Different effects of anti-TNF-alpha biologic drugs on the small bowel macroscopic inflammation in patients with ankylosing spondylitis

BACKGROUND & AIMS

Considering the ability of anti-TNF alpha drugs to lower the burden intestinal inflammation in patients with inflammatory bowel disease (IBD), and the similarity between IBD and ankylosing spondylitis (AS) regarding inflammatory intestinal involvement, we aimed to investigate the impact of anti-TNF alpha biologic therapy on subclinical intestinal inflammation in AS patients.

METHODS

Between January 2008 and December 2013, 38 AS patients and 23 controls were enrolled in the study and investigated with small bowel videocapsule endoscopy examination and ileocolonoscopy. Each tertile of the small bowel (proximal, mid and distal) was assessed by calculating the Lewis score based on the image stream.

RESULTS

The Lewis scores were significantly higher in the AS group compared to controls (580.9 ± 818 vs. 81 ± 121, p<0.001). 16 patients (42.1%) were on anti-TNF alpha therapy (Adalimumab (n = 5), Infliximab (n = 5) or Etanercept (n = 6)).31.3% of them used NSAIDs simultaneously, compared with 77.3% of the other patients (p<0.01). Their Lewis scores were lower compared to the other patients for the entire small bowel (306 ± 164 vs. 790 ± 1038, p = 0.015), its proximal and distal tertiles (238 ± 154 vs. 560 ± 543, p = 0.021, and 140 ± 189 vs. 300 ± 220, p = 0.027, respectively). The Lewis score was also lower in patients receiving Adalimumab/Infliximab compared to those on Etanercept for the entire bowel and its distal tertile (262 ± 165 vs. 380 ± 148, p = 0.069 and 62 ± 101 vs. 273 ± 236, p = 0.060, respectively).

CONCLUSION

Anti-TNF alpha therapy in patients with AS reduces the subclinical intestinal inflammation, but the magnitude seems to depend upon the class anti-TNF alpha agent used (Clinical Trials. gov NCT00768950).

Preparation regimen is more important than patient-related factors: a randomized trial comparing a standard bowel preparation before colonoscopy with an individualized approach

BACKGROUND

Optimal bowel preparation is one of the most important factors affecting the quality of colonoscopy. Several patient-related factors are known to influence the quality of bowel cleansing but randomized trials in this area are lacking. We aimed to compare an individualized bowel prep strategy based on patient characteristics to a standard preparation regimen.

MATERIAL AND METHODS

We conducted an endoscopist-blinded multicenter randomized control-trial. The Boston Bowel Prep Score (BBPS) was used to assess quality of bowel preparation and a 10 point visual analogue scale to assess patient comfort during bowel prep. Patients were randomised to either the standard regimens of split-dose 4L polyethylene-glycol (group A), split-dose sodium picosulphate/magnesium citrate (group B) or to either of the two depending on their responses to a 3-item questionnaire (individualized preparation, group C).

RESULTS

185 patients were randomized during the study period and 143 patients were included in the final analysis. Patients in the individualized group had a median BBPS of 7 compared to a median of 6 in the standard group (p = 0.7). Also, there was no significant difference in patients' comfort scores, irrespective of study group or laxative regimen. However, on multivariable analysis, a split-dose 4L polyethylene-glycol was an independent predictor for achieving a BBPS>6 (OR 3.7, 95% CI 1.4-9.8), regardless of patient-related factors.

CONCLUSION

The choice of laxative seems to be more important than patient-related factors in predicting bowel cleansing. Comfort during bowel prep is not influenced by the type of strategy used.

Density of Tryptase-Positive Mast Cells Correlated with the Presence of H. pylori in Gastric Neoplasia

BACKGROUND

Gastric cancer continues to be a platoon leader of mortality causes. A significant number of recent studies show direct or indirect involvement of mast cells (MC), with a complex role both pro- and anti-tumor growth.

AIM

To objectify the correlations between expression of MC and presence of Helicobacter pylori (HP) infection depending on neoplastic nature of the gastric damage.

SUBJECTS AND METHODS

The study was carried out on archival samples of gastric wall from 30 patients with gastric cancer versus 30 age and sex-matched subjects with gastric surgery for non-neoplastic diseases. The inclusion criteria for the case group were histologically proven stage T3/T4 malignancies with regional lymph node metastases. For each case of the study group, distribution and number of MC tryptase positive (DMC-TP) were analyzed in five different areas from the same gastrectomy specimen: intratumor area, deep and side tumor invasion front, normal gastric tissue sample 5-10 cm or more distant from the tumor and furthest resection margin.

RESULTS

Independently of HP infection, the study recorded a significantly lower value of DMC-TP in male patients. In regions with inflammatory lesions and preneoplastic changes and in control cases with non-gastric neoplasia, the DMC-TP level was higher than controls with HP-related inflammatory pathology, thus removing bacterial etiology from the forefront of MC mobilizing causes.

CONCLUSION

The presence of H. pylori infection was not found to cause significant changes in terms of mobilizing mast cells in the gastric wall with advanced tumors, with minimal stage III TNM.

Rapid fecal calprotectin testing predicts mucosal healing better than C-reactive protein and serum tumor necrosis factor α in patients with ulcerative colitis

Background and Aims. Serum and fecal biomarkers have been used as noninvasive methods for assessing disease activity in ulcerative colitis. C-reactive protein, serum tumor necrosis factor-α and fecal calprotectin are among the most promising such biomarkers. However, their role in the management of ulcerative colitis patients remains to be clarified. We aimed to evaluate the accuracy of C-reactive protein, fecal calprotectin and tumor necrosis factor-α in detecting clinical and endoscopic activity and predicting disease outcome.

Methods. A cohort of ulcerative colitis patients was prospectively evaluated for clinical and endoscopic disease activity using the Mayo score. Serum C-reactive protein and tumor necrosis factor-α levels were measured and a point-of-care method was used for determining Calprotectin levels.

Results. Fifty-three patients with ulcerative colitis were followed for a median of 12 months. Fecal calprotectin and C-reactive protein levels were significantly higher in patients with clinically active disease at baseline, but only calprotectin levels correlated with endoscopic activity. Calprotectin values over 300 μg/g had 60% sensitivity and 90% specificity for detecting active endoscopic disease and 61% sensitivity and 89% specificity for predicting mucosal healing.

Conclusion. Rapid calprotectin testing is a better predictor of mucosal healing than serum biomarkers and it could improve the management of ulcerative colitis patients by decreasing the need for invasive investigations.

Factors Influencing Complication Rates at Colonic Polypectomy: A Prospective Study from a Tertiary-Referral Center

BACKGROUND AND AIMS

Colon polypectomy decreases the incidence of colorectal cancer and related mortality. Several factors such as the size, location and type of polyp as well as endoscopist experience have been shown to correlate with the risk of ensuing procedure-related complications. This study aims to evaluate the impact of polyp and endoscopist-related factors on the rate of postpolypectomy complication in a real-life setting.

METHODS

During the study period all polypectomies performed in our unit were reported on a standard form that included data on polyp type (flat, sessile, pedunculated), size, location in the colon, resection method, endoscopist volume and procedure-related complications arising up to 30 days. The main outcome was the complication rate of polypectomies. The factors that associated with a higher risk of complications were assessed on univariate and multivariate analysis.

RESULTS

244 polyp resections from 95 patients were included in the analysis. 199 polyps were resected by low-volume endoscopists (44.7%) and 135 polypectomies were performed by high-volume endoscopists (55.3%). On multivariate analysis only polyp size correlated with the risk of procedure-related complications.

CONCLUSION

Polyp size is the most important risk factor for procedure-related complications. Both high and low-volume endoscopists have a low overall rate of serious complications.

Factors affecting colonoscopy comfort and compliance: a questionnaire based multicenter study

AIMS

Colonoscopy screening reduces colorectal cancer-related mortality and incidence. However, many patients are reluctant to undergo colonoscopy or return for follow-up because of the investigation's cumbersome and unpleasant nature. We aimed to identify patient-related factors significantly influencing comfort and quality of colonoscopy analyzing responses to a self-administered validated questionnaire.

METHODS

Patients undergoing colonoscopy under sedation in two high-volume endoscopy units were invited to answer a short prevalidated questionnaire regarding preprocedure anxiety, satisfaction with information provided, most worrisome aspect of the procedure and knowledge of the benefits of colonoscopy. Self-reported comfort during colonoscopy as graded on a 10 point visual analog scale was the main variable considered. Univariate analysis identified factors possibly associated with a higher degree of comfort during colonoscopy that were then tested through multivariate logistical regression.

RESULTS

452 questionnaires were returned. Most patients reported an acceptable degree of discomfort during colonoscopy but 70.2% of the respondents considered the information provided prior to the procedure to be insufficient. On multivariate analysis older age, higher degree of satisfaction with information provided (p = 0.04), lower preprocedure anxiety levels (p < 0.01) and endoscopy center (p < 0.01) were shown to correlate with increased comfort during colonoscopy. Education level, previous colonoscopy, gender and bowel prep quality did not influence patient comfort.

CONCLUSIONS

Patient comfort during colonoscopy is dependent on satisfaction with the information provided before the procedure. Higher availability of the physician and better interaction with the patient might decrease patient perceived burden of colonoscopy and lead to higher return rates in the screening and surveillance setting.

Biological therapies in moderate and severe psoriasis: perspectives and certainties

An inflammatory, proliferative condition with chronic evolution and systemic response, psoriasis, is positioned today among the most common inflammatory skin diseases affecting the Caucasian population worldwide. With a significant incidence, psoriasis has been increasingly defined as a disease with a major impact on the patient's life and the society to which he/she belongs. This paper conducts an analysis of the currently available therapies for the treatment of moderate and severe psoriasis, therapies with biological agents obtained through sophisticated genetic engineering technologies. Recent research and the increasing interest in therapeutic methods as complete and efficient as possible make us optimistic and confident in the future.

Polyp and endoscopist-related factors influencing complication rates in difficult colonic polypectomies: results of a multicenter observational study

BACKGROUND

Current polypectomy practices are highly variable. Endoscopists report increased size, nonpolypoid lesion type and unfavorable position as characteristic of difficult polypectomies. We studied reported difficult colonic polypectomies to determine polyp-related and operator-dependent factors influencing complication rates.

PATIENTS AND METHODS

We conducted an international multicenter observational prospective study of difficult colonic polypectomies. Endoscopists reported difficult cases of colonic polypectomies, techniques and complication rates. Per-polyp and per-endoscopist analyses were performed.

RESULTS

Ninety procedures were reported at 4 participating centers by 19 endoscopists. 43% of the lesions were pedunculated, 39% were sessile and 18% were flat. Lesion size ranged between 5-60 mm. Bleeding occurred in 18 out of 90 procedures (17 immediate, 1 delayed); no perforations were reported. Bleeding rate was independent of patient age or sex, polyp type, size and histology or resection method. Procedures were deemed difficult due to polyp size (37/90), unfavorable position (23/90), bleeding risk (12/90), lesion type (12/90) or other reasons (6/90) with no statistically significant difference between expert and beginner endoscopists (p = 0.14).

CONCLUSION

Difficult colonic polypectomies are unpredictable with a complication rate independent of polyp type or size. There was no difference between experts and beginners with regard to technical aspects of resection or complication rates.

Early virological response in 1220 patients with HCV (genotype lb) chronic hepatitis and cirrhosis treated with PegInterferon plus Ribavirin

There are over 5000 patients with genotype 1b HCV chronic infection in Romania on national waiting lists. This allowed us to evaluate the complete and partial early virological response rates (EVRc and EVRp), as well as the factors influencing the response rates to treatment.

PATIENTS

We studied 1220 treatment naive patients with HCV chronic hepatitis who started antiviral therapy during 2009. Mean age was 48 years and female gender was predominant (58%). Chronic hepatitis was documented by liver biopsy in 1129 patients (93%) or by non-invasive tests in 91 cases (7%). Most patients presented advanced liver disease (F3 + F4 Metavir = 62.3%). Viral load was over 400000 iu/mL in 61% patients and over 600000 iu/mL in 52% patients. Treatment was performed with peginterferon alpha-2a in 75.2% patients and with peginterferon alpha-2b in 24.8% patients, with comparative histology. The influence of histology, viral load, gender, age and type of peginterferon on the response rates to treatment was evaluated.

RESULTS

EVRc was obtained in 76.6% patients, while 16.2% presented EVRp. From those with EVRp, 78.8% had undetectable viral load after 6 months of therapy. The nonresponder rate was 9.6%. EVRc was influenced by viral load and age, but not by fibrosis stage or type of interferon.

CONCLUSIONS

We noticed a high rate of EVRc, which was not influenced by histology, gender or type of interferon. The number of nonresponders and of patients who interrupted therapy due to lack of compliance or adverse events was low.

Helicobacter pylori: pathological mechanism involved in gastric colonization

Since 1982, when Marshall and Warren highlighted the presence of H. pylori at the apical pole of the epithelial gastric cells, the medical literature has registered a cascade of subsequent researches concerning this amazing bacterium, its action on the human body and the body response. The apogee of these studies and conclusions about the pathogenic role of HP was touched with its certain recognition as class one carcinogenic agent (Peura 1997, WHO), becoming the first bacteria with such an action. The data gathered in the last period identify different virulence factors of HP, but fail to fully explain the relatively low incidence of gastric cancer in HP carriers; therefore, it is now considered that the carcinogenic potential related to HP infection in humans is due to the synergic and complementary association of the bacterial genetic equipment with diet and host response.