Real-Life Efficacy of Tofacitinib in Various Situations in Ulcerative Colitis: A Retrospective Worldwide Multicenter Collaborative Study

BACKGROUND AND AIMS

Tofacitinib (TFB) appears to be effective in the treatment of ulcerative colitis (UC); however, available real-world studies are limited by cohort size. TFB could be an option in the treatment of acute severe ulcerative colitis (ASUC). We aimed to investigate efficacy and safety of TFB in moderate-to-severe colitis and ASUC.

METHODS

This retrospective, international cohort study enrolling UC patients with ≥6-week follow-up period was conducted from February 1 to July 31, 2022. Indications were categorized as ASUC and chronic activity (CA). Baseline demographic and clinical data were obtained. Steroid-free remission (SFR), colectomy, and safety data were analyzed.

RESULTS

A total of 391 UC patients (median age 38 [interquartile range, 28-47] years; follow-up period 26 [interquartile range, 14-52] weeks) were included. A total of 27.1% received TFB in ASUC. SFR rates were 23.7% (ASUC: 26.0%, CA: 22.8%) at week 12 and 41.1% (ASUC: 34.2%, CA: 43.5%) at week 52. The baseline partial Mayo score (odds ratio [OR], 0.850; P = .006) was negatively associated with week 12 SFR, while biologic-naïve patients (OR, 2.078; P = .04) more likely achieved week 52 SFR. The colectomy rate at week 52 was higher in ASUC group (17.6% vs 5.7%; P < .001) and decreased with age (OR, 0.94; P = .013). A total of 67 adverse events were reported, and 17.9% resulted in cessation of TFB. One case of thromboembolic event was reported.

CONCLUSIONS

TFB is effective in both studied indications. TFB treatment resulted in high rates of SFR in the short and long terms. Higher baseline disease activity and previous biological therapies decreased efficacy. No new adverse event signals were found.

Long-term outcomes after endoscopic removal of malignant colorectal polyps: Results from a 10-year cohort

BACKGROUND

Choosing an optimal post-polypectomy management strategy of malignant colorectal polyps is challenging, and evidence regarding a surveillance-only strategy is limited.

AIM

To evaluate long-term outcomes after endoscopic removal of malignant colorectal polyps.

METHODS

A single-center retrospective cohort study was conducted to evaluate outcomes after endoscopic removal of malignant colorectal polyps between 2010 and 2020. Residual disease rate and nodal metastases after secondary surgery and local and distant recurrence rate for those with at least 1 year of follow-up were investigated. Event rates for categorical variables and means for continuous variables with 95% confidence intervals were calculated, and Fisher's exact test and Mann-Whitney test were performed. Potential risk factors of adverse outcomes were determined with univariate and multivariate logistic regression models.

RESULTS

In total, 135 lesions (mean size: 22.1 mm; location: 42% rectal) from 129 patients (mean age: 67.7 years; 56% male) were enrolled. The proportion of pedunculated and non-pedunculated lesions was similar, with en bloc resection in 82% and 47% of lesions, respectively. Tumor differentiation, distance from resection margins, depth of submucosal invasion, lymphovascular invasion, and budding were reported at 89.6%, 45.2%, 58.5%, 31.9%, and 25.2%, respectively. Residual tumor was found in 10 patients, and nodal metastasis was found in 4 of 41 patients who underwent secondary surgical resection. Univariate analysis identified piecemeal resection as a risk factor for residual malignancy (odds ratio: 1.74; P = 0.042). At least 1 year of follow-up was available for 117 lesions from 111 patients (mean follow-up period: 5.59 years). Overall, 54%, 30%, 30%, 11%, and 16% of patients presented at the 1-year, 3-year, 5-year, 7-year, and 9-10-year surveillance examinations. Adverse outcomes occurred in 9.0% (local recurrence and dissemination in 4 patients and 9 patients, respectively), with no difference between patients undergoing secondary surgery and surveillance only.

CONCLUSION

Reporting of histological features and adherence to surveillance colonoscopy needs improvement. Long-term adverse outcome rates might be higher than previously reported, irrespective of whether secondary surgery was performed.

Accuracy of the Pancolonic Modified Mayo Score in predicting the long-term outcomes of ulcerative colitis: a promising scoring system

Background

Different endoscopic scoring systems for assessing ulcerative colitis (UC) severity are available. However, most of them are not correlated with disease extent.

Objectives

Our study aimed to compare the predictive value of the PanMay score versus the endoscopic Mayo (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), and Dublin score in predicting long-term outcomes of UC.

Design

This retrospective study enrolled consecutive UC patients who underwent colonoscopy before at least a 3-year follow-up.

Methods

The PanMayo, MES, UCEIS, and Dublin scores and the baseline clinical and demographic characteristics of the participants were assessed. Endpoints were disease flare that required novel biological therapy, colectomy, and hospitalization. Patients were stratified using baseline clinical activity.

Results

Approximately 62.8% of the 250 enrolled patients were in clinical remission. In these patients, the PanMayo, MES, and Dublin scores were positively associated with the risk of clinical flare. The MES score increased with clinical flare. The PanMayo score (>12 points), but not the MES score, was associated with the need for novel biological initiation and biological escalation. Furthermore, the Dublin and UCEIS scores of patients in remission who need novel biological treatment had a similar trend. Colectomy risk was associated with PanMayo and Dublin scores.

Conclusion

The combined endoscopic assessment of disease extent and severity can be more accurate in predicting outcomes among patients with UC. PanMayo score can be utilized in addition to the existing scoring systems, thereby leading to a more accurate examination.

Summary

UC endoscopic scores do not assess extension. Our study aimed to analyze the predictive value of the PanMayo score. Based on 250 patients, results showed that the long-term disease outcomes of UC could be predicted with the PanMayo score more accurately.

[Analysis of efficacy and safety of colonoscopic screening program at the University of Szeged and the Bács-Kiskun County Teaching Hospital between 2019 and 2022]

Bevezetés: Magyarországon 2019-ben indult az 50–70 éves populáció körében a kétlépcsős vastagbélszűrő program, melynek célja a colorectalis carcinoma kialakulásának megelőzése. Célkitűzés: Kutatásunk célja volt a Szegedi Tudományegyetemen és a Bács-Kiskun Vármegyei Oktatókórházban a szűrőprogram keretein belül végzett kolonoszkópiák minőségi mutatóinak és kimeneteli indikátorainak, valamint a betegbiztonságnak a vizsgálata a magyar szakmai ajánlás tükrében. Módszerek: Intervencióval nem járó, obszervációs kohorszvizsgálatunkban az adatgyűjtés során felhasználtuk a Nemzeti Népegészségügyi és Gyógyszerészeti Központ által működtetett regiszter prospektív adatait, melyeket retrospektíven kiegészítettünk az egészségügyi nyilvántartási rendszer segítségével. Eredmények: Összesen 1739 szűrő kolonoszkópiára (átlagéletkor 62,36 ± 5,86 év, férfiarány 56,81%) került sor 97,07%-os coecumintubációs arány mellett. A béltisztaság az esetek 90,28%-ában megfelelő volt, ezen belül az esetek 63,31%-ában kiváló. Az eszközvisszahúzási időről 1397 komplett kolonoszkópia esetén volt adat, mely 96,35%-ban meghaladta az irányelv által javasolt 6 percet, átlagos hossza 9,51 ± 5,76 perc volt. Szedációt a páciensek 40,37%-a igényelt, melynek során 92,02%-ban midazolámot alkalmaztak. A kolonoszkópiák 62,51%-ában találtak neoplasztikus és 27,03%-ában csak nem neoplasztikus laesiót. Összesen 2879 polipot találtak 1064 páciensnél (polipfelismerési arány 61,18%), melyek közül a legrelevánsabbnak a mérete az esetek 39,38%-ában meghaladta az 1 cm-t, és 72,97%-a a bal colonfélben helyezkedett el. A páciensek 98,97%-a az index- és komplettáló kolonoszkópiák során polipmentessé vált. Adenoma 871 esetben igazolódott, ez 50,09%-os adenomafelismerési arányt jelent. Colorectalis carcinomát 80 páciensnél (4,60%) fedeztek fel. Szövődmény 10 főnél (0,58%) lépett fel, beavatkozással összefüggő halálozás nem következett be. Tisztázó gasztroszkópia a negatív eredményű kolonoszkópiák 24,08%-ában történt, ezek során 1 főnél nyelőcső-laphámcarcinoma igazolódott. Az utánkövetési időszakban 114 páciensnél (6,56%) történt ismételt kolonoszkópia, melynek során intervallum colorectalis carcinomát 1 esetben (0,06%) találtak. Következtetés: A kutatás során vizsgált két centrumban végzett szűrő kolonoszkópiák megfeleltek a magyar irányelvben meghatározott minőségi és kimeneteli mutatóknak, valamint betegbiztonsági szempontoknak. Ugyanakkor a regiszterbe történő adatbevitel és a negatív kolonoszkópiákat követő tisztázó gasztroszkópiák aránya korrekcióra szorul. Orv Hetil. 2024; 165(6): 221–231.

Risk Factors and Interpretation of Inconclusive Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology in the Diagnosis of Solid Pancreatic Lesions

BACKGROUND

The inconclusive cytological findings of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) remain a major clinical challenge and often lead to treatment delays.

METHODS

Patients who had undergone EUS-FNA sampling for solid pancreas lesions between 2014 and 2021 were retrospectively enrolled. The "atypical" and "non-diagnostic" categories of the Papanicolaou Society of Cytopathology System were considered inconclusive and the "negative for malignancy" category of malignancy was suspected clinically. We determined the frequency and predictors of inconclusive cytological finding.

RESULTS

A total of 473 first EUS-FNA samples were included, of which 108 cases (22.83%) were inconclusive. Significant increases in the odds of inconclusive cytological findings were observed for lesions with a benign final diagnosis (OR 11.20; 95% CI 6.56-19.54, p < 0.001) as well as with the use of 25 G FNA needles (OR 2.12; 95% CI 1.09-4.01, p = 0.023) compared to 22 G needles. Furthermore, the use of a single EUS-FNA technique compared to the combined use of slow-pull and standard suction techniques (OR 1.70; 95% CI 1.06-2.70, p = 0.027) and less than three punctures per procedure led to an elevation in the risk of inconclusive cytology (OR 2.49; 95% CI 1.49-4.14, p < 0.001). Risk reduction in inconclusive cytology findings was observed in lesions between 2-4 cm (OR 0.40; 95% CI 0.23-0.68, p = 0.001) and >4 cm (OR 0.16; 95% CI 0.08-0.31, p < 0.001) compared to lesions ≤2 cm.

CONCLUSIONS

The more than two punctures per EUS-FNA sampling with larger-diameter needle (19 G or 22 G) using the slow-pull and standard suction techniques in combination may decrease the probability of inconclusive cytological findings.

[Endoscopic ultrasound in the lower gastrointestinal tract]

Endoscopic ultrasound is a minimally invasive modality that combines endoscopy with ultrasound, providing a possibility to visualize the wall of the gastrointestinal tract and adjacent tissues and organs. Since the development of the modality in the 1980s, advancements in endoscopic ultrasound technology have led to increasingly broadening indications: besides diagnostic indications, therapeutic indications have also expanded greatly. According to recent guidelines regarding rectal cancer staging, rectal ultrasonography is mainly considered to be a secondary imaging modality compared to magnetic resonance imaging. With the use of forward-viewing echoendoscopes and ultrasound miniprobes that can be inserted through the working channel of the endoscope, endoscopic ultrasound technology can be expanded to proximal, colonic areas as well. Rectal ultrasonography can also play an important role in the differential diagnosis of subepithelial lesions, in the detection of rectal varices, in the diagnosis of inflammatory bowel diseases as well as perianal complications. Diagnostic accuracy can further be improved with the addition of ultrasound-guided sampling in certain cases. Currently, therapeutic indications are more like promising possibilities, than part of everyday clinical practice, but this might change in the near future. The purpose of this review is to summarize the current indications of rectal ultrasound in the clinical practice, including diagnostic and therapeutic ones as well. Orv Hetil. 2023; 164(30): 1176-1186.

Nationwide experiences with trough levels, durability, and disease activity among inflammatory bowel disease patients following COVID-19 vaccination

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has complicated the management of inflammatory bowel diseases (IBD).

Objectives

This study aimed to assess the efficacy of different anti-SARS-CoV-2 vaccines under different treatments in IBD patients and identify predictive factors associated with lower serological response, including anti-tumor necrosis factor (anti-TNF) drug levels.

Design

A prospective, double-center study of IBD patients was conducted following messenger ribonucleotide acid (mRNA) and non-mRNA anti-SARS-CoV-2 vaccination.

Methods

Healthy control (HC) patients were enrolled to reduce bias. Baseline and control samples were obtained 14 days after the second dose to assess the impact of conventional and biological treatments. Clinical and biochemical activity, serological response level, and anti-TNF drug levels were measured.

Results

This study included 199 IBD (mean age, 40.9 ± 12.72 years) and 77 HC participants (mean age, 50.3 ± 12.36 years). Most patients (76.9%) and all HCs received mRNA vaccines. Half of the IBD patients were on biological treatment (anti-TNF 68.7%). Biological and thiopurine combined immunomodulation and biological treatment were associated with lower serological response (p < 0.001), and mRNA vaccination promoted better antibody levels (p < 0.001). Higher adalimumab levels caused lower serological response (p = 0.006). W8 persistence of anti-SARS-CoV-2 level was equal in IBD and HC groups. Vaccination did not aggravate clinical disease activity (p = 0.65).

Conclusion

Anti-SARS-CoV-2 vaccination is considerably efficacious in IBD patients, with mRNA vaccines promoting better antibody levels. The negative impact of combined biological treatment, especially with high adalimumab drug levels, on serological response to vaccination should be considered. Although midterm durability of vaccination is encouraging, more data are needed to expand the existing understanding on this issue.

Self-reported efficacy and safety of infliximab and adalimumab biosimilars after non-medical switch in patients with inflammatory bowel disease: results of a multicenter survey

BACKGROUND

Few data are available on subjective disease control and perception of adverse events (AEs) during switching from original anti-TNF agents to biosimilars.

RESEARCH DESIGN AND METHODS

Hungarian patients with inflammatory bowel disease were interviewed after a mandatory non-medical switch from an infliximab (IFX) originator to a biosimilar GP1111 or from an adalimumab (ADA) originator to a biosimilar GP2017. Drug choice was based on patient's and physician's decision. Subjective efficacy was measured using a 10-point scale, and AEs were assessed. Difference in efficacy before and after the switch was compared within and between the drugs.

RESULTS

Seventy-three ADA and 106 IFX switching patients were interviewed. Subjective efficacy of IFX biosimilar was rated lower compared to IFX originator (8.72 ± 1.68 vs. 7.77 ± 2.34; p = 0.001). The ADA biosimilar was rated higher than its originator (9.02 ± 1.61 vs. 8.42 ± 1.93; p = 0.017). Patients receiving ADA biosimilar were more satisfied with the new treatment compared to IFX (p = 0.032). The incidence of new AEs was 85% in the ADA and 55% in the IFX group (1.79 vs. 0.93 AEs per patient, respectively, p < 0.001).

CONCLUSION

Subjective efficacy of switching to a biosimilar was proven in case of ADA, while reduced efficacy was experienced with IFX biosimilar. Perception of AEs was high and varied between biosimilars.

Effects of bowel cleansing on the composition of the gut microbiota in inflammatory bowel disease patients and healthy controls

Background

In patients with inflammatory bowel disease (IBD), Crohn's disease (CD), and ulcerative colitis (UC), numerous cases of exacerbations could be observed after colonoscopy, raising the possible pathogenetic effect of colonic microbiota alterations in IBD flare.

Objectives

We aimed to investigate the changes in the fecal microbiota composition in IBD patients influenced by the bowel preparation with sodium picosulfate.

Design

We enrolled patients with IBD undergoing bowel preparation for colonoscopy in the prospective cohort study. The control group (Con) comprised non-IBD patients who underwent colonoscopy. Clinical data, blood, and stool samples were collected before colonoscopy (timepoint A), 3 days later (timepoint B), and 4 weeks later (timepoint C).

Methods

Disease activity and gut microbiota changes were assessed at each timepoint. Fecal microbiota structure - at family level - was determined by sequencing the V4 region of the 16S rRNA gene. Statistical analysis included differential abundance analysis and Mann-Whitney tests.

Results

Forty-one patients (9 CD, 13 UC, and 19 Con) were included. After bowel preparation, alpha diversity was lower in the CD group than in the UC (p = 0.01) and Con (p = 0.02) groups at timepoint B. Alpha diversity was significantly higher in the UC group than in the CD and Con (p = 0.03) groups at timepoint C. Beta diversity difference differed between the IBD and Con (p = 0.001) groups. Based on the differential abundance analysis, the Clostridiales family was increased, whereas the Bifidobacteriaceae family was decreased in CD patients compared to the Con at timepoint B.

Conclusions

Bowel preparation may change the fecal microbial composition in IBD patients, which may have a potential role in disease exacerbation after bowel cleansing.

[Cholangitis and cholecystitis: diagnostic criteria and management]

In developed countries, diseases of the gallbladder and the biliary tract count as some of the most frequent gastrointestinal disorders. The inflammation of the gallbladder/biliary tree is a potentially severe, even lethal condition that requires rapid diagnosis and early multidisciplinary approach to be treated. Although the frequency of these diseases is high, the treatment is not unified in Hungary yet. The aim of the evidence-based recommendation is to clarify the diagnostic criteria and severity grading of these diseases and to highlight the indications and rules of proper application of the numerous available therapeutic interventions. The recent guideline is based on the consensus of the Board members of the Endoscopic Section of the Hungarian Gastroenterology Society in contribution with renown experts of surgery, infectology as well as interventional radiology and it counts as a clear and easy applicable guide during the all-day healthcare practice. Our guidelines are based on Tokyo guidelines established on the basis of the consensus reached in the International Consensus Meeting held in Tokyo which were revised in 2013 (TG13) and in 2018 (TG18). Orv Hetil. 2023; 164(20): 770-787.

Conception and reality: Outcome of SARS-CoV-2 infection and vaccination among Hungarian IBD patients on biologic treatments

Introduction

Inflammatory bowel disease potentially elevates the risk of infections, independently from age, while the disease activity and medical treatment(s) can also increase the risks. Nevertheless, it is necessary to clarify these preconceptions as well during the COVID-19 pandemic.

Methods

An observational, questionnaire based study was conducted in Hungary between February and August 2021. 2 questionnaires were completed. The first questionnaire surveyed the impact of the pandemic on patients with biologic treatments and assessed the severity and outcome of the infection, whereas the second one assessed vaccination rate and adverse events.

Results

472 patients participated in the study. 16.9 % of them acquired the infection and 6.3 % needed hospitalization. None of them required ICU care. Male sex elevated the risk of infection (p = 0.008), while glove (p = 0.02) and mask wearing (p = 0.005) was the most effective prevention strategy. Nevertheless, abstaining from community visits or workplace did not have an impact on the infection rate. Smoking, age, and disease type did not elevate the risk. UC patients had poorer condition during the infection (p = 0.003); furthermore, the disease activity could potentially worsen the course of infection (p = 0.072). The different biological treatments were equally safe; no difference was observed in the infection rate, course of COVID-19. Azathioprine and corticosteroids did not elevate the infection rate. 28 patients (35.0 %) suspended the ongoing biologic treatment, but it had no impact on the disease course. However, it resulted in changing the current treatment (p = 0.004). 9.8 % of the respondents were sceptic about being vaccinated, and 90 % got vaccinated. In one case, a serious flare-up occurred.

Discussion

Most patients acquired the infection at workplace. Biologic therapies had no effect on the COVID-19 infection, whereas male sex, an active disease, and UC could be larger threat than treatments. Vaccination was proved to be safe, and patient education is important to achieve mass vaccination of the population.

Comparison of therapeutic efficacy and treatment costs of self-expandable metal stents and plastic stents for management of malignant biliary obstruction

BACKGROUND

According to the European Society of Gastrointestinal Endoscopy guidelines, self-expandable metal stents (SEMSs) are preferable to plastic stents (PSs) in the management of pancreatic cancer, regardless of cancer stage. The aim of this study was to compare the therapeutic efficacy and treatment costs of SEMS and PS in the management of malignant biliary obstruction.

METHODS

One hundred and thirty-five patients who underwent endoscopic stent placement were retrospectively enrolled and divided into PS (41 patients), primary SEMS (39 patients) and secondary SEMS (55 patients) groups. We determined the technical and functional success rate, stent patency, and cumulative treatment cost.

RESULTS

A total of 111 SEMSs and 153 PSs were placed with similar technical (100% vs. 98.69%) and functional success rate (90.10% vs. 86.27%) but with different stent patency (10.28 vs. 22.16 weeks; p < 0.001). Multiple PS implantations and larger stent diameter increased the length of stent patency compared to 7-Fr PSs (10.88 vs. 10.55 vs. 7.63 weeks, respectively). The cumulative treatment cost of patients with different survival times did not differ significantly between groups, however, among patients surviving 2-4 months it was higher in PS group than primary SEMS and secondary SEMS groups (2888€ vs. 2258€ vs. 2144€, respectively, p = 0.3369) due to increased number of biliary reintervention (2.08 ± 1.04 vs. 1.20 ± 0.42 vs. 1.50 ± 0.53; p < 0.0274) and longer hospital stay (15.77 ± 10.14 vs. 8.70 ± 7.70 vs. 8.50 ± 6.17 days, p = 0.0527).

CONCLUSIONS

In view of treatment costs, the consequences of illness, and the processes of the health care system, SEMS implantation is recommended regardless of patients' life expectancy.

The use of ultrasound in colonic and perianal diseases

PURPOSE OF REVIEW

To revise recent literature findings regarding the use of ultrasound in colonic and perianal diseases by focusing particularly on its feasibility in inflammatory bowel diseases (IBD), colorectal neoplastic lesions, and perineal diseases, with further highlight on interventional capabilities.

RECENT FINDINGS

Treat-to-target approach in IBD raised an interest in intestinal ultrasound (IUS) for monitoring bowel activity considering its noninvasive nature, low costs, and well tolerability. New IUS indices have been developed with ever better methodologies and are at various stage of validation. A standardized over-the-wire technique for colonic US using a flexible overtube enables endoscopic ultrasound (EUS)-guided tissue sampling beyond the rectum, and forward-viewing radial-array echoendoscopes can assist identification of early neoplastic lesions in proximal colon. Intraoperative ultrasound and contrast-enhanced ultrasound carry an additional diagnostic value compared to conventional preoperative imaging modalities in detecting colorectal cancer liver metastases (CRLM).

SUMMARY

The feasibility of IUS in monitoring IBD activity is supported by growing evidence, but uniform IUS indices are still lacking. Recent advancements in EUS are expanding capabilities for determining depth of invasion of colorectal neoplasms, tissue sampling, and EUS-guided interventions to the entire colon. Ultrasonography can be a valuable tool in CRLM diagnostics as well.

Possible genetical predictors of efficacy and safety of budesonide-MMX in patients with mild-to-moderate ulcerative colitis, and safety comparison with methylprednisolone

BACKGROUND

Budesonide-MMX is a topically active corticosteroid degraded by cytochrome-P450 enzymes, resulting in favorable side-effect profile. We aimed to assess the effect of CYP genotypes on safety and efficacy, and make a direct comparison with systemic corticosteroids.

RESEARCH DESIGN AND METHODS

We enrolled UC patients receiving budesonide-MMX and IBD patients on methylprednisolone in our prospective, observational-cohort study. Before and after treatment regimen clinical activity indexes, laboratory parameters (electrolytes, CRP, cholesterol, triglyceride, dehydroepiandrosterone, cortisol, beta-crosslaps, osteocalcin), and body composition measurements were assessed. CYP3A4 and CYP3A5 genotypes were determined in the budesonide-MMX group.

RESULTS

71 participants were enrolled (budesonide-MMX: 52; methylprednisolone: 19). CAI decreased (p<0.05) in both groups. Cortisol decreased (p<0.001), and the level of cholesterol was elevated in both groups (p<0.001). Body composition altered only following methylprednisolone. Bone homeostasis (osteocalcin; p<0.05) and DHEA (p<0.001) changed more prominently after methylprednisolone. Glucocorticoid-related adverse events were more common following methylprednisolone treatment (47.4% compared to 1.9%). CYP3A5(*1/*3) genotype positively influenced efficacy, but not safety. Only one patient's CYP3A4 genotype differed.

CONCLUSIONS

CYP genotypes can affect the efficacy of budesonide-MMX; however, further studies would be needed with analyses of gene expression. Although budesonide-MMX is safer than methylprednisolone, due to glucocorticoid-related side effects, admission should require greater precaution.

Ustekinumab is associated with superior treatment persistence but not with higher remission rates versus vedolizumab in patients with refractory Crohn's disease: results from a multicentre cohort study

BACKGROUND

Treatment with antitumor necrosis factor alpha (anti-TNF-α) is safe and effective as first-line therapy; however, its efficacy is limited due to primary nonresponse (PNR) and secondary loss of response (LOR), resulting in treatment discontinuation in approximately 40%-50% of cases. Vedolizumab (VDZ) and ustekinumab (UST) therapies could be good alternatives in patient with anti-TNF failure; however, no head-to-head randomized comparison of these drugs as second- or third-line treatments has been made.

OBJECTIVES

This study aimed to assess the treatment persistence and comparative effectiveness of UST and VDZ in patients with refractory Crohn's disease (CD).

DESIGN

In this nationwide retrospective study, patients with CD on UST or VDZ maintenance therapy were enrolled. Clinical data at baseline, after induction, and at week 52 were obtained.

METHODS

Clinical and biochemical activities as well as corticosteroid-free remission (SFR) rates were assessed, while concomitant medications, comorbidities, hospitalizations, and surgeries were recorded during the follow-up to detect any predictors.

RESULTS

A total of 161 UST- and 65 VDZ-treated patients completed the follow-up. No significant difference in clinical or biochemical remission rates was observed after induction between the two treatment groups; however, clinical remission rate at week 52 was higher in UST group. UST showed superior drug persistence than VDZ (86.5%, 57.9%, p < 0.0001). The drug type was predictive of clinical SFR at week 52 [p = 0.011, odds ratio (OR) = 2.39 with UST]. Drug failure rates were higher for VDZ than those for UST (PNR rates: 21.54% and 4.97%, respectively, p < 0.001, OR = 8.267, p = 0.001). LOR and escalations were more common during UST treatment (61.5% versus 36.9%, p < 0.001; 64.2% versus 23.1%, p < 0.001). Hospital and surgical admission rates did not differ significantly. Only one adverse event occurred with VDZ at week 20, which led to drug cessation.

CONCLUSIONS

VDZ and UST were safe and effective for treating patients with CD in whom anti-TNF therapy failed. UST showed superior drug persistence than VDZ, but dose escalation was more frequent. Biologicals used in lower treatment lines resulted in better drug persistence.

Tápcsatornai endoszkópos eljárásokkal összefüggő infekciós kockázat a SARS-CoV-2-járvány idején

Bevezetés: A COVID–19-pandémia jelentősen befolyásolta az endoszkópos laboratóriumok működését. Az endoszkópos vizsgálatok nagy vírusátviteli rizikójúnak számítanak. Célkitűzés: A koronavírus-járványnak a magyarországi endoszkópos laborok működésére kifejtett hatásának és az endoszkópos személyzet SARS-CoV-2-fertőzésben való érintettségének felmérése a 2020-as évben. Módszerek: Országos szintű, keresztmetszeti, kérdőíves tanulmányunk során magyarországi endoszkópos laboratóriumok vezetőit kerestük meg online formában. Vizsgáltuk a 2020-ban elvégzett felső és alsó tápcsatornai endoszkópiák számát a 2019-es referenciaévhez viszonyítva (átlag [95%-os konfidenciaintervallum]), továbbá a SARS-CoV-2-fertőzéssel érintett dolgozók számát és fertőződésük potenciális forrását. Eredmények: A megkeresett intézmények 30%-ából érkeztek válaszok (33/111). A referenciaévhez képest sem a felső (1593 [743–1514] vs. 1129 [1020–2166], p = 0,053), sem az alsó tápcsatornai endoszkópos vizsgálatok száma (1181 [823–1538] vs. 871 [591–1150], p = 0,072) nem csökkent, bár a vírushullámoknak megfelelően mindkét vizsgálattípus esetén 80%-ot meghaladó vizsgálatszám-csökkenést tapasztaltunk. Dedikáltan fertőző betegek vizsgálatára kialakított helyiség az intézetek 12%-ában állt rendelkezésre. A védőfelszerelések az első és a második hullám alatt 70%-ban, illetve 82%-ban voltak mennyiségileg és minőségileg megfelelőek. A vizsgálat előtt fertőzöttségirizikó-stratifikáció az intézetek 85%-ában, míg PCR-vizsgálat csupán 42%-ukban történt minden esetben. Az első és második járványhullám alatt a dolgozói létszám az orvosoknál 33%-kal, illetve 26%-kal, az asszisztenseknél 19%-kal, illetve 21%-kal csökkent, elsősorban életkori korlátozás, COVID-ellátásba való áthelyezés miatt. Az asszisztensek 32%-a, az orvosok 41%-a esett át COVID-fertőzésen, 16%-ban, illetve 18%-ban nem megfelelő védőfelszerelés-használattal összefüggésben. Következtetés: A járványhullámok alatti restrikciók feloldását követően a vizsgálati terhelés emelkedik. A SARS-CoV-2-vakcinák elérhetősége előtt az endoszkópos laborok dolgozóit érintő COVID-fertőzések 15%-a nem megfelelő védőfelszerelés-használattal volt összefüggésbe hozható. Orv Hetil. 2022; 163(46): 1814–1822.

[Short term results of the FLOT neoadjuvant therapy on the surgical management of advanced gastro-oesophageal junction adenocarcinoma]

Introduction. Recently the therapeutic treatment for advanced, stage T2-T4 gastro-oesophageal junction cancer and those adjacent to the regional lymph nodes involves neoadjuvant chemotherapy with subsequent surgical intervention. Method. Neoadjuvant oncological treatment for gastro-oesophageal junction cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil (ECF) or epirubicin, cisplatin and capecitabine (ECX) combination (Group I). In the course of the new protocol (FLOT-, F: 5-FU, L: leucovorin, O: oxaliplatin, T: docetaxel), patients were included with resectable gastro-oesophageal junction cancer who had a clinical-stage cT2 or higher nodal positive cN+ disease (Group II). Between 31st of December 2013 and 1st of June 2021 we retrospectively analyzed the effect of these FLOT oncological protocols in terms of surgical outcomes in cases of T2-T4 tumors (n = 9). We compared the results of the randomly assigned nine patients from earlier ECF/ECX protocol (Group I). We analyzed the effect of the different neoadjuvant therapy on tumor regression, and evaluated the types of possible side effects, type of surgery, and the oncological radicality of surgical procedures (number of removed regional lymph nodes, resection margins). Results. Comparing the two groups we found that in cases of FLOT neoadjuvant chemotherapy complete regression was achieved significantly a higher number like in earlier ECX/ECF therapy. Furthermore, the average number of removed lymph nodes, and the safety resection margins (distal, circumferential) no significant difference was found between the two groups. Neutropenia was the most frequently encountered side effect. Leukopenia, neutropenia and nausea occurred more frequently in cases of the old protocol (Group I). Conclusions. As a result of the FLOT neoadjuvant oncological protocol for advanced gastro-oesophageal junction cancer, the number of cases with complete tumor regression has significantly increased. The present results strongly suggest a significant advantage in favor of FLOT neoadjuvant treatment following surgery. The prevalence of side effects was also appreciably lower in cases of the FLOT protocol.

The characteristics and prognostic role of acute abdominal on-admission pain in acute pancreatitis: A prospective cohort analysis of 1432 cases

INTRODUCTION

Pain is the most common symptom in acute pancreatitis (AP) and is among the diagnostic criteria. Therefore, we aimed to characterize acute abdominal pain in AP.

METHODS

The Hungarian Pancreatic Study Group prospectively collected multicentre clinical data on 1435 adult AP patients between 2012 and 2017. Pain was characterized by its intensity (mild or intense), duration prior to admission (hours), localization (nine regions of the abdomen) and type (sharp, dull or cramping).

RESULTS

97.3% of patients (n = 1394) had pain on admission. Of the initial population with acute abdominal pain, 727 patients answered questions about pain intensity, 1148 about pain type, 1134 about pain localization and 1202 about pain duration. Pain was mostly intense (70%, n = 511/727), characterized by cramping (61%, n = 705/1148), mostly starting less than 24 h prior to admission (56.7%, n = 682/1202). Interestingly, 50.9% of the patients (n = 577/1134) had atypical pain, which means pain other than epigastric or belt-like upper abdominal pain. We observed a higher proportion of peripancreatic fluid collection (19.5% vs. 11.0%; p = 0.009) and oedematous pancreas (8.4% vs. 3.1%; p = 0.016) with intense pain. Sharp pain was associated with AP severity (OR = 2.481 95% CI: 1.550-3.969) and increased mortality (OR = 2.263, 95% CI: 1.199-4.059) compared to other types. Longstanding pain (>72 h) on admission was not associated with outcomes. Pain characteristics showed little association with the patient's baseline characteristics.

CONCLUSION

A comprehensive patient interview should include questions about pain characteristics, including pain type. Patients with sharp and intense pain might need special monitoring and tailored pain management.

SIGNIFICANCE

Acute abdominal pain is the leading presenting symptom in acute pancreatitis; however, we currently lack specific guidelines for pain assessment and management. In our cohort analysis, intense and sharp pain on admission was associated with higher odds for severe AP and several systemic and local complications. Therefore, a comprehensive patient interview should include questions about pain characteristics and patients with intense and sharp pain might need closer monitoring.

Glucose levels show independent and dose-dependent association with worsening acute pancreatitis outcomes: Post-hoc analysis of a prospective, international cohort of 2250 acute pancreatitis cases

BACKGROUND

Metabolic risk factors, such as obesity, hypertension, and hyperlipidemia are independent risk factors for the development of various complications in acute pancreatitis (AP). Hypertriglyceridemia dose-dependently elicits pancreatotoxicity and worsens the outcomes of AP. The role of hyperglycemia, as a toxic metabolic factor in the clinical course of AP, has not been examined yet.

METHODS

We analyzed a prospective, international cohort of 2250 AP patients, examining associations between (1) glycosylated hemoglobin (HbA1c), (2) on-admission glucose, (3) peak in-hospital glucose and clinically important outcomes (mortality, severity, complications, length of hospitalization (LOH), maximal C-reactive protein (CRP)). We conducted a binary logistic regression accounting for age, gender, etiology, diabetes, and our examined variables. Receiver Operating Characteristic Curve (ROC) was applied to detect the diagnostic accuracy of the three variables.

RESULTS

Both on-admission and peak serum glucose are independently associated with AP severity and mortality, accounting for age, gender, known diabetes and AP etiology. They show a dose-dependent association with severity (p < 0.001 in both), mortality (p < 0.001), LOH (p < 0.001), maximal CRP (p < 0.001), systemic (p < 0.001) and local complications (p < 0.001). Patients with peak glucose >7 mmol/l had a 15 times higher odds for severe AP and a five times higher odds for mortality. We found a trend of increasing HbA1c with increasing LOH (p < 0.001), severity and local complications.

CONCLUSIONS

On-admission and peak in-hospital glucose are independently and dose-dependently associated with increasing AP severity and mortality. In-hospital laboratory control of glucose and adequate treatment of hyperglycemia are crucial in the management of AP.

Az endoszkópia minőségi követelményei

Összefoglaló. A tápcsatorna endoszkópiája a gasztrointesztinális rendszer betegségeinek legfontosabb vizsgáló eljárása, a diagnosztikán túl egyre szélesedő körben terápiás beavatkozási lehetőséget is magában foglal. A jó minőségben végzett endoszkópia javítja az esetlegesen fennálló betegség kimenetelét és növeli a betegelégedettséget. A nemzetközi emésztőszervi endoszkópos társaságok elsőrendű fontosságúnak határozták meg az endoszkópia minőségének javítását célzó törekvéseket. Az endoszkópos tevékenységek minőségének ellenőrzésében és javításában a meghatározott indikátorok folyamatos követése fontos feladat, ezek révén biztosítható betegeink számára a legmagasabb szintű ellátás. A bizonyítékon alapuló minőségi indikátorok lehetővé teszik az egyes endoszkóposok és az endoszkópos vizsgálóhelyek összehasonlítását és az általuk nyújtott szolgáltatás értékelését. A fenntartónak betegbiztonsági és költséghatékonysági szempontból is fontos ismerni, hogy melyik szolgáltató tudja teljesíteni a minimálisan elvárt és fejlődési célként kitűzött teljesítménymutatókat, melyik ellátónál milyen tényezőket szükséges megváltoztatni, javítani. A szerzők az európai útmutatókat alapul véve a felső tápcsatorna endoszkópiája, az alsó tápcsatorna endoszkópia, a pancreatobiliaris endoszkópia, a vékonybél endoszkópia, a kapszula endoszkópia és az endoszkópos szolgáltatás területén határozták meg a klinikailag releváns teljesítménymutatók auditálható magyar rendszerét. Az egységesség, a jobb digitalizálhatóság és könnyebb auditálhatóság céljából a felső, az alsó, a pancreatobiliaris, a vékonybél és a kapszula endoszkópia vonatkozásában a magyar ajánlásban a minőségi alterületeket egységesen (1-8) számozták, minden szám ugyanazon szempontrendszert jelenti. Az endoszkópos szolgáltatás komplex minőségi mutatóinál szigorúan ragaszkodtak az európai irányelvhez, itt 9 különböző alterületbe foglalták össze a 30 minőségi mutatót. A szűrő kolonoszkópia kiemelt jelentősége miatt a jelen minőségi endoszkópos útmutatóba foglalták bele eltérő szerkezettel a szűrő kolonoszkópos program során alkalmazott minőségi mutatókat, illetve a bélelőkészítést érintő néhány alapvetést is. Summary. Nowadays, endoscopy is the cornerstone in the diagnosis and therapy of gastrointestinal diseases. Good quality endoscopy can improve outcome of the disease and patients experience. International endoscopy societies prioritized efforts improving quality of endoscopy. The highest level of patient care can be provided through continuous assessment and improvement of relevant quality indicators. The comparison of these evidence based performance measures between endoscopists and endoscopy providers allow the objective evaluation of the service. Furthermore, from the point of view of patient safety and cost effectiveness the health care provider should know the minimum standards and target goals, as well, to make grounded decisions about fields of necessary changes and improvements. The authors based on European guidelines worked out this comprehensive auditable Hungarian system of performance measures in the fields of upper endoscopy, lower endoscopy, pancreatobiliary endoscopy, capsule endoscopy, enteroscopy and general endoscopy service. Due to commonality all domains were counted similarly (1-8) in different endoscopic procedures. The general endoscopy service is an exception with 9 domains and 30 quality parameters. The outstanding importance of colorectal cancer screening required involving this topic into this guideline with separate structure, as well as the basics of bowel preparation.

Surgical outcome of percutaneous transhepatic gallbladder drainage in acute cholecystitis: Ten years' experience at a tertiary care centre

Background

Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies.

Patients and Methods

We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male–female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient’s performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed.

Results

PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79–20.56), clinical progression (OR 7.62; CI 2.64–22.05) and the need for emergency CCY (OR 14.75; CI 3.07–70.81) were mostly determined by AC severity grade.

Conclusion

PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

Effect of COVID-19 pandemic on the workflow of endoscopy units: an international survey

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to healthcare. Staff and patients are at increased risk during an examination or intervention, so certain restrictions ought to be introduced. Hence, we aimed to measure the effect of the pandemic on endoscopy units in real-life settings.

METHODS

This was an observational, cross-sectional, questionnaire-based study, carried out between 7 April and 15 June 2020. Responds came from many countries, and the participation was voluntary. The survey contained 40 questions, which evaluated the effect of the COVID-19 pandemic on the endoscopy units and assessed the infection control.

RESULTS

A total of 312 questionnaires were filled, 120 from Hungary, and 192 internationally, and 54 questionnaires (17.3%) were sent from high-risk countries; 84.9% of the gastroenterologists declared that they read the European Society of Gastrointestinal Endoscopy (ESGE) statement, while only 32.1% participated in any advanced training at their workplace. Overall, 92.1% of gastroenterologists realized risk stratification, and 72.1% claimed to have enough protective equipment. In 52.6% of the endoscopy units, at least one endoscopist had to discontinue the work due to any risk factor, while 40.6% reported that the reduced staff did not affect the workflow. Gastroenterologists considered that the five most important examinations both in low and high-risk patients are the following: lower/upper gastrointestinal (GI) bleeding with hemodynamic instability, endoscopic retrograde cholangiopancreatography (ERCP) in obstructive jaundice, foreign body in the esophagus, ERCP in acute biliary pancreatitis, and iron deficiency anemia with hemodynamic instability, which correlates well with the ESGE recommendation. Significant correlation was found in the usage of the necessary protective equipment in high-risk patients depending on the countries (p < 0.001).

CONCLUSIONS

The survey found weak correlation in preliminary training depending on countries; nevertheless, in Hungary during the examined period, endoscopists considered the recommendations more strictly than in other countries. Although many physicians left the endoscopy lab, the workflow was not affected, probably due to the reduced number of examinations.

The complex relationship between viruses and inflammatory bowel disease - review and practical advices for the daily clinical decision-making during the SARS-CoV-2 pandemic

The coronavirus disease 2019 (COVID-19) outbreak emerged in December 2019 in China and rapidly spread worldwide. Inflammatory bowel disease (IBD) patients are likely to be more susceptible to viral infections, and this is significantly influenced by the type of therapy they receive. Thus, issues specifically concerning the medical treatment of IBD patients were shortly addressed at the beginning of the pandemic. However, recently available data on the occurrence and outcome of SARS-CoV-2 infection in IBD patients does not address the concerns raised at the beginning of the pandemic. Growing evidence and the rapid changes happening over the past few weeks have helped elucidate the current situation, contribute to our understanding of the disease, and many previously raised questions could now be answered. We hereby summarise available evidence regarding viral infections and IBD, focusing on SARS-CoV infections, and we provide practical recommendations related to patient management during the COVID-19 pandemic era.

Advances in the optimization of therapeutic drug monitoring using serum, tissue and faecal anti-tumour necrosis factor concentration in patients with inflammatory bowel disease treated with TNF-α antagonists

INTRODUCTION

The relationship between clinical outcomes and serum anti-TNF levels is controversial. The aim of this study was to perform simultaneous analyses of serum, mucosal, and fecal anti-TNF-α levels.

METHODS

Consecutive IBD patients who received maintenance anti-TNF-α therapy were enrolled. The number of TNF-α positive cells in the mucosa was detected using immunofluorescent labeling on biopsy samples. Serum, mucosal and fecal anti-TNF-α, serum anti-drug antibody, and fecal calprotectin levels were determined using ELISA. Each patient underwent body composition analysis as well.

RESULTS

Data of 50 patients were analyzed. The number TNF-α positive cells was significantly higher in the inflamed part of the colon than in the un-inflamed part of the colon. Tissue and fecal drug levels did not show any association with serum drug levels; moreover, serum anti-TNF concentration did not correlate with endoscopic activity. Mucosal anti-TNF levels were higher only in IFX-treated patients in remission and IFX-treated patients with detectable fecal anti-TNF had lower tissue drug levels. Presence of the drug in the feces was significantly different according to disease activity.

CONCLUSION

Fecal drug concentration is suggested to be a better predictor of endoscopic activity and loss of response, and fecal drug monitoring may improve the estimation accuracy of tissue drug levels.

Effect of COVID-19 pandemic on workflows and infection prevention strategies of endoscopy units in Hungary: a cross-sectional survey

Background

Health care professionals in endoscopic labs have an elevated risk for COVID-19 infection, therefore, we aimed to determine the effect of current pandemic on the workflow and infection prevention and control strategies of endoscopy units in real-life setting.

Methods

All members of Hungarian Society of Gastroenterology were invited between 7 and 17 April 2020 to participate in this cross-section survey study and to complete an online, anonymous questionnaire.

Results

Total of 120 endoscopists from 83 institutes were enrolled of which 35.83% worked in regions with high cumulative incidence of COVID-19. Only 33.33% of them had undergone training about infection prevention in their workplace. 95.83% of endoscopists regularly used risk stratification of patients for infection prior endoscopy. While indications of examinations in low risk patients varied widely, in high-risk or positive patients endoscopy was limited to gastrointestinal bleeding (95.00%), removal of foreign body from esophagus (87.50%), management of obstructive jaundice (72.50%) and biliary pancreatitis (67.50%). Appropriate amount of personal protective equipment was available in 60.85% of endoscopy units. In high-risk or positive patients, surgical mask, filtering facepiece mask, protective eyewear and two pairs of gloves were applied in 30.83%, 76.67%, 90.00% and 87.50% of cases, respectively. Personal protective equipment fully complied with European guideline only in 67.50% of cases.

Conclusions

Survey found large variability in indications of endoscopy and relative weak compliance to national and international practical recommendations in terms of protective equipment. This could be improved by adequate training about infection prevention.

Complete laparoscopic-transhiatal removal of duplex benign oesophageal tumour: case report and review of literature

BACKGROUND

Leiomyoma is the most common benign oesophageal tumour. Half of all leiomyoma patients have oesophagus-associated complaints, such as dysphagia and epigastric pain, and the other 50% are asymptomatic with a diagnosis made on incidental discovery. Endoscopic ultrasonography is essential for an accurate preoperative workup and can enable guided-tissue acquisition for immunohistochemistry in certain cases. Smaller tumours are amenable to traditional and novel endoscopic removal in specialized centres, but some complex cases require surgical enucleation with a minimally invasive approach.

CASE PRESENTATION

An asymptomatic 60-year-old woman was accidentally diagnosed with a bifocal oesophageal mass, which was discovered by chest computed tomography. We report a rare case of a duplicated lower-third oesophageal leiomyoma, which was completely removed via the laparoscopic transhiatal approach. The patient has recovered successfully from the surgery. She has been followed up for six months with a normal oesophagram, adequate oesophageal function and no complaints observed. Pathological examination confirmed the diagnosis of leiomyoma in both lesions.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of duplex oesophageal leiomyomas removed laparoscopically. Using the minimally invasive abdominal technique, the lower oesophagus can be mobilised to the mediastinum without pleura injury and offers a good alternative to the thoracoscopic approach in patients with possible intrathoracic difficulties. At experienced centres, laparoscopic transhiatal enucleation of lower oesophageal leiomyomas and other benign tumours with a combination of intraoperative oesophagoscopy is a safe, fast and effective operation.

Evidence for diagnosis of early chronic pancreatitis after three episodes of acute pancreatitis: a cross-sectional multicentre international study with experimental animal model

Chronic pancreatitis (CP) is an end-stage disease with no specific therapy; therefore, an early diagnosis is of crucial importance. In this study, data from 1315 and 318 patients were analysed from acute pancreatitis (AP) and CP registries, respectively. The population from the AP registry was divided into AP (n = 983), recurrent AP (RAP, n = 270) and CP (n = 62) groups. The prevalence of CP in combination with AP, RAP2, RAP3, RAP4 and RAP5 + was 0%, 1%, 16%, 50% and 47%, respectively, suggesting that three or more episodes of AP is a strong risk factor for CP. Laboratory, imaging and clinical biomarkers highlighted that patients with RAP3 + do not show a significant difference between RAPs and CP. Data from CP registries showed 98% of patients had at least one AP and the average number of episodes was four. We mimicked the human RAPs in a mouse model and found that three or more episodes of AP cause early chronic-like morphological changes in the pancreas. We concluded that three or more attacks of AP with no morphological changes to the pancreas could be considered as early CP (ECP).The new diagnostic criteria for ECP allow the majority of CP patients to be diagnosed earlier. They can be used in hospitals with no additional costs in healthcare.

ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis - Analysis of the Hungarian ERCP registry data

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis.

OBJECTIVES

ABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP.

METHODS

The rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded.

RESULTS

Significantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241-2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415-9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p = 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates.

CONCLUSION

ERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.

Endoscopic treatment of gastric antral vascular ectasia in real-life settings: Argon plasma coagulation or endoscopic band ligation?

OBJECTIVE

The efficacy of argon plasma coagulation (APC) on gastric antral vascular ectasia (GAVE) may be impaired over time and depends greatly on the application settings. Endoscopic band ligation (EBL) may be an alternative, but study on its efficacy is limited. This study aimed to evaluate and compare the clinical efficacy of APC and EBL in treating GAVE.

METHODS

Changes in the need for blood transfusion, number of treatment sessions and hospitalizations were retrospectively assessed in 63 transfusion-dependent patients with GAVE (mean age: 67.1 y, 54.0% female) treated with either APC or EBL (45 and 18 patients, respectively) in four tertiary endoscopic centers.

RESULTS

Both methods substantially increased hemoglobin levels and decreased patients' need for a transfusion (22.0 ± 4.0 g/L and -5.62 ± 2.30 units of packed red blood cells [RBC] with APC, and 27.4 ± 6.1 g/L and -4.79 ± 2.46 units of packed RBC with EBL), without a significant statistical difference between the methods. However, fewer EBL sessions were required both for the cessation of need for a transfusion compared with those for the resolution of GAVE lesions (0.90 ± 0.10 vs 1.69 ± 0.31, P = 0.028).

CONCLUSIONS

Both APC and EBL are effective in GAVE treatment. EBL may be superior in terms of number of treatment sessions, but not in its influence on hemoglobin level and need for transfusion. Further prospective studies with large, homogeneous sample size and standardized APC settings are needed.

Efficacy, tolerability and safety of a split-dose bowel cleansing regimen of magnesium citrate with sodium picosulfate - a phase IV clinical observational study

BACKGROUND

There are contradictory results about the effect of magnesium citrate plus sodium picosulfate bowel cleansing agents on the fluid and electrolyte balance. Therefore, this study aimed to determine the efficacy, tolerability and safety of this medication in colonoscopy preparation.

METHODS

233 patients were enrolled in this phase IV prospective observational study. The effectiveness of bowel cleansing was assessed using the Boston Bowel Preparation Scale (BBPS). Adequate cleansing was defined as BBPS ≥ 6 and excellent cleansing as BBPS > 7. Tolerability was examined using a standardized questionnaire. In the safety analysis, the change of serum electrolytes levels and renal function during bowel cleansing was assessed.

RESULTS

Adequate and excellent bowel cleansing were achieved 94.85% and 72.96% of cases, respectively. None or very mild symptoms were reported in 47.21% of cases. Statistically significant changes occurred in serum potassium (4.38±0.43 vs. 4.25±0.43 mmol/L, p<0.0001), urea (4.86±1.37 vs. 3.84±1.43 mmol/L, p<0.0001) and creatinine (male: 81.07±16.02 vs. 84.54±15.11 μmol/L; female: 69.32±12.22 vs. 72.96±12.11 μmol/L, p<0.0001) levels during the colonoscopy preparation. However, the number of patients with values outside of the normal range increased significantly only in the case of serum urea (3.95% vs. 26.97%, p<0.0001).

CONCLUSION

Magnesium citrate with sodium picosulfate is outstandingly effective, well tolerated and a safe agent in colonoscopy preparation. It caused significant, but non-clinically relevant changes in serum electrolytes levels and renal function.

Long-term follow-up of inflammatory bowel disease patients receiving anti-tumor necrosis factor-alpha therapy

Összefoglaló. Bevezetés: A gyulladásos bélbetegségek kezelésében a tumornekrózisfaktor-alfa-ellenes (anti-TNFα) antitestek elsődleges választási lehetőséget jelentenek a kortikoszteroid- és immunmoduláns kezelésre refrakter páciensek kezelési stratégiájában. Ezek a hatóanyagok hatékonyak, ám hosszú távú hatásosságukkal kapcsolatban sok az ellentmondás. Célkitűzés: Vizsgálatunk célja megvizsgálni az anti-TNFα-terápia (infliximab [IFX], adalimumab [ADA]) hosszú távú hatékonyságát gyulladásos bélbetegek körében. Módszerek: Retrospektív, adatgyűjtéses vizsgálatunkba a Szegedi Tudományegyetem I. Sz. Belgyógyászati Klinikáján gondozott, 18-65 év közötti gyulladásos bélbetegeket vontunk be. Az adatgyűjtést a Klinika informatikai rendszeréből végeztük a betegek ambuláns megjelenéseinek kezelőlapjaiból, illetve a zárójelentésekből. Eredmények: 102 beteg adatait elemeztük (Crohn-beteg: 67 fő, colitis ulcerosás: 35 fő). A Crohn-betegség diagnózisát követően átlagosan 7,84 év, a colitis ulcerosa diagnózisát követően átlagosan 9,86 év telt el az első anti-TNFα-terápia elkezdéséig. Az első kezelési ciklus átlagosan 2,64 évig tartott, a ciklus végén az IFX-t kapó betegek 50%-ánál, az ADA-t kapó betegek 46%-ánál volt remisszióban a betegség. A második kezelési ciklus átlagosan 4,67 évig tartott, a ciklus végén az IFX-t kapó betegek 36%-a, az ADA-t kapó betegek 40%-a volt remisszióban. Az első, illetve a második kezelési ciklus alatt az allergiás reakciók gyakorisága IFX esetében 13% és 18%, ADA esetében 4% és 3% volt. A primer hatástalanság és a másodlagos hatásvesztés az első ciklusban IFX esetében 4% és 10,5%, ADA esetében 11,5% és 19% volt. A második kezelési ciklusban IFX esetében 9%-ban és 18%-ban, ADA esetében 23%-ban és 10%-ban jelentették a ciklus végét. Következtetés: Az anti-TNFα-terápiák eredményeink alapján hosszú távon is hatékonynak és biztonságosnak bizonyultak. Másodlagos hatásvesztés kisebb arányban fordult elő a vizsgált populációban az irodalmi adatokhoz képest. Orv Hetil. 2020; 161(47): 1989-1994.

SUMMARY

INTRODUCTION

Anti-tumor necrosis factor-alpha (anti-TNFα) treatment is reserved for steroid-dependent or steroid/immunomodulator-refractory inflammatory bowel diseases patients. These agents are effective, however, their long-term safety is still questionable.

OBJECTIVE

We aimed to assess the long-term efficacy and safety of two anti-TNFα therapies.

METHODS

In our retrospective study, we reviewed medical records via the administration system of the First Department of Medicine, University of Szeged. Female and male patients, aged between 18-65 years who received anti-TNFα therapy between 2010-2019 were enrolled.

RESULTS

102 patients with inflammatory bowel disease were enrolled (Crohn's disease: 67, ulcerative colitis: 35). The first anti-TNFα therapy was introduced after an average 7.84 and 9.86 years from diagnosis of Crohn's disease and ulcerative colitis. The first treatment period lasted for 2.64 years; 50% of patients receiving IFX and 46% of patients receiving ADA were in remission at the end of the period. The second treatment period lasted for 4.67 years, 36% of IFX-treated patients and 40% of ADA-treated patients were in remission at the end of the period. 13% and 18% of patients treated by IFX and 4% and 3% of patients treated by ADA experienced infusion reaction during the first and the second treatment period. Primary non-response and loss of response rates were 4% and 10.5% (IFX) and 11.5% and 19% (ADA) during the first treatment period. These rates were 9% and 18% (IFX) and 23% and 10% (ADA) during the second treatment period.

CONCLUSION

Our study confirmed the long-term efficacy and safety of the anti-TNFα therapies. Loss of response rate is lower in our population compared to the literature. Orv Hetil. 2020; 161(47): 1989-1994.

Slow-pull technique yields better quality smears: prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine-needle aspiration

BACKGROUND

Diagnostic accuracy and quality of smears obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are influenced by characteristics of suction and examined organ.

AIMS AND METHODS

Efficiency of EUS-FNA and quality of smears obtained by slow-pull (SP) and standard suction (SS) techniques was prospectively compared in the sampling of pancreatic (N = 56) and extrapancreatic (N = 145) tumors.

RESULTS

SS technique resulted in a higher number of smear pairs both in pancreatic (1.74 vs. 3.19; p < 0.001) and extrapancreatic tumors (1.62 vs. 3.28; p < 0.001); however, it decreased the proportion of diagnostic smears (46.69% vs. 36.52%; p = 0.002 and 49.17% vs. 30.67%; p < 0.001) and increased the bloodiness (1.51 vs. 2.07; p < 0.001 and 1.48 vs. 2.05; p < 0.001). In pancreatic cancers, no difference was observed in terms of diagnostic accuracy (81.38% vs. 83.45%) and cellularity (1.44 vs. 1.27; p = 0.067); however, they were substantially higher in extrapancreatic tumors using SP technique (71.41% vs. 60.71% and 1.34 vs. 0.77; p < 0.001). Only SP technique resulted in a significant difference between examiners in terms of technical success rate and quality of smears without any decrease of diagnostic accuracy.

CONCLUSIONS

SP technique yields better quality smears independently from tumors characteristics; however, it shows significant examiner-dependency. SS technique reduces the diagnostic accuracy of sampling in extrapancreatic tumors.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Development of disturbance of consciousness is associated with increased severity in acute pancreatitis

BACKGROUND

Disturbance of consciousness (DOC) may develop in acute pancreatitis (AP). In clinical practice, it is known that DOC may worsen the patient's condition, but we have no exact data on how DOC affects the outcome of AP.

METHODS

From the Hungarian Pancreatic Study Groups' AP registry, 1220 prospectively collected cases were analyzed, which contained exact data on DOC, included patients with confusion, delirium, convulsion, and alcohol withdrawal, answering a post hoc defined research question. Patients were separated to Non-DOC and DOC, whereas DOC was further divided into non-alcohol related DOC (Non-ALC DOC) and ALC DOC groups. For statistical analysis, independent sample t-test, Mann-Whitney, Chi-squared, or Fisher exact test were used.

RESULTS

From the 1220 patients, 47 (3.9%) developed DOC, 23 (48.9%) cases were ALC DOC vs. 24 (51.1%) Non-ALC DOC. Analysis between the DOC and Non-DOC groups showed a higher incidence of severe AP (19.2% vs. 5.3%, p < 0.001), higher mortality (14.9% vs. 1.7%, p < 0.001), and a longer length of hospitalization (LOH) (Me = 11; IQR: 8-17 days vs. Me = 9; IQR: 6-13 days, p = 0.049) respectively. Patients with ALC DOC developed more frequently moderate AP vs. Non-ALC DOC (43.5% vs. 12.5%), while the incidence of severe AP was higher in Non-ALC vs. ALC DOC group (33.3% vs. 4.4%) (p < 0.001). LOH showed a tendency to be longer in Non-ALC DOC compared to ALC DOC, respectively (Me:13; IQR:7-20 days vs. Me:9.5; IQR:8-15.5 days, p = 0.119).

CONCLUSION

DOC during AP is associated with a higher rate of moderate and severe AP and increases the risk of mortality.

Efficacy of the population-based pilot colorectal cancer screening, Csongrád county, Hungary, 2015

Background/aim

In Hungary, a nationwide colorectal screening program is about to be introduced in order to improve the high mortality rate of colorectal cancer (CRC). The aim was to summarize experiences from and assess short-term efficacy of the population- based pilot colorectal screening program in 2015 in Csongrád county, Hungary.

Materials and methods

Asymptomatic individuals between the ages of 50 and 70 with average risk of colorectal cancer participated in the program that was based on the two-step screening method: immune fecal blood test and colonoscopy. The short-term efficacy was assessed as the change in total CRC incidence and initial tumor stage in the screening year (2015).

Results

22,130 individuals were invited to participate, and the participation rate was 46.4%. Immune fecal blood test proved to be nonnegative in 1,343 cases (13%), screening colonoscopy was performed in 766 of them (7.5%). Total colonoscopy was performed in 711 individuals. Based on the reports, adenoma was detected in 358 (50.3%) and malignancy in 42 (5.9%) individuals. In the background population, the incidence of colon cancer was higher (183 vs. 228; P = 0.026) and was diagnosed at earlier stage (P = 0.002), while lymph node involvement was lower in 2015 (48.3% vs. 37.1%; P = 0.049).

Conclusion

The Csongrád county population-based colorectal cancer screening was evidently successful on the short-term considering participation rate, and the changes in CRC incidence and stage, thus its national extension is necessary.

Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BACKGROUND

Indication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging.

AIMS

In this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers.

METHODS

Clinical data on ABP patients (2013-2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed.

RESULTS

There were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24-48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)].

CONCLUSION

Optimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.

Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations

BACKGROUND

Unwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis.

METHODS

Four methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals.

RESULTS

The systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31-82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy.

CONCLUSIONS

The authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.

Lactose intolerance but not lactose maldigestion is more frequent in patients with irritable bowel syndrome than in healthy controls: A meta-analysis

BACKGROUND AND PURPOSE

Irritable bowel syndrome (IBS) affects 10%-20% of the adult population and is characterized by abdominal symptoms without relevant organic disease. There are numerous clinical trials available investigating the relationship between IBS, lactose maldigestion (LM), and lactose intolerance (LI), but there have been no meta-analyses on this topic yet. We aimed to assess the prevalence of LM, objective and subjective (self-reported) LI in IBS patients compared to healthy controls (HC) without IBS.

METHODS

A systematic literature search was conducted up to 24 April 2018 in PubMed, Embase, and Cochrane Library. Adult IBS patients had to be diagnosed according to the Rome criteria or other well-defined criteria system. We enrolled controlled studies including healthy adult participants without IBS, as control group. Odds ratios with 95% confidence intervals were calculated.

KEY RESULTS

Altogether 14 articles were suitable for statistical analyses. IBS patients reported themselves significantly more frequently lactose intolerant than HCs (odds ratio [OR] = 3.499; 95% confidence interval [CI] = 1.622-7.551). Generally, there was no significant difference in the prevalence of LM based on ingested lactose dose (OR = 1.122; 95% CI = 0.929-1.356) and test type (OR = 1.156; 95% CI = 0.985-1.356). However, significantly more IBS patients had objective LI (OR = 2.521; 95% CI = 1.280-4.965).

CONCLUSIONS AND INFERENCES

Lactose intolerance, but not LM is more frequent among patients with IBS compared to HCs. According to our results, IBS among other functional bowel disorders is a possible contributing factor of LI in people with LM.

Prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine needle aspiration in the diagnosis of solid pancreatic cancer

Background

The usage of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for the diagnosis of solid pancreatic cancer is increasing, however mainly retrospective studies are available about the detailed methods of sampling.

Methods

To compare prospectively the diagnostic yield of EUS-FNA samples obtained with slow-pull (SP) and with standard suction technique (SS).

Results

EUS-FNA sampling was diagnostic in 72 of 92 cases (78.3%). Diagnostic yield was 67.4% in the SS and 65.2% in the SP group. The number of smear pairs (1.84 vs. 3.56; p < 0.001) and blood contamination (1.50 vs. 2.19; p < 0.001) were significantly higher in the SS group, which resulted in lower rate of diagnostic samples (41.8% vs. 30.0%; p = 0.003). There was no difference in the cellularity (1.58 vs. 1.37; p = 0.2554), or in the sensitivity and specificity in the identification of malignancy between SP and SS subgroups (69.9, 100% vs. 73.5, 100%). Histological samples were obtained in 60 cases (with SP: 49 cases; with SS: 46 cases). There was no difference in the diagnostic yield of histological samples between the groups (63 and 58.7%).

Conclusion

The diagnostic yield, the cellularity of smears and the rate of acquiring sufficient histological material are similar in the SP and SS group, but due to lower bloodiness and decreased number of slides, the pathological diagnosis is faster and more cost-effective.

Short-Course Antibiotic Treatment Is Not Inferior to a Long-Course One in Acute Cholangitis: A Systematic Review

AIMS

Our aim was to summarize the available literature on the effect of short- versus long-course antibiotic therapy on acute cholangitis.

METHODS

A systematic review was performed according to the PRISMA Statement. We searched three databases for papers discussing the length of ABT in acute cholangitis. Long and short therapy groups were defined based on the most recent guideline available at the time of publication of the articles. Primary outcomes were the rate of recurrent cholangitis and mortality; secondary outcomes included length of hospitalization and the duration of fever after ERCP. Data were extracted on these outcomes and on general characteristics. A narrative synthesis was then provided based on collected data.

RESULTS

Out of 692 articles produced by our search, four met our inclusion and exclusion criteria. These contained 205 acute cholangitis patients, with 137 and 68 patients receiving short and long antibiotic therapy, respectively. No significant difference was observed in any of the studies on the outcomes of mortality and duration of fever after ERCP between the two groups. One out of four studies found the rate of recurrent cholangitis to be significantly lower in the short antibiotic therapy group (0.0% vs. 13.3%, p = 0.036). Length of hospitalization was only compared in the same retrospective article, where it was found to be significantly shorter in the short-term antibiotic therapy group (with a median of 14 vs. 17.5 days, p < 0.001).

CONCLUSIONS

Our review suggests short-course antibiotic therapy is non-inferior to long-course treatment; however, several limitations underline the need for well-designed randomized trials.

[Transfer of care of adolescent inflammatory bowel disease patients without longitudinal transition. Lesson from 10 years experiences]

INTRODUCTION

Transfer is a planned movement of patients and their medical records from one provider to another. Only a few data are available from real life in inflammatory bowel disease patients in this topic.

AIM

Our aim was to retrospectively evaluate the results of the transfer of our patients without longitudinal transition.

METHOD

Data of the transferred patients at the University of Szeged were analysed. Patients were diagnosed in paediatric care. Transfer strategy at our departments was detailed medical summary.

RESULTS

59 patients were enrolled in this study. 28.8% of the patients had mild to moderate disease activity and 71.2% was in remission at the time of transfer. Steroid therapy was initiated in 58% of the patients within an average of 9.1 months after the transfer. Anti-tumor necrosis factor therapy was given to 24% of the patients during the paediatric care and to an additional 23% in the adult care within an average of 28 months. Almost 70% of the patients received immunosuppressive therapy during paediatric and adult care. Surgery was required in 17% of the patients within an average 10.7 months after the transfer.

CONCLUSION

Our results revealed that one-third of the paediatric patients have been transferred to adult care in active stage of disease. Shortly after the transfer 58% of the patients required corticosteroids and 17% surgery. Every fifth patient needed biological therapy to be initiated after the transfer. Longitudinal transition may have a potential to decrease the need for therapeutic change and the relatively high rate of surgery. Orv Hetil. 2018; 159(44): 1789-1793.

Infliximab biosimilar CT-P13 therapy is effective in maintaining endoscopic remission in ulcerative colitis - results from multicenter observational cohort

BACKGROUND

CT-P13, the first biosimilar monoclonal antibody to infliximab (IFX), has previously been confirmed to be efficacious in inducing mucosal healing in ulcerative colitis (UC) patients. The aim of this study was to evaluate the efficacy of CT-P13 therapy in maintaining mucosal healing in UC.

METHODS

CT-P13 trough levels, antibody positivity, serum inflammatory markers as CRP level, fecal calprotectin at weeks 14 and 54, concomitant steroid and azathioprine therapy at the time of induction therapy and at weeks 14 and 54, previous use of anti TNF drug and the need of dose intensification as possible predictive factors for mucosal healing at week 54 were evaluated in this prospective study.

RESULTS

61 patients had already completed the 54-week treatment period. Mucosal healing was shown in 65.5 % and 62.1 %, complete mucosal healing was present in 31% and 38 % at week 14 and 54, respectively. The median values of CRP, leukocytes, thrombocytes, and albumin showed significant difference between baseline and week 54. Serum antibody positivity was proved in 6.5 % and 19.7 % of cases at week 14 and 54, respectively.

CONCLUSION

Our study confirmed the long-term efficacy of CT-P13 therapy on mucosal healing in UC.

Biological therapy and surgery rates in inflammatory bowel diseases - Data analysis of almost 1000 patients from a Hungarian tertiary IBD center

Inflammatory bowel diseases (IBD) [Crohn’s disease (CD) and ulcerative colitis (UC)], are chronic relapsing disorders of unknown etiology. The aim of this study was to determine demographic features, disease phenotypes, medical and surgical therapies in our IBD patients and to identify which parameters are in association with the need of surgery and/or biologic therapy. Data on demographic and clinical characteristics of the patients were analyzed from the IBD registry of the 1^st Department of Medicine, University of Szeged. The study period was between January 2007 and March 2015. Data of 911 IBD patients (428 CD, 483 UC) were analyzed. The median lag time between onset of symptoms and diagnosis proved to be significantly longer in UC than in CD (4.6 years vs. 2.1 years, p = 0.01). 40% of the patients received biological therapy, 301 patients underwent surgery required more frequently for CD than UC. Surgery was more common in CD patients with ileal location and penetrating behaviour. In UC, more severe disease onset predicted to unfavourable disease course. Higher proportion of surgery was shown in patient aged above 40 years in both CD and UC. Diagnostic delay of more than 1 year and appendectomy predicted to unfavourable disease outcome of both CD and UC. This analysis revealed that more than 1 year of diagnostic delay, disease activity at diagnosis in UC, CD, ileal location and penetrating behaviour are factors that may influence disease outcome. Use of thiopurines seemed to be protective in UC.

Centralized Care For Acute Pancreatitis Significantly Improves Outcomes

Aims: In this observational study, we investigated whether specialized care improves outcomes for acute pancreatitis (AP).Methods: Consecutive patients admitted to two university hospitals with AP were enrolled in this study between 1 January 2016 and 31 December 2016 (Center A: specialized center; Center B: general hospital). Data on demographic characteristics and AP etiology, severity, mortality and quality of care (enteral nutrition and antibiotic use) were extracted from the Hungarian Acute Pancreatitis Registry. An independent sample t-test, Mann–Whitney test, chi-squared test or Fisher’s test were used for statistical analyses. Costs of care were calculated and compared in the two models of care.Results: There were 355 patients enrolled, 195 patients in the specialized center (Center A) and 160 patients in the general hospital (Center B). There was no difference in mean age (57.02 ±17.16 vs. 57.31 ±16.50 P=0.872) and sex ratio (56% males vs. 57% males, P=0.837) between centres, allowing a comparison without selection bias. Center A had lower mortality (n=2, 1.03% vs. n=16, 6.25%, p=0.007), more patients received enteral feeding (n=179, 91.8%, vs. n=36, 22.5%, p<0.001) and fewer patients were treated with antibiotics (n=85, 43.6% vs. n=123, 76.9%, p=0.001). In Center A the median length of hospitalization was shorter (Me 6, IQR 5–9 vs. Me 8, IQR 6–11, p=0.02) and the costs of care were by 25% lower.Conclusion: Our data suggests that treatment of AP in specialized centers reduces mortality, length of hospitalization and thus might reduce the costs.

How disease extent can be included in the endoscopic activity index of ulcerative colitis: the panMayo score, a promising scoring system

Background

Colonoscopy plays crucial role in the establishment of the diagnosis, management and follow-up of ulcerative colitis (UC). None of the currently widely used endoscopic scores consider disease extent, and therefore do not correlate with the real severity of UC. Our aim was to assess the accuracy of a new score, the Pancolonic Modified Mayo Score that can reflect not only the severity, but the extent of active UC.

Methods

One hundred and four UC patients were enrolled in this prospective study. The Endoscopic Mayo Scores of the involved area of the five colorectal segments were added; furthermore, the sum was multiplied by 3 in case of eMayo ≥2 (range 0 [normal] to 45 [most severe]) to obtain the Pancolonic Modified Mayo Score (panMayo) in order to clearly distinguish the active and inactive disease. We analysed the correlation of panMayo Score with eMayo and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and complicated disease outcome. We compared the endoscopic indices with serum and faecal inflammatory parameters and Riley Score.

Results

The panMayo Score correlated with eMayo and UCEIS. Every endoscopic score showed correlation with Riley Score, CRP, haemoglobin, haematocrit, serum iron, faecal MMP-9 and calprotectin and also predicted a complicated disease outcome. Only panMayo score correlated exclusively with the extent of UC.

Conclusions

We suggest that this new score gives additional information about disease extent besides disease activity with a strong correlation with laboratory parameters of inflammation and with the other widely used endoscopic indices.

[Efficacy of the population-based pilot colorectal screening program. Hungary, Csongrád county, 2015]

INTRODUCTION

In Hungary, a nationwide colorectal screening program is about to be introduced in order to improve the extremely high mortality rate of colorectal cancer (CRC).

AIM

The aim of our study was to summarize experiences and assess short-term efficacy of the population-based pilot colorectal screening program in 2015 in Csongrád County, Hungary.

PATIENTS AND METHOD

Asymptomatic individuals between the ages of 50 and 70 with average risk of colorectal cancer participated in the program that was based on the two-step screening method (i.e. immune fecal blood test and colonoscopy). The short-term efficacy of the screening program was assessed as the change in total CRC incidence and initial tumor stage in the screening year (2015) compared to a control year (2013) in Szeged and its surroundings. Participation rate, positive predictive value of the screening methods and tumor detection rate was assessed.

RESULTS

22,130 individuals were invited, the participation rate was 46.4%. Immune fecal blood test proved to be non-negative in 1,343 cases (13%), screening colonoscopy was performed in 766 of them (7.5%). Total colonoscopy was performed in 711 individuals. Based on the reports, adenoma was detected in 358 (50.3%) and malignancy in 42 (5.9%) individuals. In the background population, the incidence of colon cancer was significantly higher (183 vs. 228; p = 0.026) and was diagnosed at significantly earlier stage (p = 0.002). Lymph node involvement was significantly lower in 2015 (48.3% vs. 37.1%; p = 0.049).

CONCLUSION

The Csongrád county population-based colorectal cancer screening was evidently successful on the short term considering participation rate, and the changes in CRC incidence and stage, thus its national extension is necessary. Orv Hetil. 2017; 158(42): 1658-1667.

Infliximab biosimilar CT-P13 therapy is effective and safe in maintaining remission in Crohn's disease and ulcerative colitis - experiences from a single center

BACKGROUND

CT-P13, the first biosimilar monoclonal antibody to infliximab (IFX), has been confirmed to be efficacious in inducing remission in inflammatory bowel diseases (IBD). The aim of this study was to evaluate the long-term efficacy and safety of CT-P13 therapy in Crohn's disease (CD) and ulcerative colitis (UC), and to identify predictors of sustained clinical response during a 54-week CT-P13 treatment period.

PATIENTS AND METHODS

Patients with CD and UC, who were administered CT-P13, were prospectively enrolled. Clinical response was assessed at week 14 and week 54. Predictive factors for disease outcome at week 54 were evaluated.

RESULTS

57 CD and 57 UC patients were included; 55 CD and 49 UC patients completed the induction therapy and 50 CD and 46 UC patients completed the 54-week treatment period. Clinical remission was achieved in 65.5% of CD and 75.5% of UC patients at week 14. Rate of continuous clinical response was 51% in both CD and UC at week 54. None of the examined parameters were predictive to the clinical outcome neither in CD, nor in UC.

CONCLUSION

This study confirmed the long-term efficacy and safety of CT-P13 therapy in IBD. Response rates at week 54 were similar in CD and UC.