Increased risk of liver-related outcomes in chronic hepatitis B patients with metabolic syndrome: A systematic review and meta-analysis

Introduction: Chronic hepatitis B (CHB) patients with metabolic syndrome (MetS) may present increased risk of liver-related outcomes (LROs) but prior studies were limited by small sample size and/or conflicting results. Using a systematic review and meta-analytic approach, we aimed to determine the association between MetS and LROs in CHB. Methods: Two researchers independently screened studies from the PubMed, Embase, Web of Science, and Cochrane Library databases from inception to January 21, 2020 and extracted the data. Estimates were pooled using a random-effects model. Results: We screened 2,228 articles and included 10 eligible studies (18,360 CHB patients, 2,557 with MetS). MetS was significantly associated with LROs overall (OR=2.45, 95%CI=1.39-4.32) but not the individual LRO components but subgroup analyses were limited by small study numbers. Discussion/Conclusion: MetS is associated with almost 3 folds higher risk of LROs in CHB and should be considered in management decisions. However, additional studies are needed.

Clinical profiles of Asians with NAFLD: A systematic review and meta-analysis

Introduction: NAFLD is increasingly prevalent in Asia, where people suffer more metabolic comorbidities at a lower body mass index (BMI), suggesting potential differences in their clinical profile. Therefore, we attempted to characterize the clinical profile of Asians with NAFLD via a meta-analytic approach. Methods: We searched Pubmed, EMBASE, and Cochrane databases from January 1, 2000 to January 17, 2019. Two authors independently reviewed and selected 104 articles (2,247,754 persons) that identified NAFLD in Asians and reported relevant data, especially BMI and ALT, and excluded individuals with other liver disease and excessive alcohol consumption. Individual patient-level data were obtained from seven cohorts in Asia to complement meta-analyzed data. Results: Overall, the mean age was 52.07 (95%CI:51.28-52.85) years with those from Southeast Asia (42.66, 95%CI: 32.23-53.11) being significantly younger. The mean BMI was 26.2 kg/m2, higher in moderate-severe vs. mild hepatic steatosis (28.3 vs. 25.7) patients and NFS ≥-1.455 vs. <-1.455 (27.09 vs. 26.02), with 34% having non-obese NAFLD. The mean ALT was 31.74 U/L, higher in NFS <-1.455 vs. ≥-1.455 (33.74 vs. 27.83), though no differences were found by obesity or steatosis severity. The majority of males (85.7%) and females (60.7%) had normal to minimally elevated ALT (1-1.5x 95% ULN). Individual patient-level data analysis (N=7,668) demonstrated similar results. Conclusion: About one-third of Asians with NAFLD were non-obese and the majority did not have markedly elevated ALT. Therefore, abnormal ALT or BMI are not recommended as a criterion for NAFLD screening in this population. Additionally, there were significant differences in the clinical profiles of NAFLD among the different regions of Asia.

The thin red line between pathological and physiological inflammatory background in the gastric mucosa

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Compared the effectiveness and safety of different methods of colorectal endoscopic submucosal dissection: a systematic review and network meta-analysis

Background: Traditional endoscopic submucosal dissection (ESD) has developed different methods, such as pocket method(P-ESD), traction-assisted method(T-ESD) and Hybrid method(H-ESD). In this meta-analysis, the benefits and drawbacks of different ESD methods were discussed and ranked. Study design: Studies comparing different methods of colorectal ESD were searched by PubMed, Embase, and Cochrane Library databases. The study was conducted for five endpoints: en bloc resection rate, R0 resection rate, operation time, dissection speed, and adverse events rate. Pairwise and network meta-analyses were performed through Rev Man 5.4 and Stata 16.0. The quality of all included studies was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. Results: Twenty-six studies met the inclusion criteria, including 7 RCTs and 19 non-RCTs, with a total of 3002 patients. The pooled analysis showed that the en bloc resection rate of H-ESD was significantly lower than C-ESD, P-ESD and T-ESD [RR=0.28, 95%CI (0.12, 0.65); RR = 0.11, 95% CI (0.03, 0.44); RR = 8.28, 95% CI (2.50, 27.42)]. Compared with C-ESD, the operation time of H-ESD and T-ESD was significantly shorter [MD=-21.83, 95%CI (-34.76, -8.90); MD=-23.8, 95%CI (-32.55, -15.06)]. Meanwhile, the operation time of T-ESD was also significantly shorter than P-ESD [MD=-18.74, 95%CI (-31.93, -5.54)]. The dissection speed of T-ESD was significantly faster than C-ESD [MD=6.26, 95%CI (2.29, 10.23)]. Conclusion: P-ESD and T-ESD are probably the two best methods of colorectal ESD at present. The advantages of P-ESD are high en bloc resection rate and low incidence of adverse events. The advantages of T-ESD are rapid dissection and short operation time.

Signs of dissociation and symptoms of post-traumatic stress disorder in inflammatory bowel disease. A case-control study

Background. Several psychological disorders have been described in patients affected by Inflammatory Bowel Disease (IBD). Few studies have focused on the relationship between IBD and Post-Traumatic Stress Disorder (PTSD) symptoms, and no data are available on the relationship between IBD and dissociative symptoms. Aim of the present study was to evaluate the prevalence of PTSD and dissociative symptoms in a sample of IBD patients compared to healthy controls. A possible relationship with disease activity was also investigated. Methods: A total of 112 IBD patients, 55 Crohn’s disease (CD) and 57 Ulcerative Colitis (UC), and 114 healthy individuals were evaluated. IBD patients were divided into three subgroups according to disease activity (remission, mild, moderate). The revised version of the Impact of Event Scale (IES-R) and the Dissociative Experience Scale (DES) were administered to patients and controls. Results: IBD patients showed significantly higher rates of PTSD and dissociative symptoms compared to healthy controls. No differences were found between CD and UC patients. PTSD and dissociative symptoms were higher among CD patients with mild to moderate-severe activity compared to the remission group. No differences were found among UC patients with different activity levels. Conclusion: IBD patients show a high prevalence of dissociative and traumatic affective disorders. Future studies are needed to investigate the role of these disorders in the clinical course and management of IBD patients according to different disease activity phase.

A steep early learning curve for Endoscopic Submucosal Dissection (ESD) in the live porcine model

Background: Endoscopic Submucosal Dissection (ESD) is a demanding procedure requiring high level of expertise. ESD training programs incorporate procedures with live animal models. This study aimed to assess the early learning curve for performing ESD on live porcine models by endoscopists without any or limited previous ESD experience. Methods: In a live porcine model ESD workshop, number of resections, completeness of the resections, en bloc resections, adverse events, tutor intervention, type of knife, ESD time and size of resected specimens were recorded. ESD speed was calculated. Results: A total of 70 procedures were carried out by 17 trainees. The percentage of complete resections, en bloc resections and ESD speed increased from the first to the latest procedures (88,2% to 100%; 76,5% to 100%; 8,6 to 31,4mm2/min, respectively). The number of procedures in which a trainee needed tutor intervention and the number of adverse events also decreased throughout the procedures (4 to 0 and 6 to 0, respectively). During the workshop, when participants changed to a different type of knife, ESD speed slightly decreased (18,5mm2/min to 17,0mm2/min) and adverse events increased again (0 to 2). Conclusions: Through successive procedures, complete resections, en bloc resections and ESD speed improve whereas adverse events decrease, supporting the role of the live porcine model in the preclinical learning phase. Changing ESD knives has a momentarily negative impact on the learning curve.

Antibody response to SARS-CoV-2 vaccination in patients with inflammatory bowel disease – results of a single-center cohort study in a tertiary hospital in Germany

COVID-19 was first described in 2019, with significant impact on everyday life since then. In 2020, the first vaccine against COVID-19 was approved. Little is known about immune response to vaccination in patients with inflammatory bowel disease (IBD). Aim of our study was to investigate antibody response to SARS-CoV-2 vaccination in IBD patients receiving immunomodulators/biologics compared to healthy controls. This was a single-center retrospective study. 72 patients with IBD were included. Data from 72 healthy employees were used as control group matched by propensity score. Blood samples were analyzed for antibody response. 65 (90.3%) patients of the IBD group received immunomodulatory therapy. Mean antibody level for IBD patients was 1257.1 U/ml (SD 1109.626) in males and 1500.1 U/ml (SD 1142.760) in females (reduced antibody response IBD group 1383.76 U/ml SD 1125.617; control group 1885.65 U/ml SD 727.572, p < 0.05)). There was no vaccination failure in IBD group. After first vaccination, side effects were reported more often in IBD patients (total symptoms IBD group 58.3 %, control group 34.5 %, p < 0.007) with the opposite after the second vaccination (total symptoms IBD group 55.4 %, control group 76 %, p = 0.077)). There was a trend to reduced immune response in elderly. Disease duration and immunomodulatory therapy had no impact on immune response. Longer time to last medication given and time passed to vaccination in IBD group seem to have a positive impact on antibody levels. High antibody response to vaccination in all patients with IBD was seen. Vaccination was well tolerated. Concomitant immunomodulatory therapy had no impact on seroconversion. Antibody levels in the IBD group were lower compared to control group.

Retrospective Database Analysis: Dose Escalation and Adherence in Patients Initiating Biologics for Ulcerative Colitis

Background: Biologic therapies are often used in patients with ulcerative colitis who are non-responsive to conventional treatments. However, non-response or loss of response to biologics often occurs, leading to dose escalation, combination therapy, and/or treatment switching. We investigated real-world treatment patterns of biologic therapies among patients with ulcerative colitis in the USA. Methods: This study analyzed data from the IBM® MarketScan® Commercial and Medicare Supplemental Databases (medical/pharmacy claims for >250 million patients in the USA) to identify patients with ulcerative colitis initiating a biologic therapy (adalimumab, infliximab, golimumab, or vedolizumab) with 12 months of follow-up post-initiation. Key measures were patient baseline characteristics, dose escalation (average maintenance dose >20% higher than label), adherence (proportion of days covered), and ulcerative colitis-related healthcare costs in the 12 months following biologic therapy initiation. Results: Of 2,331 patients included in the study (adalimumab [N=1,291], infliximab [N=810], golimumab [N=127], vedolizumab [N=103]), 28.1% used concomitant immunosuppressant therapy within 12 months post-initiation. Overall, 23.6% (adalimumab), 34.8% (infliximab), 9.9% (golimumab), and 39.2% (vedolizumab) of patients dose escalated within 12 months. Patients who dose escalated incurred $20,106 higher total ulcerative colitis-related healthcare costs over 12 months than those who did not. Adherence (covariate-adjusted proportion of days covered) ranged from 0.63 to 0.73, and 39.3% of patients discontinued within 12 months (median treatment duration=112 days). Conclusion: Dose escalation was common, and incurred higher costs, in patients with ulcerative colitis initiating biologic therapies. Sub-optimal adherence and/or discontinuation within 12 months of initiation occurred frequently, highlighting the challenges in managing these patients.

A systematic review on the effectiveness of clinician directed interventions to improve compliance to post polypectomy surveillance guidelines

Introduction Clinical practice guidelines recommend periodic colonoscopy surveillance following colorectal adenoma excision. Inappropriate use of post polypectomy surveillance is common and lead to improper resource utilisation.The aim of this review is to identify structured interventions which can affect post polypectomy surveillance practices and to evaluate the effectiveness of these various interventions in improving clinician adherence to post polypectomy surveillance guidelines. Methods A computerised search was performed to identify relevant studies between 1997 to November 2020. Two investigators identified eligible studies and extracted data independently. The quality of the included studies was assessed by the Newcastle-Ottawa risk of assessment scoring system. Results The search identified 5602 citations. Forty-one articles were retrieved for full text analysis and seven studies met the inclusion criteria. Compliance to PPS guidelines were higher following interventions which included medical education, specialist nurse coordinators facilitation, continuous quality improvement and clinical decision support systems. Conclusion This study demonstrates that medical education, specialist nurse coordinators, continuous quality improvement and clinical decision support systems are effective in improving clinicians’ compliance to post polypectomy surveillance guidelines and is associated with reduction in over- and underutilisation of colonoscopy surveillance resources.

Effects of washed microbiota transplantation on serum uric acid levels, symptoms and intestinal barrier function in patients with acute and recurrent gout: a pilot study

Introduction: Gut dysbiosis has been reported to be closely associated with gout. Washed microbiota transplantation (WMT) is considered as an effective way to restore a healthy gut microbiota with less adverse events than the conventional fecal microbiota transplantation. In this study, we aimed to evaluate the effects of WMT on serum uric acid levels, symptoms and the intestinal barrier function in patients with acute and recurrent gout. Methods: We performed a pilot study of WMT for acute and recurrent gout. The primary outcome was the changes in serum uric acid level and gout symptoms. The secondary outcomes included the changes in levels of diamine oxidase (DAO), D-lactic acid and endotoxin. Results: Eleven patients received WMT treatment. The averaged serum uric acid levels in patients with gout reduced after WMT (P = 0.031), accompanied with a decrease in the frequency and duration time of acute gout flares (P < 0.01). The levels of DAO, D-lactic acid and endotoxin were higher in patients than in healthy donors (P < 0.05). After WMT treatment, the levels of DAO and endotoxin decreased (P < 0.05). Conclusions: WMT is effective for reducing serum uric acid levels and improving gout symptoms in patients with gout, and contributes to improve their impaired intestinal barrier function.