in CD to UC and directly shows a genetic association in patients with low drug concentrations. This work builds on existing literature to suggest that genetic screening could be a useful tool for clinicians concerned with patient anti-TNF immunogenicity.

CLINICAL TRIAL REGISTRATION NUMBERS

SERENE CD (NCT02065570), SERENE UC (NCT02065622).

Novel targets for mucosal healing in inflammatory bowel disease therapy

Inflammatory bowel disease (IBD) is a chronic condition affecting the gastrointestinal tract, primarily manifesting as ulcerative colitis (UC) or Crohn's disease (CD). Both inflammation and disruption of the intestinal epithelial barrier are key factors in IBD pathogenesis. Substantial evidence has revealed a significant association between aberrant immune responses and impairment of the intestinal epithelial barrier in IBD pathogenesis. The components of the intestinal epithelium, particularly goblet cells and Paneth cells, are crucial to gut homeostasis, as they secrete mucin, antimicrobial peptides (AMPs), and cytokines. Furthermore, impairment of epithelial integrity, which is regulated by tight junctions, is a hallmark of IBD pathology. While common treatments for IBD, such as anti-inflammatory drugs, target various signaling pathways with varying efficacies, therapeutic approaches focused on mucosal and epithelial barrier healing have been largely neglected. Moreover, high costs, side effects, and insufficient or inconsistent therapeutic outcomes remain major drawbacks of conventional anti-IBD drugs. Recent studies on epithelial barrier regeneration and permeability reduction have introduced promising therapeutic targets, including farnesoid X receptor (FXR), urokinase-type plasminogen activator (uPA)-urokinase-type plasminogen activator receptor (uPAR) interaction, fecal microbiota transplantation (FMT), and insulin receptor (INSR). Notably, the simultaneous targeting of intestinal inflammation and promotion of epithelial barrier healing shows promise for efficient IBD treatment. Future research should explore targeted therapies and combination treatments, including natural remedies, microbiota colonization, stem cell approaches, and computer-aided drug design. It is also crucial to focus on accurate prognosis and developing a thorough understanding of IBD development mechanisms.

Targeting hyaluronan synthesis enhances the therapeutic effectiveness of biologics in inflammatory bowel disease

Although biologics have been revolutionizing the treatment of inflammatory bowel diseases (IBD) over the past decade, a significant number of patients still fail to benefit from these drugs. Overcoming the nonresponse to biologics is one of the top challenges in IBD treatment. In this study, we revealed that hyaluronan (HA), an extracellular matrix (ECM) component in the gut, is associated with nonresponsiveness to infliximab and vedolizumab therapy in patients with IBD. In murine colitis models, inhibition of HA synthase 2-mediated (HAS2-mediated) HA synthesis sensitized the therapeutic response to infliximab. Mechanistically, HA induced the expression of MMP3 in colonic fibroblasts by activating STAT3 signaling, thereby mediating the proteolytic cleavage of multiple IgG1 biologics. Finally, we found that macrophage-derived factors upregulated HAS2 expression in fibroblasts, thereby contributing to infliximab nonresponse. In summary, we identified a pathogenic connection between abnormal ECM remodeling and biologics nonresponse and provided insights for the precise therapy for IBD.

Pancreatic stent improves the success rate of needle-knife papillotomy in patients with difficult biliary cannulation

BACKGROUND

Needle-knife precut papillotomy (NKP) is typically performed freehand. However, it remains unclear whether pancreatic stent (PS) placement can improve the outcomes of NKP.

AIM

To explore whether PS placement improves the success rate of NKP in patients with difficult biliary cannulation.

METHODS

This single-center retrospective study included 190 patients who underwent NKP between January 2017 and December 2021 after failed conventional biliary cannulation. In cases with incidental pancreatic duct cannulation during conventional biliary cannulation, the decision for pre-NKP PS placement was made at the endoscopist's discretion. The primary outcome was the difference in the NKP success rate between patients with and without PS placement; the secondary outcome was the adverse event rate.

RESULTS

Among the 190 participants, 82 received pre-NKP PS (PS-NKP group) whereas 108 did not [freehand or freehand NKP (FH-NKP) group]. Post-NKP selective biliary cannulation was successful in 167 (87.9%) patients, and the PS-NKP had a significantly higher success rate than the FH-NKP group (93.9% vs 83.3%, P = 0.027). The overall adverse event rates were 7.3% and 11.1% in the PS-NKP and FH-NKP groups, respectively (P = 0.493). A periampullary diverticulum (PAD) and significant intraoperative bleeding during NKP were independently associated with NKP failure; however, a pre-NKP PS was the only predictor of NKP success. Among the 44 participants with PADs, the PS-NKP group had a non-significantly higher NKP success rate than the FH-NKP group (87.5% and 65%, respectively; P = 0.076).

CONCLUSION

PS significantly improved the success rate of NKP in patients with difficult biliary cannulation.

Eleven Grand Challenges for Inflammatory Bowel Disease Genetics and Genomics

The past 2 decades have witnessed extraordinary advances in our understanding of the genetic factors influencing inflammatory bowel disease (IBD), providing a foundation for the approaching era of genomic medicine. On behalf of the NIDDK IBD Genetics Consortium, we herein survey 11 grand challenges for the field as it embarks on the next 2 decades of research utilizing integrative genomic and systems biology approaches. These involve elucidation of the genetic architecture of IBD (how it compares across populations, the role of rare variants, and prospects of polygenic risk scores), in-depth cellular and molecular characterization (fine-mapping causal variants, cellular contributions to pathology, molecular pathways, interactions with environmental exposures, and advanced organoid models), and applications in personalized medicine (unmet medical needs, working toward molecular nosology, and precision therapeutics). We review recent advances in each of the 11 areas and pose challenges for the genetics and genomics communities of IBD researchers.

The Ivermectin Related Compound Moxidectin Can Target Apicomplexan Importin α and Limit Growth of Malarial Parasites

Signal-dependent transport into and out of the nucleus mediated by members of the importin (IMP) superfamily is crucial for eukaryotic function, with inhibitors targeting IMPα being of key interest as anti-infectious agents, including against the apicomplexan Plasmodium species and Toxoplasma gondii, causative agents of malaria and toxoplasmosis, respectively. We recently showed that the FDA-approved macrocyclic lactone ivermectin, as well as several other different small molecule inhibitors, can specifically bind to and inhibit P. falciparum and T. gondii IMPα functions, as well as limit parasite growth. Here we focus on the FDA-approved antiparasitic moxidectin, a structural analogue of ivermectin, for its IMPα-targeting and anti-apicomplexan properties for the first time. We use circular dichroism and intrinsic tryptophan fluorescence measurements to show that moxidectin can bind directly to apicomplexan IMPαs, thereby inhibiting their key binding functions at low μM concentrations, as well as possessing anti-parasitic activity against P. falciparum in culture. The results imply a class effect in terms of IMPα's ability to be targeted by macrocyclic lactone compounds. Importantly, in the face of rising global emergence of resistance to approved anti-parasitic agents, the findings highlight the potential of moxidectin and possibly other macrocyclic lactone compounds as antimalarial agents.

Ustekinumab Drug Levels and Outcomes in Inflammatory Bowel Disease

BACKGROUND

Data regarding the utility of therapeutic drug monitoring with ustekinumab (UST) are sparse. Our aim was to determine the correlation of UST levels with outcomes in a cohort of patients with inflammatory bowel disease (IBD).

METHODS

This was a multicenter, retrospective study of all patients with IBD who received UST from January 1, 2014 to March 1, 2022. The primary outcomes were the correlation of UST level with clinical remission (per physician global assessment), endoscopic healing [the absence of ulcers/erosions in Crohn's disease (CD) and Mayo endoscopic score ≤1 for ulcerative colitis (UC)], and normal serum C-reactive protein (CRP) (≤5 mg/L). Secondary outcomes included defining optimal UST trough levels associated with favorable outcomes.

RESULTS

A total of 71 patients (74.6% with CD; 57.7% female) were included. The median age was 39.5 years [interquartile range (IQR): 26 to 52] and 12.6% were on combination therapy with immunomodulators. Median UST trough levels were significantly higher in patients who achieved endoscopic healing at 5.4 µg/mL versus 3.5 µg/mL ( P =0.035) and normal CRP at 5.5 µg/mL versus. 3.1 µg/mL ( P =0.002). A cutoff UST level of 4.8 µg/mL yielded the highest area under the curve (AUC) of 0.73 (95% CI: 0.61-0.80) to predict a normal CRP followed by a cutoff of 3.5 µg/mL which yielded an AUC of 0.66 (95% CI: 0.52-0.81) to predict endoscopic healing.

CONCLUSIONS

UST trough levels were significantly higher in patients who achieved a normal CRP and endoscopic healing. A cutoff UST level of 4.8 µg/mL reliably predicted CRP normalization.

Review Article: Green Management of IBD-New Paradigms for an Eco-Friendly Approach

BACKGROUND

The worldwide prevalence of inflammatory bowel disease (IBD) is increasing, with its potential evolution as a global disease and a consequent increase in its burden on healthcare systems. These estimates do not factor in the 'real' price of IBD, which, beyond curbing career aspirations, instilling social stigma, and impairing the quality of life in patients, could also significantly affect the environment.

AIM

To highlight potential areas for intervention and develop management strategies aimed at minimising environmental impacts in the field of IBD over time.

METHODS

Various aspects of IBD care (organisation of IBD centres, diagnostics and therapeutics) are examined from an environmental sustainability perspective.

RESULTS

Each stage, from the patient's means of transport to the hospital to the physician's diagnostic and therapeutic decisions, contribute to CO2 and waste production. Strategies to contain the environmental impact are feasible. Some are easy to implement, such as ensuring the appropriateness of the diagnostic and therapeutic pathway for patients; others need to be implemented in synergy with healthcare providers' policies and pharmaceutical companies.

CONCLUSIONS

With an inevitable increase in the number of patient visits, endoscopies, laboratory testing, and long-term therapeutic strategies for IBD, the clinical community should be aware of environmental concerns and investigate possible strategies to reduce the environmental impact of IBD care.

Development and validation of a machine learning-based, point-of-care risk calculator for post-ERCP pancreatitis and prophylaxis selection

BACKGROUND AND AIMS

A robust model of post-ERCP pancreatitis (PEP) risk is not currently available. We aimed to develop a machine learning-based tool for PEP risk prediction to aid in clinical decision making related to periprocedural prophylaxis selection and postprocedural monitoring.

METHODS

Feature selection, model training, and validation were performed using patient-level data from 12 randomized controlled trials. A gradient-boosted machine (GBM) model was trained to estimate PEP risk, and the performance of the resulting model was evaluated using the area under the receiver operating curve (AUC) with 5-fold cross-validation. A web-based clinical decision-making tool was created, and a prospective pilot study was performed using data from ERCPs performed at the Johns Hopkins Hospital over a 1-month period.

RESULTS

A total of 7389 patients were included in the GBM with an 8.6% rate of PEP. The model was trained on 20 PEP risk factors and 5 prophylactic interventions (rectal nonsteroidal anti-inflammatory drugs [NSAIDs], aggressive hydration, combined rectal NSAIDs and aggressive hydration, pancreatic duct stenting, and combined rectal NSAIDs and pancreatic duct stenting). The resulting GBM model had an AUC of 0.70 (65% specificity, 65% sensitivity, 95% negative predictive value, and 15% positive predictive value). A total of 135 patients were included in the prospective pilot study, resulting in an AUC of 0.74.

CONCLUSIONS

This study demonstrates the feasibility and utility of a novel machine learning-based PEP risk estimation tool with high negative predictive value to aid in prophylaxis selection and identify patients at low risk who may not require extended postprocedure monitoring.

Immunogenicity of Therapeutic Antibodies Used for Inflammatory Bowel Disease: Treatment and Clinical Considerations

The introduction of tumor necrosis factor inhibitors has led to a paradigm shift in the management of inflammatory bowel disease (IBD). The subsequent introduction of both anti-integrins and cytokine blockers has since expanded the biologic armamentarium. However, immunogenicity, defined as the production of anti-drug antibodies (ADAs) to the prescribed biopharmaceutical, means a significant fraction of patients exposed to biologic agents will experience a secondary loss of response to one or more of the drugs. In clinical settings, immunogenicity may be caused by several factors, both patient related (e.g., underlying chronic disease, systemic immune burden, including previous biologic therapy failure, and [epi]genetic background) and treatment related (e.g., dose and administration regimens, drug physical structure, photostability, temperature, and agitation). Here, we outline these elements in detail to enhance biopharmaceutical delivery and therapy for patients with IBD. Moreover, concurrent immunomodulator medication may reduce the risks of ADA generation, especially when using the chimeric drug infliximab. Summarizing the latest developments and knowledge in the field, this review aims to provide strategies to prevent ADA production and information on managing non-responsiveness or loss of response to biologics. Better understanding of the molecular mechanisms underlying the formation of ADAs and the critical factors influencing the immunogenicity of biopharmaceuticals may lead to improved health outcomes in the IBD community that may benefit both the individual patient and society through lower healthcare expenses.

Development and validation of a competency evaluation index system for nurse endoscopists with different stages performing endoscopy nursing in China: A modified Delphi study

BACKGROUND

The advancement of endoscopic techniques has resulted in an increasing need for comprehensive competency in endoscopy nursing. However, there is currently no unified competency evaluation index system for nurse endoscopists in China.

AIMS

To develop and validate of a competency evaluation index system for nurse endoscopists with different stages performing endoscopy nursing in China.

DESIGN

A modified Delphi study.

SETTINGS

Data were collected in a medical university affiliated hospital.

PARTICIPANTS

A total of 569 participants in different fields were included at various phases of this research.

METHODS

The preliminary indicators were designed after conducting a literature review, semi-structured interviews and questionnaires. Two rounds of correspondence with 30 experts using the Delphi method were conducted to evaluate the content of the index followed by reliability and validity tests. The competency evaluation index system for nurse endoscopists at different stages was developed through expert meetings based on the Delphi consultation results according to the novice-to-expert model.

RESULTS

After two rounds of Delphi method consultation, we have established 4 first-level indicators ('Cognitive skill', 'Practice professional skills', 'Professional development skills' and 'Personal characteristics and inner qualities') and 21 s-level indicators, which are the detailed description of first-level indicators. According to the index weight analysis, the four first-level indicators are ranked from the largest to the smallest as practical professional skills, cognitive skills, professional development skills, personal characteristics and intrinsic qualities. Three different stages of nurse endoscopists competency evaluation forms and criteria were developed: primary stage (New skilled), intermediate stage (Capable) and advanced stage (Expert).

CONCLUSIONS

The establishment of a competency evaluation index system based on the novice-to-expert model can accurately assess competency levels and help to effectively train the nurse endoscopists at different stages. Future research should focus on imbedding these competencies in nurse education.

Model-informed precision dosing in inflammatory bowel diseases

Therapeutic drug monitoring (TDM) for biologic therapies in inflammatory bowel disease (IBD) primarily aims to optimize dosing. However, several unmet needs remain. These include the identification of optimal drug concentrations, accounting for variability in pharmacokinetics (PK) and pharmacodynamics (PD), and the frequent delays between sampling and clinical decision-making. Recent technical advances, such as population PK/PD modeling and model-informed precision dosing (MIPD) tools developed from such models, as well as point-of-care (POC) and self-sampling assays and novel software programs, offer potential solutions. Successful implementation of these innovations may help to establish MIPD for patients with IBD. This would enable personalized dosing, advancing a one-size-fits-all approach to TDM that currently is inadequate to fulfill the needs for every patient with IBD.

Acute severe ulcerative colitis: defining the precise moment for colectomy

INTRODUCTION

Acute severe ulcerative colitis (ASUC) is a critical manifestation of ulcerative colitis (UC), often necessitating colectomy when medical management fails. Despite advancements in therapeutic interventions such as corticosteroids, biologics, and JAK inhibitors, a significant proportion of patients require surgery, with colectomy rates ranging from 10% to 15%.

AREAS COVERED

This paper reviews the factors influencing the timing and necessity of colectomy in ASUC management, emphasizing the importance of multidisciplinary decision-making involving gastroenterologists and surgeons.

EXPERT OPINION

Key surgical indications include failure of medical therapy, toxic megacolon, perforation, uncontrolled bleeding, and systemic deterioration. Delays in surgery can result in higher morbidity and mortality rates, making timely intervention essential. This review highlights surgical techniques, including total colectomy and end ileostomy, and discusses potential complications, urging a balanced approach to optimize patient outcomes.

Development of American Society for Gastrointestinal Endoscopy standards for training in advanced endoscopy within dedicated advanced endoscopy fellowship programs

BACKGROUND AND AIMS

Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a "high-quality" nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs.

METHODS

The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods.

RESULTS

Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures.

CONCLUSIONS

This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education's Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency.

Adherence to patient blood management strategy in patients with gastrointestinal bleeding: a prospective nationwide multicenter study

INTRODUCTION

Patient blood management (PBM) adherence in clinical practice is unclear. This real-world practice study assessed the management of patients with gastrointestinal (GI) bleeding after the implementation of the PBM strategy.

METHODS

This was a nationwide multicenter and prospective study involving consecutive adults with GI bleeding between March 2019 and March 2021. Patients were examined according to hemoglobin (Hb) level at admission (<7 g/dl, n  = 93; 7-8 g/dl, n  = 47; 8-9 g/dl, n  = 61; and >9 g/dl, n  = 249). Study outcomes measures were morbidity and mortality during hospitalization and at 3- and 6-month follow-up. Appropriate anemia or iron deficiency management was considered when adherence to PBM policy was higher than 75%.

RESULTS

A total of 450 patients (57.6% men, median age: 74 years, interquartile range: 63-82) were included. Overall, 55.1% and 59.3% of patients received transfusion and iron supplementation, respectively. The rates of appropriate transfusion and iron supplementation adherence were 90.9% (range: 86.9-93.5%, P  = 0.109) and 81.8% (range: 78.5-85.1%, P  = 0.041), depending on Hb level, respectively. No associations were observed between adherence to the PBM strategy and length of stay ( P  = 0.263) or risk of further bleeding ( P  = 0.742). Patients who were transfused [hazard ratio (HR): 0.79, 95% confidence interval (CI): 0.27-0.85] and iron supplemented (HR: 0.91, 95% CI: 0.38-1.41), however, appropriately achieved a lower risk of death. Age (HR: 1.12, 95% CI: 1.12-1.25) and further bleeding (HR: 39.08, 95% CI: 4.01-181.24) were poor prognostic factors. No serious adverse events were reported.

CONCLUSIONS

In this nationwide study, there is a high level of adherence and safety of PBM for the treatment of GI bleeding. Adherence to the PBM strategy improved outcomes in patients with GI bleeding.

Colonic stents: who, where, when

Large bowel obstruction can be caused by advanced colonic cancer, extracolonic obstruction or benign strictures. The technical success rate of colonic stents for the treatment of colorectal obstruction is about 87% with complications or technical failure at about 14%. Mortality associated with the procedure is <4% and perforation is 4.5%. This article will discuss who would benefit from colonic stents including bridge to surgery, palliation, benign strictures and who should be performing this procedure. The insertion of stents in the colon has been primarily studied in the left colon, although proximal obstruction will also be discussed. The timing of stent insertion, in relation to symptoms and chemotherapy, will be discussed.

The dual role of toll-like receptors in COVID-19: Balancing protective immunity and immunopathogenesis

Toll-like receptors (TLRs) of human are considered as the most critical immunological mediators of inflammatory pathogenesis of COVID-19. These immunoregulatory glycoproteins are located on the surface and/or intracellular compartment act as innate immune sensors. Upon binding with distinct SARS-CoV-2 ligand(s), TLRs signal activation of different transcription factors that induce expression of the proinflammatory mediators that collectively induce 'cytokine storm'. Similarly, TLR activation is also pivotal in conferring protection to infection and invasion as well as upregulating the tissue repair pathways. This dual role of the human TLRs in deciding the fate of SARS-CoV-2 has made these receptor proteins as the critical mediators of immunoprotective and immunopathogenic consequences associated with COVID-19. Herein, pathbreaking discoveries exploring the immunobiological importance of the TLRs in COVID-19 and developing TLR-directed therapeutic intervention have been reviewed by accessing the up-to-date literatures available in the public domain/databases. In accordance with our knowledge in association with the importance of TLRs' role against viruses and identification of viral particles, they have been recognized as suitable candidates with high potential as vaccine adjuvants. In this regard, the agonists of TLR4 and TLR9 have effective potential in vaccine technology while the others need further investigations. This comprehensive review suggests that basal level expression of TLRs can act as friends to keep our body safe from strangers but act as a foe via overexpression. Therefore, selective inhibition of the overexpressed TLRs appears to be a solution to counteract the cytokine storm while TLR-agonists as vaccine adjuvants could lessen the risk of infection in the naïve population.

Consensus statements on the current landscape of artificial intelligence applications in endoscopy, addressing roadblocks, and advancing artificial intelligence in gastroenterology

BACKGROUND AND AIMS

The American Society for Gastrointestinal Endoscopy (ASGE) AI Task Force along with experts in endoscopy, technology space, regulatory authorities, and other medical subspecialties initiated a consensus process that analyzed the current literature, highlighted potential areas, and outlined the necessary research in artificial intelligence (AI) to allow a clearer understanding of AI as it pertains to endoscopy currently.

METHODS

A modified Delphi process was used to develop these consensus statements.

RESULTS

Statement 1: Current advances in AI allow for the development of AI-based algorithms that can be applied to endoscopy to augment endoscopist performance in detection and characterization of endoscopic lesions. Statement 2: Computer vision-based algorithms provide opportunities to redefine quality metrics in endoscopy using AI, which can be standardized and can reduce subjectivity in reporting quality metrics. Natural language processing-based algorithms can help with the data abstraction needed for reporting current quality metrics in GI endoscopy effortlessly. Statement 3: AI technologies can support smart endoscopy suites, which may help optimize workflows in the endoscopy suite, including automated documentation. Statement 4: Using AI and machine learning helps in predictive modeling, diagnosis, and prognostication. High-quality data with multidimensionality are needed for risk prediction, prognostication of specific clinical conditions, and their outcomes when using machine learning methods. Statement 5: Big data and cloud-based tools can help advance clinical research in gastroenterology. Multimodal data are key to understanding the maximal extent of the disease state and unlocking treatment options. Statement 6: Understanding how to evaluate AI algorithms in the gastroenterology literature and clinical trials is important for gastroenterologists, trainees, and researchers, and hence education efforts by GI societies are needed. Statement 7: Several challenges regarding integrating AI solutions into the clinical practice of endoscopy exist, including understanding the role of human-AI interaction. Transparency, interpretability, and explainability of AI algorithms play a key role in their clinical adoption in GI endoscopy. Developing appropriate AI governance, data procurement, and tools needed for the AI lifecycle are critical for the successful implementation of AI into clinical practice. Statement 8: For payment of AI in endoscopy, a thorough evaluation of the potential value proposition for AI systems may help guide purchasing decisions in endoscopy. Reliable cost-effectiveness studies to guide reimbursement are needed. Statement 9: Relevant clinical outcomes and performance metrics for AI in gastroenterology are currently not well defined. To improve the quality and interpretability of research in the field, steps need to be taken to define these evidence standards. Statement 10: A balanced view of AI technologies and active collaboration between the medical technology industry, computer scientists, gastroenterologists, and researchers are critical for the meaningful advancement of AI in gastroenterology.

CONCLUSIONS

The consensus process led by the ASGE AI Task Force and experts from various disciplines has shed light on the potential of AI in endoscopy and gastroenterology. AI-based algorithms have shown promise in augmenting endoscopist performance, redefining quality metrics, optimizing workflows, and aiding in predictive modeling and diagnosis. However, challenges remain in evaluating AI algorithms, ensuring transparency and interpretability, addressing governance and data procurement, determining payment models, defining relevant clinical outcomes, and fostering collaboration between stakeholders. Addressing these challenges while maintaining a balanced perspective is crucial for the meaningful advancement of AI in gastroenterology.

Ivermectin as a Treatment Modality in COVID-19 Patients: A Systematic Review and Meta-Analysis of Up-To-Date RCTs

The objective of this systematic review and meta-analysis is to assess the efficacy and safety of Ivermectin compared to placebo or standard of care for the treatment and prevention of COVID-19 disease. Literature search was carried out in PubMed, Scopus, and google scholar. Clinical trial registries (clinical trail.gov) and preprint servers (Medrxiv) were also searched for registered and preprint data respectively. Mortality, Clinical recovery, Clinical worsening, duration of hospital stay, and adverse events were considered as primary outcomes while viral clearance is considered as a secondary outcome. Revised Cochrane risk of bias assessment tool was used to assess the risk of bias. Random effect meta-analysis was carried out for all the outcomes. GRADE was used to rate the certainty of evidence. A total of 19 RCTs with 1111 patients were included in the analysis. Ivermectin use did was not associated with a reduction in the incidence of mortality, duration of hospitalization, clinical worsening, and incidence of adverse events nor it was associated with an increase in clinical improvement compared to either placebo or standard of care. Ivermectin also did not show any reduction in viral clearance compared to both placebo or standard of care and this was associated with substantial inconsistency. The overall certainty of the evidence was very low to low. Based on the very low to low certainty of the evidence, we consider Ivermectin ineffective in the management of COVID-19 disease, both as treatment and prophylaxis.

Antinuclear Antibodies in Non-Rheumatic Diseases

Antinuclear antibodies (ANAs) are critical immunological markers commonly associated with various connective tissue diseases (CTDs). However, these autoantibodies are also detectable in healthy individuals, patients with non-rheumatic autoimmune diseases, those with viral infections, and subjects using specific medications (such as procainamide, hydralazine, and minocycline) that can lead to drug-induced ANA elevation. The standard method for ANA detection is indirect immunofluorescence, a process that requires precision and thoroughness as it assesses both titer and fluorescence patterns. Additionally, immunoblotting and enzyme-linked immunosorbent assay (ELISA) are recommended to identify specific ANAs precisely, highlighting the importance of precision in ANA detection. This review explores the advantages and limitations of current ANA detection methods. It also describes the clinical implications of ANA presence in non-rheumatic diseases, including autoimmune disorders, infectious conditions, non-autoimmune and non-infectious diseases, and autoimmune cutaneous diseases. The presence of elevated ANA titers in these contexts can complicate clinical decision-making, as the diagnostic value of ANA testing alone is limited in non-rheumatic conditions. However, despite these limitations, ANA remains a key component in diagnosing and prognosis systemic CTDs, as it can indicate disease activity, severity, and response to treatment, which is of utmost importance in rheumatology and internal medicine. This paper provides a comprehensive review of the role of ANA in non-rheumatic diseases. It focuses on ANA diagnostic and prognostic significance and offers valuable insights for clinical practice.

Therapeutic drug monitoring and immunogenetic factors associated with the use of adalimumab in Crohn's disease patients

Crohn's disease (CD) involves immune system interactions with intestinal tissue, driven by pro-inflammatory cytokines like Tumor Necrosis Factor (TNF-α). Adalimumab, targeting TNF-α, regulates associated inflammatory responses. Despite being humanized, it may induce immunogenic processes, affecting treatment effectiveness. Thus, monitoring serum adalimumab and anti-drug antibody (ADA) levels can optimize therapy. Understanding genetic factors influencing adalimumab response can enhance personalized treatment and improve patient quality of life. We aimed to quantify adalimumab serum levels, assess test interchangeability, detect ADA, examine immune complex formation, and investigate genetic phenotypes related to immunogenicity in CD patients. Seventy CD patients in the maintenance phase with adalimumab were classified into active (CDA) and remission (CDR) groups. Adalimumab concentration was determined via enzyme-linked immunosorbent assay (ELISA-Promonitor) and lateral flow assay (Quantum Blue), with assay interchangeability assessed statistically. ADA and immune complex formation were quantified using ELISA assays. DNA was genotyped for the genes ATG16L1, CD96, and CD155. No significant differences in adalimumab serum concentrations were observed between groups, regardless of the assay. However, a statistical difference between the tests indicated measurement disparity (P = 0.003), with moderate agreement (Lin's correlation of 0.247). ADA was detected in 4 of 27 of the patients with infratherapeutic levels, 3 in the CDA group and 1 in the CDR group. Analysis of immune complexes revealed significantly higher concentrations in the CDA group (P = 0.0125). The genotypic evaluation revealed significant associations for the CD96 CC (wild-type) genotype with higher CRP levels, colonic involvement, and infratherapeutic levels of adalimumab. ATG16L1 CC genotype was associated with higher CDEIS and fecal calprotectin values, while the variant (TT) genotype had lower platelet counts. The effectiveness of treatment with adalimumab was not directly related to higher medication levels in this cohort. The disparity between tests indicates the need to use only one test in patient follow-up to ensure accuracy in therapeutic monitoring. Genotypic differences highlight the correlation between the wild genotype for CD96 and ATG16L1 with unfavorable laboratory and endoscopic response to adalimumab. Finally, the more significant levels of immune complexes in the CDA group indicate an association with a worse response to adalimumab.

Long-term adenoma recurrence and development of colorectal cancer following endoscopic mucosal resection in large non-pedunculated colonic polyps ≥4 cm

OBJECTIVES

Data of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis.

METHODS

We retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4-6) months after the initial PWF-EMR procedure and the second one (SC2) after (12-18) months. In 2023, all cases were checked for PCPCRC development.

RESULTS

Residual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC .

CONCLUSIONS

This historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.

Self-Expandable Metal Stents for Obstructing Colon Cancer and Extracolonic Cancer: A Review of Latest Evidence

Colorectal cancer (CRC) is a leading cause of cancer mortality, with many patients presenting with malignant colorectal obstruction (MCO). Self-expandable metal stents (SEMSs) have emerged as a minimally invasive key intervention, both as a bridge to surgery (BTS) in curative setting sand for palliation in advanced disease. This review aims to provide an evidence-based analysis of SEMS indications, contraindications, and efficacy across curative and palliative contexts, with focus on long-term outcomes. Based on data from recent trials and guidelines, we examine SEMS placement outcomes, focusing on specific scenarios, including BTS for left-sided MCO, chemotherapy (with angiogenic agents) safety during stent therapy, the optimal timing between SEMS placement and surgery, and oncological outcomes. We also discuss the use of SEMSs in challenging contexts such as proximal colon obstruction and extracolonic obstruction, and the relevant technical considerations. Findings indicate that using a SEMS in the BTS setting reduces emergency surgery needs, minimizes complications, and decreases stoma formation. Long-term oncologic outcomes, particularly recurrence, are still debated, but recent evidence shows that SEMS placement is safe, without worsening long term outcomes. Palliative SEMS placement shows high efficacy in symptom relief with manageable adverse events. Success depends on patient selection and technical expertise, with multidisciplinary approaches essential for optimal outcomes.

Surgical Emergencies in Rectal Cancer: A Narrative Review

Colorectal cancer (CRC) is the third most diagnosed cancer worldwide and the second most common cause of cancer death. About 20% of patients diagnosed with rectal cancer present with emergency symptoms. Typical symptoms include acute bleeding, obstruction, and perforation. These emergency situations can be life-threatening and may lead to decreased life expectancy and quality of life. Bowel perforation is the most common cause of emergency presentation, followed by obstruction and acute bleeding. This narrative review analyzes the existing literature regarding the acute presentation of rectal cancer, producing three flow charts for the management of the main rectal emergencies. The treatment of acute bleeding differs based on the hemodynamic status. Treatment for bowel perforation or occlusion differs depending on whether the lesion is intraperitoneal or extraperitoneal. Emergency presentations seem to be strongly associated with several poor prognostic factors, including lymphovascular invasion, perineural invasion, and high-grade or poorly differentiated tumors. An association between emergency presentation and larger tumor size, advanced tumor stage, node-positive disease, and metastatic disease is reported in the literature. The difference between colon and rectal cancer, both in terms of treatment and prognosis, has been widely acknowledged. Thus, comprehensive studies and dedicated guidelines are needed, considering the lack of literature published about rectal cancer in an emergency setting.

Comparative efficacy and safety of 3 endoscopic techniques for the treatment of large common bile duct stones (≥15 mm): long-term follow-up

BACKGROUND AND AIMS

The effectiveness of endoscopic papillary large balloon dilation (EPLBD) alone versus EPLBD combined with endoscopic sphincterotomy (EST) in treating large common bile duct stones (CBDSs; ≥15 mm) remains unclear. This study aimed to evaluate the safety and treatment outcomes of EPLBD combined with limited or large EST versus EPLBD alone in removing large CBDSs.

METHODS

Between January 2013 and September 2024, total of 408 patients underwent EPLBD, either alone or in combination with EST, to treat large CBDSs (≥15 mm). Patients were divided into 3 groups: EPLBD alone (n = 92), EPLBD with limited EST (n = 124), and EPLBD with large EST (n = 192). The study compared the first-session stone clearance rate, overall stone success rate, mechanical lithotripsy use, and adverse event rate.

RESULTS

Compared with the EPLBD alone group, the EPLBD with limited EST and the EPLBD with large EST groups exhibited higher initial stone clearance rates, required fewer endoscopic procedures for complete stone removal, and had lower rates of mechanical lithotripsy use and CBDS recurrence. Compared with the EPLBD with limited EST group, the EPLBD with large EST group showed a higher initial stone clearance rate, fewer endoscopic procedures required for complete CBDS removal, and no significant differences in adverse events. The multivariate analysis showed that the endoscopic technique and number of endoscopic operations were strongly associated with CBDS recurrence.

CONCLUSIONS

EPLBD combined with large EST may represent a more rational endoscopic technique for treating large CBDSs.

Self-efficacy in patients with inflammatory bowel disease: the effect of self-care education by two randomized methods-teach-back and a smartphone application

The use of the best teaching method to promote self-care in patients with inflammatory bowel disease (IBD) has not been well defined. Therefore, the current study was conducted to compare the effect of self-care education by two methods of teach-back and a smartphone application. The current clinical trial with a pre- and post-test design was conducted among 78 patients with IBD. Patients were allocated to three groups of application, teach-back and control using a simple blocked randomization. Data were collected using a checklist for demographic information and Inflammatory Bowel Disease Self-efficacy Scale. Collected data were analyzed using SPSS. Participants in all three groups were homogeneous in terms of demographic variables. The mean pretest scores of self-efficacy (SE) in the application, teach-back and control groups were 191.37 ± 49.15, 193.92 ± 45.54 and 192.76 ± 43.12, respectively. The mean post-test scores of SE in the application, teach-back and control groups were 224.51 ± 49.89, 207.48 ± 48.109 and 189.92 ± 40.28, respectively (P = 0.033). The results of the current study showed that self-care education by the application can better improve the mean scores of SE and its four dimensions of managing stress and emotions, managing symptoms and disease, managing medical care and maintaining remission, compared to other methods. It seems that the use of the application as a continuous and cost-effective educational strategy will become widespread in the future for patient education among most healthcare and treatment systems.

Atypical Presentation of Small Bowel Crohn's Disease: Case Report of Musculoskeletal and Hepatic Complications Without Gastrointestinal Symptoms

Herein, we described a case of small bowel Crohn's disease with recurrent, unexplained fevers, pain in the right lower back, hip, and groin area over 20 months. The patient did not present any gastrointestinal symptoms and colonoscopy showed no abnormalities. Imaging revealed a liver abscess and multiple lesions with pneumatosis in the muscles of the right lower back region. Initially, disseminated infection was suspected and the antibiotics was administered without success. Subsequently, Magnetic resonance (MR) enterography suggested the possibility of a small bowel fistula which was confirmed during exploratory laparotomy. Inflammation was prominent in a 27-cm segment starting from 30-cm proximal to the ileocecal junction. The segment was resected and pathological examination confirmed Crohn's disease. Postoperatively, mesalazine was administered, but showed limited efficacy. After modifying the treatment plan to infliximab and azathioprine, the patient was symptom-free and no obvious inflammation was found in the colonoscopy reexamination.

Acute Severe Ulcerative Colitis: An International Delphi Consensus on Clinical Trial Design and Endpoints

BACKGROUND & AIMS

Interventional clinical trials in acute severe ulcerative colitis (ASUC) are characterized by substantial heterogeneity due to a lack of consensus in several key areas of trial design-this impedes clinical research efforts to identify novel therapies. The objective of this initiative was to achieve the first consensus and provide clear position statements on ASUC trial design.

METHODS

A modified Delphi consensus approach was employed with a panel of 20 clinicians with international representation and expertise in ASUC trial design and delivery. Agreement was defined as at least 75% of participants voting as "agree" with each statement.

RESULTS

In total, 30 statements achieved consensus and were approved. Statements centred on proposing suitable eligibility criteria (disease extent, disease severity, prior therapy exposure), optimizing trial design (randomization, stratification, corticosteroid handling, timing of assessments), and recommending primary and secondary endpoints alongside defining key efficacy outcomes (clinical and endoscopic response and remission, treatment failure, quality of life).

CONCLUSIONS

The expansion of drugs to treat moderate-severe ulcerative colitis over the past decade, particularly the rapidly acting Janus kinase inhibitors, is promising and has reignited the interest in identifying suitable therapeutic candidates for ASUC. Clinical trials in this high-risk population are challenging to conduct and this consensus provides a framework for future trials to advance drug development.

Long-Term Effectiveness and Safety of Proactive Therapeutic Drug Monitoring of Infliximab in Paediatric Inflammatory Bowel Disease: A Real-World Study

BACKGROUND

This study evaluated the long-term effectiveness and safety of a multidisciplinary early proactive therapeutic drug monitoring (TDM) program combined with Bayesian forecasting for infliximab (IFX) dose adjustment in a real-world dataset of paediatric patients with inflammatory bowel disease (IBD).

METHODS

A descriptive, ambispective, single-centre study of paediatric patients with IBD who underwent IFX serum concentration measurements between September 2015 and September 2023. The patients received reactive TDM before September 2019 (n = 17) and proactive TDM thereafter (n = 21). We analysed for clinical, biological, and endoscopic remission; treatment failure; hospitalisations; emergency visits; and adverse drug reactions. The IFX doses were adjusted to maintain trough concentrations ≥ 5 µg/mL, with specific targets for proactive TDM.

RESULTS

Of the 38 patients, 21 had Crohn's disease (CD), 16 ulcerative colitis (UC), and 1 undetermined IBD. The mean (standard deviation) IFX trough concentrations were 6.83 (5.66) µg/mL (reactive) and 12.38 (9.24) µg/mL (proactive) (p = 0.08). No statistically significant differences between groups were found in remission rates or treatment failure. The proactive group had fewer hospitalisations (14.29% vs. 23.53%; p = 0.47) and shorter median hospitalisation days (6 vs. 19; p = 0.50), although the difference was not statistically significant. The number of patients with adverse reactions (infusion related reactions and infections) was higher in the proactive group (38.10% vs. 23.53%; p = 0.34) but the difference was not significantly different.

CONCLUSIONS

Proactive TDM showed no significant differences in treatment outcomes compared to reactive TDM. However, the results in both the reactive and proactive TDM groups were not worse than those reported in other studies. Further studies with larger samples are needed to optimize the treatment strategies for pediatric IBD patients.

Factors Associated with the Severity of ERCP-Related Complications: A Retrospective Single-Centre Study

Objectives: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications have been extensively studied and are well established; most complications are mild and self-limiting. This study aims to identify patients at risk of severe early post-ERCP complications. Methods: We conducted a retrospective cohort study with data from 2810 ERCP procedures performed at Ghent University Hospital between 2016 and 2022. Patient records and a maintained ERCP registry were used to identify all ERCP-related complications and possible risk factors. The AGREE classification was used to determine the severity of the complication. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of severe complications. Results: Out of 2810 procedures, 223 cases (7.9%) had post-ERCP complications, with severe complications occurring in 20.3% of cases. The most common severe complication was haemorrhage (22/49 severe complications, 44.9%), with perforation having the highest probability of being severe (10/15 cases, 67%). Independent predictors of severe complications included anticoagulative therapy (OR 6.3, 95% CI 1.4-28.3, p = 0.016) and high procedural difficulty (Schutz category 3: OR 11.5, 95% CI 2.4-54.6, p = 0.002; category 4: OR 5.9, 95% CI 1.4-23.5, p = 0.012). Conclusions: Patients on anticoagulation and those undergoing complex ERCP procedures (Schutz 3 or 4) are at particular risk of severe procedure-related complications.

Giant Primary Choledocholithiasis: A Rare Case Report and Comprehensive Review of Literature

Choledocholithiasis is the second most common complication of gallstone disease. Giant primary choledocholithiasis is a rare occurrence. Ultrasonography is the initial mode of imaging, and endoscopic ultrasound is considered superior to other modalities. Endoscopic retrograde cholangiopancreatography can be used for stone extraction. Other treatment modalities include laparoscopic or open common bile duct (CBD) exploration. Many institutions in underdeveloped countries still practice open CBD exploration. Factors such as larger stone diameter, edema of the CBD, and the presence of multiple lithiasis can influence the treatment approach. In this article we are presenting a case of 62 years-old-female with no any known comorbidities had presented to emergency with severe upper quadrant pain and giant choledocholithiasis was diagnosed in ultrasound and computed tomography scan with no other features of complications and patient successfully underwent open CBD exploration with intraoperative choledochoscopy and primary closure.

Transition to Subcutaneous Infliximab vs Vedolizumab in Inflammatory Bowel Disease: A Prospective Multicenter Study

BACKGROUND AND AIMS

Transition from intravenous (IV) to subcutaneous (SC) administration is an option in inflammatory bowel disease (IBD) with Infliximab (IFX) or Vedolizumab (VDZ). The aim was to compare the adherence, the persistence in therapy, and quality of life (QoL) at baseline, at 6, at 12 months of SC IFX versus SC VDZ.

METHODS

This was a prospective, observational, multicenter study on patients with IBD in treatment with IV IFX or VDZ who switched to SC. All patients investigated the QoL by the short IBD Questionnaire (sIBDQ) and the concerns and expectations by a 6-item survey. Any adverse events, local and systemic, were reported. Safety, concerns, and satisfaction were evaluated.

RESULTS

One hundred and eight out of 93 patients were replaced, 51 to SC IFX and 42 to SC VDZ. The majority accepted the SC route. Persistence in therapy was similar between the two groups. The QoL improved after 6 months (p = 0.004), but at T12 both groups show a significant decline in QoL. SC administration has not caused any concern for patients. As safety, both groups reported a similar number of local reactions (IFX 19.60% vs VDZ 19.04%). In the IFX group were reported more systemic reactions (IFX 11.6% vs VDZ 7.14%) without the need for hospitalization.

CONCLUSION

The transition from IV to SC administration is an appropriate and safe option for treatment with IFX or VDZ. It is very important to consider the patient's choice and preference. The SC administration led to a significant benefit in QoL, especially in the first 6 months of therapy.

Does HLA-DQA1*05 carriage have a greater impact on the outcome of infliximab therapy for isolated small-bowel Crohn's disease?

Carriage of HLA-DQA1*05 is thought to increase the formation of anti-tumour necrosis factor alpha (TNF-α) antibodies, reducing the drug efficacy in Crohn's disease (CD) patients. However, little data are currently available for small-bowel Crohn's disease (SB-CD). A specific assessment of the impact of HLA-DQA1*05 on the clinical response to treatment with infliximab (IFX), a TNF-α antagonists, in SB-CD patients is necessary. We conducted a single-center retrospective study that included 106 SB-CD patients treated with IFX. The serum samples were collected for antibodies to infliximab (ATI) testing and HLA-DQA1*05 genotyping. Double-balloon enteroscopy (DBE) was performed following the IFX treatment, with endoscopic outcomes evaluated using the partial simple endoscopic score for CD (pSES-CD), whereas the clinical response was assessed with the Crohn's disease activity index (CDAI). Multivariate logistic regression and multivariate COX regression analyses were employed to analyze the correlation of the HLA-DQA1*05 genotypes with other clinical variables. In this study, 30.2% of SB-CD patients carried the HLA-DQA1*05 allele, which significantly increased their risk of ATI generation (odds ratio [OR] = 2.337, p = .043), but it was not associated with the clinical response to IFX and drug persistence (OR = 2.356, p = .145; OR = 0.457, p = .249). The endoscopic remission rates were 40.6% (13/32) and 55.4% (41/74) in HLA-DQA1*05 carriers and non-carriers, respectively. HLA-DQA1*05 was not associated with endoscopic remission (OR = 0.684, p = .414). The HLA-DQA1*05 variant is identified as a significant risk factor of ATI formation in Chinese patients with SB-CD, but is not associated with the clinical response of IFX treatment and endoscopic remission of SB lesions.

Electronic address: clinicalpractice@gastro.org. AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis

BACKGROUND & AIMS

This American Gastroenterological Association (AGA) living guideline is intended to support practitioners in the pharmacological management of moderate-to-severe ulcerative colitis (UC).

METHODS

A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations on the pharmacological management of moderate-to-severe UC.

RESULTS

The AGA guideline panel made 14 recommendations. In adult outpatients with moderate-to-severe UC, the AGA recommends the use of infliximab, golimumab, vedolizumab, tofacitinib, upadacitinib, ustekinumab, ozanimod, etrasimod, risankizumab, and guselkumab, and suggests the use of adalimumab, filgotinib, and mirikizumab over no treatment. In patients who are naïve to advanced therapies, the AGA suggests using a higher-efficacy medication (eg, infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, and guselkumab) or an intermediate-efficacy medication (eg, golimumab, ustekinumab, tofacitinib, filgotinib, and mirikizumab) rather than a lower-efficacy medication (eg, adalimumab). In patients who have previously been exposed to 1 or more advanced therapies, particularly tumor necrosis factor (TNF)-α antagonists, the AGA suggests using a higher-efficacy medication (eg, tofacitinib, upadacitinib, and ustekinumab) or an intermediate-efficacy medication (eg, filgotinib, mirikizumab, risankizumab, and guselkumab) rather than a lower-efficacy medication (eg, adalimumab, vedolizumab, ozanimod, and etrasimod). In adult outpatients with moderate-to-severe UC, the AGA suggests against using thiopurine monotherapy for induction of remission, but suggests using thiopurine monotherapy over no treatment for maintenance of (typically corticosteroid-induced) remission. The AGA suggests against using methotrexate monotherapy, for induction or maintenance of remission. In adult outpatients with moderate-to-severe UC, the AGA suggests the use of infliximab, adalimumab, and golimumab in combination with an immunomodulator over corresponding monotherapy. However, the AGA makes no recommendation in favor of, or against, the use of non-TNF antagonist biologics in combination with an immunomodulator over non-TNF biologic alone. In patients with UC who are in corticosteroid-free clinical remission for at least 6 months on combination therapy of TNF antagonists and an immunomodulator, the AGA suggests against withdrawal of TNF antagonists, but makes no recommendation in favor of, or against, withdrawing immunomodulators. In adult outpatients with moderate-to-severe UC, who have failed 5-aminosalicylates, and have escalated to therapy with immunomodulators or advanced therapies, the AGA suggests stopping 5-aminosalicylates. Finally, in adult outpatients with moderate-severe UC, the AGA suggests early use of advanced therapies and/or immunomodulator therapy, rather than gradual step-up after failure of 5-aminosalicylates. The panel also proposed key implementation considerations for optimal use of these medications and identified several knowledge gaps and areas for future research.

CONCLUSIONS

This guideline provides a comprehensive, patient-centered approach to the pharmacological management of patients with moderate-to-severe UC.

SARS-CoV-2 vaccination in inflammatory bowel disease patients is not associated with flares: a retrospective single-centre Swiss study

INTRODUCTION

Vaccination hesitancy is an important barrier to vaccination among IBD patients. The development of adverse events is the main concern reported. The purpose of this monocentric study was to assess SARS-CoV-2 vaccination safety in IBD patients by evaluating the postvaccination flare risk and incidence of overall adverse events.

METHODS

Surveys were handed out on three consecutive months to each patient presenting at the Crohn-Colitis Centre, where they documented their vaccination status and any side effects experienced after vaccination.Dates of flares occurring in 2021 were recorded from their electronic medical records. Baseline and IBD characteristics and flare incidence were compared between the vaccinated and unvaccinated patients, and among the vaccinated population before and after their vaccination doses. The characteristics of patients who developed side effects and of those who did not were compared.

RESULTS

We enrolled 396 IBD patients, of whom 91% were vaccinated. The proportion of patients who experienced flares was statistically not different between the vaccinated and the unvaccinated population (1.8 vs 2.6 flares per 100 person-months (p = 0.28)). Among vaccinated patients, there was no difference across the prevaccination, 1 month post any vaccination, and more than 1 month after any vaccination periods, and between the Spikevax and Cominarty subgroups. Overall, 46% of patients reported vaccination side effects, mostly mild flu-like symptoms.

CONCLUSION

SARS-CoV-2 vaccination with mRNA vaccines seems safe, with mostly mild side effects. The IBD flare risk is not increased in the month following any vaccination.

Impact of self-expanding metal stents on long-term survival outcomes as a bridge to surgery in patients with colon cancer obstruction: Current state and future prospects

Since self-expanding metal stents (SEMS) were first introduced in acute colon cancer obstruction, the increased rate of primary anastomosis and improved quality of life following SEMS placement have been clearly shown. However, it was demonstrated that SEMS are associated with higher recurrence rates. Although several trials have shown that overall and disease-free survival in patients following SEMS placement is similar with patients undergoing emergency surgery, obstruction and a high incidence of recurrence imposed many concerns. The optimal time interval from SEMS to surgery is still a matter of debate. Some studies have recommended a time interval of ~2 weeks between SEMS insertion and elective surgery. A prolonged interval of time from SEMS insertion to elective surgery and the administration of neoadjuvant chemotherapy (NAC) has been proposed. SEMS-NAC might have advantages for improving the surgical and long-term survival outcomes of patients with acute colon cancer obstruction, which is an optional approach in the management of acute colon cancer obstruction.

Standard Cannulation versus Fistulotomy for Biliary Access in Endoscopic Retrograde Cholangiopancreatography: Should We Expect the Same Success when Treating Choledocholithiasis?

Introduction

To access the common bile duct in endoscopic retrograde cholangiopancreatography (ERCP), needle-knife fistulotomy (NKF) can be associated with a shorter sphincterotomy compared to standard cannulation. We aimed to compare the success and safety of NKF versus standard cannulation in the treatment of choledocholithiasis.

Methods

A cohort of 379 naïve patients with choledocholithiasis who underwent ERCP between 2005 and 2022 was retrospectively analyzed. The patients were divided into two groups: group A (179 consecutive patients) underwent NKF, while group B (180 patients) received standard biliary access and were matched for stone characteristics and ERCP year.

Results

Stone removal success rate for group A was significantly lower than that for group B in the initial ERCP (82.0% vs. 92.1%, p = 0.003). In group A, success rates for stone removal were 90.2%, 80%, and 29.4% for stone sizes <10 mm, 10 mm-15 mm, and >15 mm, respectively (p < 0.001). In contrast, group B showed success rates of 99.2%, 81.5%, and 71.4% for the same stone size categories (p < 0.001). Pancreatitis occurred in 3.7% of group A and 5.8% of group B patients (p = 0.340). Regression analysis revealed that NKF cannulation, stone size (>10 mm), and having 4 or more stones were associated with lower stone removal success compared to standard cannulation in the initial ERCP (OR 0.34, p = 0.015; stone size 10-15 mm: OR 0.20, p < 0.001; stone size >15 mm: OR 0.05, p < 0.001; 4 or more stones: OR 0.4, p = 0.040).

Conclusions

The removal of common bile duct stones after NKF access, although safe and effective, is less successful than after a standard cannulation, especially at the baseline ERCP.

Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience

BACKGROUND AND AIMS

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree.

METHODS

A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes.

RESULTS

65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005).

CONCLUSIONS

ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

Medical Ethics and Informed Consent to Treatment: Past, Present and Future

It has been asserted that there was an erosion of medical ethics during the Covid-19 pandemic and a departure from the principle of obtaining fully informed consent from patients before treatment. In light of these assertions, this article reviews the historical development of medical ethics and the approach to obtaining informed consent and critiques the consent practices before and during the pandemic. It then describes a new tool for displaying key statistics on the benefits and risks of interventions to help explain them to patients and suggests a more rigorous process for seeking fully informed consent in the future.

Primary Needle-Knife Fistulotomy Versus Standard Transpapillary Technique for Cannulation of Long-Size Papilla: A Randomized Clinical Trial

INTRODUCTION

The morphology of the major papilla plays a crucial role in the selection of the cannulation method for the common bile duct during endoscopic retrograde cholangiopancreatography. Nevertheless, there is limited evidence available that compares the efficacy and safety of cannulation approaches in certain papilla morphologies. The aim of this study was to assess the safety and effectiveness of 2 cannulation methods, including primary needle-knife fistulotomy (pNKF) and standard transpapillary (STP), in patients with long-size papilla.

METHODS

A total of 260 patients with intact long-size papilla were enrolled and were randomly assigned to the pNKF or STP groups (n = 130 in each group). The primary endpoint was the rate of postendoscopic retrograde cholangiopancreatography pancreatitis. Biliary cannulation success rates, the duration of cannulation and the overall procedure, and the incidence of adverse events were also compared between the groups. All of the patients were hospitalized for at least 24 hours after the procedure.

RESULTS

A total of 125 (96.2%) patients in the pNKF and 114 (87.7%) patients in the STP groups had successful primary biliary cannulation ( P = 0.01) and were included in the final analysis. Postendoscopic retrograde cholangiopancreatography pancreatitis occurred in 11 patients in the STP group and 3 patients in the pNKF group (9.6% vs 2.4%, P = 0.02; number needed to treat [95% confidence interval] = 13.9 [7.5-83.2]). Moreover, compared with the pNKF, STP was associated with more cannulation attempts (3.4 vs 2.5, P < 0.001) and longer cannulation time (258 vs 187 seconds, P < 0.001).

DISCUSSION

In patients with long-size papilla, pNKF is a safer, easier, and more efficient approach to gain primary biliary access than the STP technique.

A rare case of appendiceal haemorrhage causing life-threatening haematochezia

Our case involved a 28-year-old man who presented with life-threatening haematochezia. Computed tomography angiogram revealed contrast extravasation from the appendix pooling in the caecum. Management via laparoscopic stapled partial caecectomy was successful. Histopathology revealed focal mild acute appendicitis with focal ulceration to submucosa.

Perception of the impact of intravenous biological treatment on the work and professional environment in patients with inflammatory bowel disease

INTRODUCTION

In the treatment of inflammatory bowel disease (IBD), we have biologic therapies administered intravenously and subcutaneously. Recently, some drugs can be administered by either of these routes. The real impact that intravenous administration has on the perception of the disease and the personal and work life of the patient is unknown.

METHODS

All IBD patients receiving intravenous infliximab treatment for at least 6 months were anonymously invited to participate. They were provided with a specific structured questionnaire with visual analogue scales (0-10) at two reference centers in the Barcelona area.

RESULTS

A total of 90 patients with a median age of 45 years (36-56) and a median infliximab treatment duration of 48 months (24-84) were included. The visit and therapy with infliximab in the day hospital were globally well evaluated (9, IQR 7-10). 78% of patients combined day hospital stays with other activities (26% employment). The personal impact was generally low (4, IQR 0-5.8), but the patient's job was threatened in 43% of patients on intensified treatment.

CONCLUSIONS

The intravenous administration of biologic drugs on an outpatient basis is highly satisfactory among IBD patients. The impact on the work sphere appears to be more pronounced than on the personal sphere, an aspect that should be considered in shared decision-making with the patient.

Mechanism of Xue-Jie-San treating Crohn's disease complicated by atherosclerosis: Network pharmacology, molecular docking and experimental validation

BACKGROUND

Crohn's disease (CD), as a chronic systemic inflammatory disease, is strongly associated with the development of premature atherosclerosis (AS). Atherosclerotic cardiovascular disease, including coronary heart disease, myocardial infarction and stroke, is a lethal complication of CD. Nowadays, there is a lack of effective monotherapy for CD complicated by AS.

PURPOSE

To explore the underlying effects and mechanisms of Xue-Jie-San (XJS) on treating CD complicated by AS via network pharmacology and experimental validation.

METHODS

The targets of XJS components were obtained from TCMSP, ETCM and PubChem databases as well as the disease genes of CD and AS from GeneCards, DisGeNET and OMIM databases. The core targets were screened out from the drug-disease common targets identified by protein-protein interaction (PPI) network analysis and then analyzed with GO and KEGG enrichment. The interaction between core target and XJS component was detected by molecular docking and molecular dynamics simulation. Subsequently, the core targets were validated via GEO datasets and their biological functions were confirmed in vitro. Nile red staining was used to evaluated lipid accumulation in human umbilical vein endothelial cells (HUVECs) challenged by lipopolysaccharide (LPS) combined with oxidized low-density lipoprotein (ox-LDL). Levels of pro-inflammatory cytokines were examined by enzyme-linked immunosorbent assay. Chemokine CCL2 and CXCL8 were detected by immunofluorescence staining. The activity of the TLR4/Myd88/NF-κB signaling pathway was assessed using Western blot.

RESULTS

In total, 26 common target genes of XJS, CD and AS were found. Among them, 11 core genes were identified by PPI network analysis. The effects of XJS treating CD complicated by AS were mainly mediated by the lipid and atherosclerosis pathway, inflammatory bowel disease pathway and toll-like receptor signaling pathway. Molecular docking and molecular dynamics simulation displayed strong binding affinity between XJS component and the core target. Six core genes including TLR4, IL-1β, TNF, ICAM1, CCL2 and CXCL8 were validated by GEO datasets. In vitro, the effects of XJS on reducing lipid accumulation, secretion of IL-1β, IL6, TNF-α, CCL2 and CXCL8, and the protein expressions of TLR4, Myd88, p-p65 and ICAM1 were verified.

CONCLUSION

XJS is a potential candidate drug for the treatment of CD complicated by AS. The underlying mechanisms involve mitigation of lipid accumulation-mediated endothelial dysfunction and blockage of immune inflammatory response by targeting TLR4.