Combination of corticosteroids and 5-aminosalicylates or corticosteroids alone for patients with moderate-severe active ulcerative colitis:A global survey of physicians'practice

AIM To examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates(5ASA) with corticosteroids(CS) versus corticosteroids alone for patients with active ulcerative colitis(UC). METHODS A cross-sectional questionnaire exploring physicians' attitude toward 5ASA + CS combination therapy vs CS alone was developed and validated. The questionnaire was distributed to gastroenterology experts in twelve countries in five continents. Respondents' agreement with stated treatment choices were assessed by standardized Likert scale. Background professional characteristics of respondents were analyzed for correlation with responses. RESULTS Six hundred and sixty-four questionnaires were distributed and 349 received(52.6% response rate). Of 340 eligible respondents, 221(65%) would continue 5ASA in a patient hospitalized for intravenous CS treatment due to a moderate-severe UC flare, while 108(32%) would stop the 5ASA(P < 0.001), and 11(3%) are undecided. Similarly, 62% would continue 5ASA in an out-patient starting oral CS. However, only 140/340(41%) would proactively start 5ASA in a hospitalized patient not receiving 5ASA before admission. Most(94%) physicians consider the safety profile of 5ASA as very good. Only 52% consider them inexpensive, 35% perceive them to be expensive and 12% are undecided. On multi-variable analysis, less years of practice and perception of a plausible additive mechanistic effect of 5ASA + CS were positively associated with the decision to continue 5ASA with CS. CONCLUSION Despite the absence of data supporting its benefit, most gastroenterologists endorse combination of 5ASA + CS for patients with active moderate-to-severe UC. Randomized controlled trials are needed to assess if 5ASA confer any benefit for these patients.

Vedolizumab for ulcerative colitis: Real world outcomes from a multicenter observational cohort of Australia and Oxford

BACKGROUND Vedolizumab(VDZ),a humanised monoclonal antibody that selectively inhibits alpha4-beta7 integrins is approved for use in adult moderate to severe ulcerative colitis(UC)patients.AIM To assess the efficacy and safety of VDZ in the real-world management of UC in a large multicenter cohort involving two countries and to identify predictors of achieving remission.METHODS A retrospective review of Australian and Oxford,United Kingdom data for UC patients.Clinical response at 3 mo,endoscopic remission at 6 mo and clinical remission at 3,6 and 12 mo were assessed.Cox regression models and Kaplan Meier curves were performed to assess the time to remission,time to failure and the covariates influencing them.Safety outcomes were recorded.RESULTS Three hundred and three UC patients from 14 centres in Australia and United Kingdom,[60%n=182,anti-TNF naïve]were included.The clinical response was 79%at 3 mo with more Australian patients achieving clinical response compared to Oxford(83%vs 70%P=0.01).Clinical remission for all patients was 56%,62%and 60%at 3,6 and 12 mo respectively.Anti-TNF naive patients were more likely to achieve remission than exposed patients at all the time points(3 mo 66%vs 40%P<0.001,6 mo 73%vs 46%P<0.001,12 mo 66%vs 51%P=0.03).More Australian patients achieved endoscopic remission at 6 mo compared to Oxford(69%vs 43%P=0.01).On multi-variate analysis,anti-TNF naïve patients were 1.8(95%CI:1.3-2.3)times more likely to achieve remission than anti-TNF exposed(P<0.001).32 patients(11%)had colectomy by 12 mo.CONCLUSION VDZ was safe and effective with 60%of UC patients achieving clinical remission at 12 mo and prior anti-TNF exposure influenced this outcome.

Hepatocellular carcinoma staging systems: Hong Kong liver cancer vs Barcelona clinic liver cancer in a Western population

BACKGROUND Despite being the world’s most widely used system for staging and therapeutic guidance in hepatocellular carcinoma(HCC)treatment,the Barcelona clinic liver cancer(BCLC)system has limitations,especially regarding intermediate-grade(BCLC-B)tumors.The recently proposed Hong Kong liver cancer(HKLC)staging system appears useful but requires validation in Western populations.AIM To evaluate the agreement between BCLC and HKLC staging on the management of HCC in a Western population,estimating the overall patient survival.METHODS This was a retrospective study of HCC patients treated at a university hospital in southern Brazil between 2011 and 2016.Demographic,clinical,and laboratory data were collected.HCC staging was carried out according to the HKLC and BCLC systems to assess treatment agreement.Overall survival was estimated based on the treatment proposed in each system.RESULTS A total of 519 HCC patients were assessed.Of these,178(34.3%)were HKLC-I;95(18.3%)HKLC-IIA;47(9.1%)HKLC-IIB;29(5.6%)HKLC-IIIA;30(5.8%)HKLCIIIB;75(14.4%)HKLC-IV;and 65(12.5%)HKLC-V.According to the BCLC,25(4.9%)were BCLC-0;246(47.4%)BCLC-A;107(20.6%)BCLC-B;76(14.6%)BCLCC;and 65(12.5%)BCLC-D.The general agreement between the two systems was 80.0%-BCLC-0 and HKLC-I(100%);BCLC-A and HKLC-I/HKLC-II(96.7%);BCLC-B and HKLC-III(46.7%);BCLC-C and HKLC-IV(98.7%);BCLC-D and HKLC-V(41.5%).When sub-classifying BCLC-A,HKLC-IIB,HKLC-IIIA and HKLC-IIIB stages according to the up-to-7 in/out criterion,13.4,66.0,100 and 36.7%,respectively,of the cases were classified as up-to-7 out.CONCLUSION In a Western population,the general agreement between the two systems was 80.0%,although in BCLC-B cases the agreement was low,suggesting that some individuals could be candidates for the curative treatment recommended by the HKLC.The authors suggest that the BCLC system should be routinely employed,although for BCLC-B cases it should be associated with the HKLC system.

Capsule endoscopy capture rate: Has 4 frames-per-second any impact over 2frames-per-second?

AIM: To compare the current capsule and a new prototype at 2 and 4 frames-per-second, respectively, in terms of clinical and therapeutic impact.

Brown slits for colorectal adenoma crypts on conventional magnifying endoscopy with narrow band imaging using the X1 system

BACKGROUND Accurate diagnosis of colorectal premalignant polyps,including adenomas,is vital in clinical practice.AIM To investigate the diagnostic yields of novel findings of brown slits for adenomas.METHODS Patients who underwent colonoscopy at the Toyoshima Endoscopy Clinic were enrolled.Polyps sized≥5 mm suspected of adenomas or clinically significant serrated polyps were included in the study.We defined the surface structures of colorectal polyps,which were brown curves inside and along the tubular glands identified using a combination of a new X1 system(Olympus Corporation)and a conventional magnifying colonoscope with non-staining narrow band imaging(NBI),as brown slits.The brown slits corresponded to slit-like lumens on endocytoscopy and histological crypt openings of an adenoma.We evaluated the diagnostic performance of brown slits for adenoma.RESULTS A total of 108 Lesions from 62 patients were eligible.The average age was 60.4 years and 41.9%were male.The mean polyp size was 7.45±2.83 mm.Fifty-seven lesions were positive for brown slits.Histopathological diagnosis comprised 59 low-grade tubular adenomas,16 sessile serrated lesions,and 33 hyperplastic polyps.Among 59 adenomas,56(94.9%)were positive for brown slits.Among 16 sessile serrated lesions,0(0%)was positive for brown slits.Among 33 hyperplastic polyps,1(3.0%)was positive for brown slits.The sensitivity,specificity,and accuracy of brown slits for adenoma were 94.9%,98.0%,and 96.3%,respectively.The positive predictive value and negative predictive value of brown slits for adenoma were also excellent for 98.2%,and 94.1%,respectively.CONCLUSION Brown slits on conventional magnifying endoscopy with non-staining NBI using the X1 system were useful for diagnosing colorectal adenoma.The new endoscopy system could be examined using new standards.

重型慢性胰腺炎支架植入后长期结果

Background and Study Aims: Although it has been proved that pancreatic stentin g is effective in the symptomatic management of severe chronic pancreatitis, lon g-term outcomes after stent removal have not been fully evaluated. Patients and Methods: A total of 100 patients (75 men, 25 women; median age 49) with severe chronic pancreatitis and pancreatic duct strictures were successfully treated fo r pancreatic pain using polyethylene pancreatic stents and were followed up for at least 1 year after stent removal. The stents were exchanged “on demand" (in cases of recurrence of pain) and a definitive stent removal was attempted on the basis of clinical and endoscopic findings. Clinical variables were retrospectiv ely assessed as potential predictors of re-stenting. Results: The etiology of t he chronic pancreatitis was alcoholic (77%), idiopathic (18%), or hereditary ( 5%). Patients were followed up for a median period of 69 months (range 14-163 months) after study entry, including a median period of 27 months (range 12 -12 6 months) after stent removal. The median duration of pancreatic stenting before stent removal was 23 months (range 2 -134 months). After attempted definitive stent removal, 30 patients (30%) required re-stenting within the first year of follow-up, at a median time of 5.5 months after stent removal (range 1-12 mon ths), while in 70 patients (70%) pain control remained adequate during that period. By the end of the follow-up period a total of 38 patients had require d re-stenting and four ultimately underwent pancreaticojejunostomy. Pancreas di visum was the only factor significantly associated with a higher risk of re-ste nting (P = 0.002). Conclusions: The majority (70%) of patients with severe chro nic pancreatitis who respond to pancreatic stenting maintain this response after definitive stent removal. However,a significantly higher re-stenting rate was observed in patients with chronic pancreatitis and pancreas divisum.