Predicting variceal bleeding in patients with biliary atresia

Abstract

Background/aims: Variceal bleeding is the main cause of morbidity and mortality in children with portal hypertension and biliary atresia. The aim of this study is to predict high-risk varices by analyzing various clinical factors, thus improve prognosis of patients with biliary atresia.

Methods: A total of 157 patients with biliary atresia who underwent Kasai portoentrostomy were enrolled in a single center. Clinical data including laboratory values, endoscopic findings and values of transient elastography (FibroScan^®) were analyzed retrospectively.

Results: The bleeding group and the non-bleeding group showed statistically significant differences in several variables; The FibroScan^® value (HR 1.05, 95% CI (1.03–1.07), p < .01) was higher in the bleeding group. The bleeding group had values of lower albumin after 3?months of operation (HR 0.28, 95% CI (0.11–0.73), p = .01), higher bilirubin after 3?months of operation (total bilirubin: HR 1.18, 95% CI (1.04–1.33), p = .01), (direct bilirubin: HR 1.21, 95% CI (1.05–1.41), p = .01). Gastric varix (HR 4.10, 95% CI (1.62–10.36), p < .01) was more frequent in the bleeding group. And the presence of red sign was also predictive of bleeding. The FibroScan^® cut-off value with the predictive power of bleeding was 31.5?kPa (HR 7.7, 95% CI (3.36–17.73), p < .01).

Conclusions: Several clinical factors including high value of transient elastography (FibroScan^®), gastric varix or red sign of endoscopy, and low albumin or high bilirubin values after 3?months of Kasai operation can be useful in predicting variceal bleeding in patients with biliary atresia.     

Serological markers in diagnosis of pediatric inflammatory bowel disease and as predictors for early tumor necrosis factor blocker therapy

Objective: To describe the prevalence of serological markers in newly diagnosed treatment-naïve pediatric inflammatory bowel disease (IBD), their utility in differentiating Crohn’s disease (CD), ulcerative colitis (UC) and symptomatic non-IBD patients and whether serological markers are associated with early TNF blocker treatment.

Material and methods: Ninety-six children and adolescents <18 years, 58 with IBD and 38 symptomatic non-IBD controls were included. At diagnosis and after 1–2 years, serological antibodies (anti-Saccharomyces cerevisiae antibodies (ASCA), perinuclear anti-neutrophil cytoplasmic antibody (pANCA), flagellin expressed by Clostridial phylum (anti-CBir1), outer membrane porin of Escherichia coli (anti-OmpC), Pseudomonas fluorescens-associated sequence (anti-I2), CRP, ESR and fecal calprotectin were analyzed. The choice of treatment was made at the discretion of the treating pediatrician.

Results: Of the IBD patients, 20 (36%) and 26 (47%) were positive for ASCA and pANCA compared to 3(8%), p?<?.01 and 10 (27%), p?=?.04 of the controls. Thirteen (72%) of UC patients were pANCA positive, versus 13 (35%) of CD patients (p?<?.01). None of the UC patients was ASCA positive versus 20 (54%) of CD patients (p?<?.0001). Compared to conventionally treated patients, the 18 (49%) TNF blocker treated CD patients had higher presence of ASCA (p?<?.01), lower presence of pANCA (p?=?.02) and higher levels of fecal calprotectin, CRP and ESR at diagnosis. In multivariate analyses ASCA and pANCA status, but not CRP, ESR or calprotectin, were independently associated with early TNF blocker treatment.

Conclusions: ASCA and pANCA status were associated with having IBD and with early TNF blocker treatment in CD.     

Heparin bridge therapy and post-polypectomy bleeding

AIM To identify risk factors for post-polypectomy bleeding(PPB), focusing on antithrombotic agents. METHODS This was a case-control study based on medical records at a single center. PPB was defined as bleeding that occurred 6 h to 10 d after colonoscopic polypectomy and required endoscopic hemostasis. As risk factors for PPB, patient-related factors including anticoagulants, antiplatelets and heparin bridge therapy as well as polyp- and procedure-related factors were evaluated. All colonoscopic hot polypectomies, endoscopic mucosal resections and endoscopic submucosal dissections performed between January 2011 and December 2014 were reviewed. RESULTS PPB occurred in 29(3.7%) of 788 polypectomies performed during the study period. Antiplatelet or anticoagulant agents were prescribed for 210(26.6%)patients and were ceased before polypectomy except for aspirin and cilostazol in 19 cases. Bridging therapy using intravenous unfractionated heparin was adopted for 73 patients. The univariate analysis revealed that anticoagulants, heparin bridge, and anticoagulants plus heparin bridge were significantly associated with PPB(P 0.0001) whereas antiplatelets and antiplatelets plus heparin were not. None of the other factors including age, gender, location, size, shape, number of resected polyps, prophylactic clipping and resection method were correlated with PPB. The multivariate analysis demonstrated that anticoagulants and anticoagulants plus heparin bridge therapy were significant risk factors for PPB(P 0.0001). Of the 29 PPB cases, 4 required transfusions and none required surgery. A thromboembolic event occurred in a patient who took anticoagulant. CONCLUSION Patients taking anticoagulants have an increased risk of PPB, even if the anticoagulants are interrupted before polypectomy. Heparin-bridge therapy might be responsible for the increased PPB in patients taking anticoagulants.     

Liver cirrhosis stages and the incidence of hepatocellular carcinoma in chronic hepatitis B patients receiving antiviral therapy

Objectives: Long-term antiviral therapy decreases the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB), however, it cannot eliminate the risk. We investigated the incidence of HCC at different stages of liver cirrhosis (LC) and identified clinical predictors for HCC development during antiviral therapy.

Methods: The data from 356 treatment-naïve patients aged 40 to 69 years without a history of HCC who had received entecavir for ≥6 months were collected retrospectively. The incidence of HCC was evaluated in patients with CHB only, with LC without varices (stage 1), with varices (stage 2), and with ascites (stage 3).

Results: The median follow-up period was 3.6 years. In total, 45 patients (12.6%) developed HCC. The annual incidence rates of HCC in patients with CHB only or LC in stages 1, 2, and 3 were 0.4%, 2.6%, 9.8%, and 6.7%, respectively. In multivariate analyzes, LC at stage 2 (hazard ratio [HR] 17.16, 95% confidence interval [C.I.] 3.93–75.01, p?<?.001), alcohol consumption (HR 3.84, 95% C.I. 1.99–7.39, p?<?.001), and older age (HR 1.06, 95% C.I. 1.01–1.11, p?=?.010) were significantly associated with HCC development. The risk decreased in those who stopped drinking after 2 years of abstinence (p?=?.0314).

Conclusions: LC with significant portal hypertension (varices or ascites), alcohol consumption, and older age at the time of starting antiviral therapy are independent predictors for future HCC development.     

Risk of colonoscopic post-polypectomy bleeding in patients after the discontinuation of antithrombotic therapy

Background/AimsFew studies have examined the incidence of post-polypectomy bleeding (PPB) after discontinuation of antithrombotic therapies. Therefore, this study aimed to evaluate the incidence of PPB and thromboembolic events in patients whose antithrombotic agents were discontinued before colonoscopy.Materials and MethodsWe retrospectively selected all patients who underwent colon polypectomy at a community hospital. A total of 282 patients (540 polypectomies) discontinued antithrombotic agents (group 1), and 1,648 patients (2,827 polypectomies) did not take antithrombotic agents (group 2). The cessation periods before and after polypectomies were 4 and 3 days for warfarin, 5 and 3 days for anti-platelet agents, and 7 and 5 days of combination therapy, respectively. Main outcome measurements were the incidence of PPB and thromboembolic events.ResultsImmediate PPB rates were 3.9% (11/282) in group 1 and 4.6% (76/1648) in group 2 (adjusted odds ratio [OR], 0.85; 95% confidence interval [CI], 0.42–1.72; p=0.65). Delayed PPB rates were 1.4% (4/282) in group 1 and 1.1% (18/1648) in group 2 (adjusted OR, 1.24; 95% CI, 0.36–4.24; p=0.732). No thromboembolic events were observed in either group.ConclusionOur cessation periods were appropriate, and further shortening of these periods is possible.     

Development of psoriasis in IBD patients under TNF-antagonist therapy is associated neither with anti-TNF-antagonist antibodies nor trough levels

Background: The cause of anti-TNF-induced psoriasis is still unknown.

Objective: We aimed to evaluate if the appearance of psoriasis under anti-TNF therapy is associated with anti-TNF antibody levels and TNF-antagonist trough levels.

Methods: In this case-control study we identified 23 patients (21 with Crohn’s disease [CD], two with ulcerative colitis [UC]) who developed psoriasis under infliximab (IFX, n?=?20), adalimumab (ADA, n?=?2), and certolizumab pegol (CZP, n=?1) and compared them regarding the anti-TNF-antagonist antibody levels with 85 IBD patients (72 with CD, 13 with UC) on anti-TNF therapy without psoriasis.

Results: Median disease duration was not different between the two groups (7 years in the group with psoriasis under TNF-antagonists vs. 10 years in the control group, p?=?0.072). No patient from the psoriasis group had antibodies against TNF-antagonists compared to 10.6% in the control group (p?=?0.103). No difference was found in IFX trough levels in the group of patients with psoriasis compared to the control group (2.6?μg/mL [IQR 0.9–5.5] vs. 3.4?μg/mL [IQR 1.4–8.1], p?=?0.573). TNF-antagonist therapy could be continued in 91.3% of patients with TNF-antagonist related psoriasis and most patients responded to topical therapies.

Conclusion: Anti-TNF-induced psoriasis seems to be independent of anti-TNF antibodies and trough levels. Interruption of Anti-TNF therapy is rarely necessary.     

Outcomes following laparoscopic versus open major hepatectomy: a meta-analysis

Objective: The role of laparoscopic major hepatectomy (LMH) remains uncertain in current liver surgery. This meta-analysis aimed to compare surgical and oncological outcomes of LMH versus open major hepatectomy (OMH).

Methods: A systematic search was conducted in PubMed, Embase, and the Cochrane Library database to identify all relevant publications. The statistical analysis was performed using Review Manager version 5.3. Continuous variables were calculated by standardized mean differences (SMD) with 95% confidence interval (CI), whereas dichotomous variables were calculated by odds ratio (OR) with 95%CI.

Results: A total of 10 eligible studies with 1130 patients were identified, of which 455 (40.3%) patients in the LMH group and 675 (59.7%) patients in the OMH group. LMH was associated with less blood loss (SMD?=??0.30, 95%CI: ?0.43 to ?0.18, p?p?=?.007), decreased postoperative morbidity (OR?=?0.56, 95%CI: 0.42–0.76, p?=?.0001), and shorter hospital stay (SMD?=??0.46, 95%CI: ?0.69 to ?0.24, p?p?=?.01). Both the two groups achieved similar surgical margin and R0 resection rate for malignant lesions.

Conclusions: This meta-analysis demonstrated that LMH appeared to be feasible and safe in current liver surgery. LMH is associated with less blood loss, decreased postoperative morbidity, shorter hospital stay, and comparable oncological outcomes compared with OMH.     

Hepatocellular carcinoma surveillance with liver imaging is not associated with improved survival

Abstract

Objective: International guidelines recommend hepatocellular carcinoma (HCC) surveillance with ultrasound in high-risk patients with chronic liver diseases. However, there is low-strength evidence about the effects on mortality. The aim of our study was to assess the impact of surveillance on the clinical course and survival of HCC patients seen at a tertiary referral center in Germany.

Material and methods: We retrospectively evaluated the data of 401 HCC patients, who presented to our clinic between 1997 and 2015. Two groups were compared regarding patient and disease outcomes: one group included patients who received at least two ultrasound examinations for surveillance purposes prior to first diagnosis (n?=?111). The other group consisted of patients with HCC at first presentation without foregoing HCC surveillance (n?=?290).

Results: Median follow-up in the surveillance group was 76?months (range 4–310?months). Patients in the surveillance group had smaller median tumor sizes (3.5?cm vs. 4.5?cm; p?<?.001), fulfilled more often Milan criteria (64% vs. 42%; p?<?.001) and received more often liver transplantation (27% vs. 9%, p?<?.001) when compared with the non-surveillance group. However, HCC surveillance was not associated with an improved survival (14?months in the surveillance group vs. 12?months in the non-surveillance group, p?=?.375), hazard ratio regarding overall mortality for the surveillance group: 0.80 (95% CI: 0.62–1.04, p?=?.09).

Conclusions: HCC surveillance with ultrasound led to the detection of earlier disease stages but was not significantly associated with improved survival. Further prospective and long-term studies are needed to clarify benefits and harms of HCC surveillance programs on mortality.     

Clinical feature and anti-phospholipid antibody profiles of pregnancy failure in young women with antiphospholipid antibody syndrome treated with conventional therapy

Objective: To elucidate clinical feature and anti-phospholipid antibody (aPL) profiles, including lupus anticoagulant (LA), anti-cardiolipin (CL) antibodies and anti-phosphatidylserine/prothrombin (PS/PT) antibodies, of pregnancy failure in patients with antiphospholipid antibody syndrome (APS) already treated with conventional therapy.

Materials and methods: Thirty-four women with a history of pregnancy who were diagnosed with APS between 2008 and 2016 were included in the study. We defined the successful pregnancy group as women who gave birth to a healthy baby over 1500?g after 34 weeks of pregnancy under conventional treatment (heparin and/or low-dose aspirin). The unsuccessful pregnancy group was defined as women whose pregnancy outcomes did not meet the aforementioned criteria despite the conventional therapy. The clinical features and aPL profiles were compared between the two groups.

Results: Fifteen women were classified into the unsuccessful pregnancy group; seven women were in the successful pregnancy group. Having history of both thrombosis and pregnancy morbidity and LA positivity were significantly more prevalent in the unsuccessful pregnancy group than in the successful pregnancy group (p?<.05, respectively). In contrast, single positivity of anti-CL antibody was negatively associated with APS-associated pregnancy morbidity under the conventional treatment (p?<.01). The proportion of anti-PS/PT IgG-positive patients was significantly higher in the unsuccessful pregnancy group (p?=?.02, OR 18.7, 95% CI 1.50, 232.29) with high concordance rate with LA (97% consistence).

Conclusion: History of both thrombosis and pregnancy morbidity and the positivity of LA and/or anti-PS/PT-IgG, not but anti-CL-antibodies were correlated with APS-associated pregnancy morbidity refractory to conventional treatment. Clinical feature and aPL profiles might help us to make risk assessment for adverse pregnancy outcomes in patients with APS.     

Initiation of therapy for obstructive sleep apnea syndrome: a randomized comparison of outcomes of telemetry-supported home-based vs. sleep lab-based therapy initiation

Purpose

Diagnosis and treatment of obstructive sleep apnea are traditionally performed in sleep laboratories with polysomnography (PSG) and are associated with significant waiting times for patients and high cost. We investigated if initiation of auto-titrating CPAP (APAP) treatment at home in patients with obstructive sleep apnea (OSA) and subsequent telemonitoring by a homecare provider would be non-inferior to in-lab management with diagnostic PSG, subsequent in-lab APAP initiation, and standard follow-up regarding compliance and disease-specific quality of life.

Methods

This randomized, open-label, single-center study was conducted in Germany. Screening occurred between December 2013 and November 2015. Eligible patients with moderate-to-severe OSA documented by polygraphy (PG) were randomized to home management or standard care. All patients were managed by certified sleep physicians. The home management group received APAP therapy at home, followed by telemonitoring. The control group received a diagnostic PSG, followed by therapy initiation in the sleep laboratory. The primary endpoint was therapy compliance, measured as average APAP usage after 6 months.

Results

The intention-to-treat population (ITT) included 224 patients (110 home therapy, 114 controls); the per-protocol population (PP) included 182 patients with 6-month device usage data (89 home therapy, 93 controls). In the PP analysis, mean APAP usage at 6 months was not different in the home therapy and control groups (4.38 ± 2.04 vs. 4.32 ± 2.28, p = 0.845). The pre-specified non-inferiority margin (NIM) of 0.3 h/day was not achieved (p = 0.130); statistical significance was achieved in a post hoc analysis when NIM was set at 0.5 h/day (p < 0.05). Time to APAP initiation was significantly shorter in the home therapy group (7.6 ± 7.2 vs. 46.1 ± 23.8 days; p < 0.0001).

Conclusion

Use of a home-based telemonitoring strategy for initiation of APAP in selected patients with OSA managed by sleep physicians is feasible, appears to be non-inferior to standard sleep laboratory procedures, and facilitates faster access to therapy.

     

The efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy compared with conventional antiplatelet therapy in patients with acute coronary syndrome or undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials

Abstract

Cytochrome P450 (CYP) 2C19 genotype is closely associated with the metabolism and efficacy of clopidogrel, thereby having an important impact on clinical outcomes of patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). This study aimed to evaluate the efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy in patients with ACS or undergoing PCI. PubMed, EMBASE, the Cochrane Library and clinicaltrials.gov were searched to identify randomized controlled trials (RCTs) comparing CYP2C19 genotype-guided antiplatelet therapy with conventional therapy in patients with ACS or undergoing PCI. Eight RCTs involving 6708 patients were included in this meta-analysis. CYP2C19 genotype-guided antiplatelet therapy was slightly superior to the conventional antiplatelet therapy in reducing the risk of MACE [RR(95%CI): 0.71(0.51–0.98), p = .04]. Meanwhile, the genotype-guided therapy group had significantly lower incidence of myocardial infarction [RR(95%CI): 0.56(0.40–0.78), p < .01], but similar risk of all-cause mortality, cardiovascular mortality, stent thrombosis, urgent revascularization and stroke compared to the conventional therapy group. Incidences of major/minor bleeding and major bleeding were comparable between the two groups. In patients with ACS or undergoing PCI, CYP2C19 genotype-guided antiplatelet therapy displayed benefit over conventional antiplatelet therapy in reducing the risk of MACE and myocardial infarction, without increasing bleeding risk. Further RCTs are needed to provide more evidences for CYP2C19 genotype-guided antiplatelet therapy.     

Anorectal function and the effect of biofeedback therapy in ambulatory spinal cord disease patients having constipation

Abstract

Objective. Constipation in patients with mild spinal cord disease is not well investigated yet. We aimed to investigate anorectal function and the effect of biofeedback therapy in constipated patients with mild spinal cord diseases. Material and methods. A total of 14 constipated patients with myelopathy and 32 with radiculopathy were enrolled retrospectively. All patients were able to walk independently. The control group comprised of 100 constipated patients without any neurologic problem. Colonic transit time and the presence of dyssynergia were assessed before biofeedback therapy. All patients answered structured questionnaires on constipation, before and after biofeedback therapy. Results. The mean rectosigmoid colonic transit time of the myelopathy group was significantly delayed (myelopathy, 18.6 ± 14.6 h; radiculopathy, 12.8 ± 11.9 h; control, 9.6 ± 11.2 h; p = 0.032). Delay in total colonic transit time was more frequent in the myelopathy group (myelopathy, 57.1%; radiculopathy, 23.3%; control, 18.5%; p = 0.004). On anorectal manometry, the squeezing pressure of the anal sphincter was decreased in the myelopathy group (myelopathy, 132.3 ± 73.3 mmHg; radiculopathy, 179.9 ± 86.1 mmHg; control 200.4 ± 82.4 mmHg; p < 0.05). The success rate of biofeedback therapy was lower in the myelopathy group (28.6% for myelopathy vs. 62.0% for control group; p = 0.034). The response rate to biofeedback therapy was similar between radiculopathy and control group (62.5% for radiculopathy vs. 62.0% for control group; p = 1.000). Conclusions. In constipation associated with mild myelopathy, delayed colonic transit and dyssynergic defecation were major pathophysiologic abnormalities and biofeedback was less effective compared with control group. However, in the radiculopathy group, biofeedback was as effective as in the control group.     

Acute diverticulitis in immunocompromised patients: evidence from an international multicenter observational registry (Web-based International Register of Emergency Surgery and Trauma,Wires-T)

Background

Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis.

Methods

We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2).

Results

Data from 482 patients were analyzed—229 patients (47.5%) [M:F = 1:1; median age: 60 (24–95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26–94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann’s procedure is mainly performed in grades 1–2 (p < 0.0001). Major complications increased significantly after a Hartmann’s procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002).

Conclusions

Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann’s procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay.

     

KL-6 is a long-term disease-activity biomarker for interstitial lung disease associated with polymyositis/dermatomyositis,but is not a short-term disease-activity biomarker

Abstract

Objectives: We aimed to evaluate the usefulness of serum KL-6 for interstitial lung disease (ILD) with polymyositis/dermatomyositis (PM/DM).

Methods: All consecutive and previously untreated adult patients with PM/DM who were admitted to our hospital from 2010 to 2015 were included. The associations between serum KL-6 levels and clinical information were retrospectively analyzed.

Results: Baseline serum KL-6 levels were significantly higher in patients with ILD than in those without (n?=?41 and 15, respectively; p?<?.001). In the 14 patients whose ILD improved within 4 weeks post-treatment, their serum KL-6 levels did not significantly decrease at 2 weeks, 4 weeks, or 3 months post-treatment (p?=?1.00, 1.00, and .83, respectively). Conversely, their serum KL-6 levels significantly decreased at 6, 9, and 12 months post-treatment (p?=?.01 in all comparisons). In the 12 patients whose ILD remained unchanged or deteriorated in 4 weeks post-treatment, only the difference between their serum KL-6 levels at 3 and 12 months was significant (p?=?.003).

Conclusions: The present study validated the serum KL-6 as a diagnostic marker for ILD in PM/DM. However, serum KL-6 is not a short-term disease-activity biomarker for ILD with PM/DM, but it is a long-term disease-activity biomarker.     

Efficacy of combination therapy with transcatheter arterial chemoembolization and radiofrequency ablation for intermediate-stage hepatocellular carcinoma

Abstract

Objectives: Transcatheter arterial chemoembolization (TACE) is the standard therapy for patients with intermediate-stage hepatocellular carcinoma (HCC). This study aimed to determine whether combination therapy with radiofrequency ablation (RFA) and TACE was superior to TACE monotherapy for intermediate-stage HCC and identify cases in which this technique was the most effective.

Materials and methods: We selected patients with intermediate HCC who met the following eligibility criteria: (1) ≥ 20 years of age, (2) receiving initial therapy, (3) ≤7 tumors, and (4) maximum tumor diameter <5?cm. We performed propensity score matching (PSM) using potential confounding factors. We retrospectively compared the cumulative overall survival rate and recurrence-free survival rate between the TACE?+?RFA and TACE groups. Additionally, a sub-group analysis was performed for preoperative factors.

Results: Among the 103 patients, 92 were selected using PSM. The cumulative overall survival rates at 1, 3, and 5 years for the TACE?+?RFA group were 97.4%, 70.4%, and 60.4%, respectively, which were significantly higher than those for the TACE group (92.7%, 55.7%, and 22.8%, respectively, p?=?.045). The recurrence-free survival rates at 0.5, 1, and 2 years for the TACE?+?RFA group were 80.0%, 58.6%, and 33.3%, respectively, which were significantly higher than those for the TACE group (34.5%, 8.8%, and 2.9%, respectively, p?p?=?.036).

Conclusions: The addition of RFA to TACE improved cumulative overall and recurrence-free survival in patients with intermediate-stage HCC, especially in patients with AFP <100.     

Concurrent immunomodulator therapy is associated with higher adalimumab trough levels during scheduled maintenance therapy

Introduction: Combination therapy with infliximab and immunomodulators is superior to monotherapy, resulting in better outcomes and higher trough levels of infliximab. The role of concurrent immunomodulatory therapy on adalimumab trough levels has not been adequately investigated. We evaluated the impact of concomitant immunomodulation on adalimumab trough levels in patients on scheduled maintenance therapy.

Method: We conducted a prospective observational, cross-sectional study of all inflammatory bowel disease patients on maintenance therapy who had adalimumab trough levels measured between January 2013 and January 2016. Drug level and anti-drug antibody measurements were performed on sera using a solid phase assay. Pairwise comparison of means was used to compare trough levels in patients with and without concomitant immune modulator therapy.

Results: In total, 79 patients were included. Twenty-three patients (29.1%) were on weekly dosing whereas 56 (70.9%) were on alternate weeks. Median adalimumab trough levels were comparable in patients with and without clinical remission (6.8?μg/ml (IQR 5.6–8.1) versus 6.7?μg/ml (IQR 3.9–8.1), respectively. Patients with an elevated faecal calprotectin?>250?μg/g had lower adalimumab trough levels (median 6.7, IQR 3.9–8) compared to patients with faecal calprotectin?<250?μg/g (median 7.7, IQR 6.1–8.1) though this did not achieve statistical significance (p?=?.062). Median adalimumab trough levels among patients on concurrent immunomodulators was 7.2?μg/ml (IQR 5.7–8.1) compared to those not on concurrent immunomodulator, 6.1?μg/ml (IQR 2.7–7.7, p?=?.0297).

Conclusion: Adalimumab trough levels were significantly higher in patients on concurrent immunomodulators during maintenance therapy. There was a trend towards a lower adalimumab trough level in patients with elevated calprotectin.     

A randomized comparison of two direct oral anticoagulants for patients undergoing cardiac ablation with a contemporary warfarin control arm

Background

The safety and efficacy of periprocedural use of direct oral anticoagulants (DOACs) for atrial fibrillation (AF) remain unclear. We compared the incidence of asymptomatic cerebral micro-thromboembolism and hemopericardium following AF ablation among patients receiving edoxaban, rivaroxaban, and warfarin and between normal- and low-dose use of edoxaban and rivaroxaban.

Methods

This prospective randomized study included 170 consecutive AF patients. Patients taking DOACs upon admission to our hospital were randomly assigned to an edoxaban group or to a rivaroxaban group. Warfarin was continued in patients receiving warfarin at admission. All patients underwent AF ablation, and cerebral MRI was performed to evaluate asymptomatic cerebral micro-thromboembolism the day after the procedure.

Results

Sixty-one patients were assigned to edoxaban and 63 to rivaroxaban. Warfarin was continued in 46 patients. Although asymptomatic cerebral micro-thromboembolism was detected in 25 patients (16.3%), there were no significant differences among the groups. Hemopericardium occurred in 2 patients (one each in the rivaroxaban and warfarin groups). The incidence of asymptomatic cerebral micro-thromboembolism was higher in the low-dose group (9 patients, 25.7%) than in the normal-dose group (8 patients, 10.0%) for patients prescribed either edoxaban or rivaroxaban (p?<?0.05). The proportion of males (88.0%, 69.5%, p?<?0.05), history of prior AF ablation (64.0%, 42.2%, p?<?0.05), and hypertension (68.0%, 46.1%, p?<?0.05) were significantly higher in patients with cerebral thromboembolism.

Conclusions

The incidence of asymptomatic cerebral micro-thromboembolism and hemopericardium in AF ablation was similar among patients using edoxaban, rivaroxaban, and warfarin. However, low doses of DOACs may increase the risk of asymptomatic stroke.

     

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

Background: Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

Patients and methods: We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

Results: The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p?<?.01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43–12.6; p?<?.01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p?<?.01).

Conclusions: Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.     

Endoscopists' view on superficial spreading type of early gastric cancer – endoscopic resection or surgery?

Abstract

Objective. The superficial spreading type of early gastric cancer (EGC) possesses unique features different from other types of EGC. We aimed to elucidate the clinicopathological features of superficial spreading type of EGC. Material and methods. We analyzed 1455 EGC lesions from 1398 patients who had undergone surgical treatment at Samsung Medical Center from 2000 to 2002. Then the clinicopathological features of 224 superficial-spreading EGC lesions (15.4%) was compared to that of 1231 lesions of a common type of EGC. Results. In the superficial spreading type of EGC, the incidence of undifferentiated type and submucosal invasion were higher than those of common type of EGC (55.4 vs 38.0%, p <?.01 and 58.5 vs 37.8%, p <?.01, respectively). Lymph node metastasis and lymphovascular invasion were more frequent in superficial spreading type than in common type of EGC (19.2 vs 7.6%, p <?.01 and 15.2 vs 7.4%, p <?.01, respectively). There was no difference in recurrence rate or 5-year survival rate between the two groups. Conclusion. Considering higher risk of submucosal invasion and lymph node metastasis in superficial spreading type, a careful consideration should be done before the application of endoscopic resection to the superficial spreading type of EGC.     

Incidence and risk factors of delayed postpolypectomy bleeding in patients with chronic liver disease

Objective Hepatologists and colonoscopists often hesitate to perform a colonoscopic polypectomy in patients with chronic liver disease (CLD), especially those with cirrhosis, because of the risk of postpolypectomy bleeding (PPB). We aimed to investigate the incidence and risk factors of delayed PPB after a colonoscopic polypectomy in patients with CLD. Materials and methods In total, 152 patients with CLD who underwent colonoscopic polypectomy from December 2005 to December 2012 were retrospectively reviewed. Results Cirrhosis was identified in 80 (52.6%) patients. During the study period, 442 polyps were removed and delayed PPB developed in 14 (9.2%) patients. The incidence of delayed PPB was significantly higher in patients with cirrhosis than in those without the disease (13.8% [n?=?11] vs. 4.2% [n?=?3], p?=?0.041). The polyp size (odds ratio, 1.087; 95% confidence interval, 1.009–1.172) and cirrhosis (odds ratio, 8.535; 95% confidence interval, 2.417–30.140) were independent risk factors for delayed PPB. In patients with cirrhosis, the optimal cut-off size to identify high-risk polyps for delayed PPB was 10 mm (area under the receiver operating characteristics curve, 0.737; sensitivity, 52%; specificity, 88%). Conclusion Caution is needed when colonoscopic polypectomy is planned in patients with CLD who have larger polyps and cirrhosis.