Study on fecal calprotectin in predicting disease activity and mucosal healing in patients with small intestinal Crohn′s disease / 中华消化杂志

Objective:To explore the differences of fecal calprotectin (FC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) between colon and small intestinal Crohn′s disease, and their predictive values for disease activity and mucosal healing in patients with small intestinal Crohn′s disease.Methods:From January 2017 to January 2023, 64 patients with Crohn′s disease who underwent capsule endoscopy in the First Affiliated Hospital of Zhejiang Chinese Medical University were enrolled, among them 28 patients had only small intestinal lesions (small intestine group) and 36 patients had lesions involving both small intestine and colon or only colon involvement (ileocolon group). The FC, CRP, and ESR levels of the two groups were detected and compared 15 days before capsule endoscopy examination. Wilcoxon rank-sum test was used for statistical analysis. Receiver operating characteristic curve analysis was used to evaluate the predictive value of FC, CRP, and ESR for disease activity and mucosal healing in patients with small intestinal Crohn′s disease.Results:The FC, CRP, and ESR levels of the small intestine group during the active phase of the disease were 1 689.00 μg/g (727.75 μg/g, 1 800.00 μg/g), 5.67 mg/L (1.00 mg/L, 17.01 mg/L), and 4.50 mm/1 h (2.00 mm/1 h, 11.00 mm/1 h), respectively; while FC, CRP, and ESR levels during the mucosal healing phase were 112.00 μg/g (46.50 μg/g, 130.50 μg/g), 1.00 mg/L (1.00 mg/L, 1.62 mg/L), and 2.00 mm/1 h (2.00 mm/1 h, 5.50 mm/1 h), respectively. The FC, CRP, and ESR levels of the ileocolon group during the active phase of the disease were 1 800.00 μg/g (895.50 μg/g, 1 800.00 μg/g), 4.94 mg/L (3.10 mg/L, 14.80 mg/L), and 10.00 mm/1 h (2.00 mm/1 h, 27.75 mm/1 h), respectively, while FC, CRP, and ESR levels during the mucosal healing phase were 66.00 μg/g (32.50 μg/g, 97.50 μg/g), 1.00 mg/L (1.00 mg/L, 1.55 mg/L), and 2.00 mm/1 h (2.00 mm/1 h, 4.50 mm/1 h), respectively. There were no statistically significant differences in FC, CRP, and ESR between the small intestine group and the ileocolon group during the active phase of the disease and mucosal healing phase (all P> 0.05). In the small intestine group, the levels of FC and CRP of patients during the active phase of the disease were 1 173.00 μg/g (312.00 μg/g, 1 800.00 μg/g) and 2.10 mg/1 L (1.00 mg/L, 16.00 mg/L), which were both higher than those of patients during the mucosal healing phase (112.00 μg/g (46.50 μg/g, 130.50 μg/g) and 1.00 mg/L (1.00 mg/L, 1.62 mg/L)), and the differences were statistically significant ( Z=-4.35 and-2.67, P<0.001 and =0.008). In the small intestine group, the level of ESR of patients during the active phase of the disease was 4.00 mm/1 h (2.00 mm/1 h, 16.00 mm/1 h), and there was no significant difference compared with that of patients during the mucosal healing phase (2.00 mm/1 h (2.00 mm/1 h, 5.50 mm/1 h)) ( P>0.05). When the cut-off level of FC was 188.50 μg/g, the sensitivity, specificity, and area under the curve for predicting disease activity in patients with small intestinal Crohn′s disease was 93.3%, 100.0%, and 0.964, respectively. When the cut-off value of CRP was 3.12 mg/L, the sensitivity, specificity, and area under the curve for predicting disease activity in patients with small intestinal Crohn′s disease was 46.7%, 92.3%, and 0.744, respectively. When the cut-off level of ESR was 10.00 mm/1 h, the sensitivity, specificity, and area under the curve for predicting disease activity in patients with small intestinal Crohn′s disease was 33.3%, 100.0%, and 0.654, respectively. There were no statistically significant differences in the area under the curve between the combinations of FC and CRP, FC and ESR, FC, CRP and ESR, and FC alone for predicting disease activity in patients with small intestinal Crohn′s disease (0.964, 0.959, and 0.959 vs. 0.964, all P> 0.05). There was a statistically significant difference in the area under the curve between the combination of CRP and ESR and FC alone in predicting disease activity in patients with small intestinal Crohn′s disease (0.708 vs. 0.964, Z=-2.57, P=0.010). Conclusions:There are no statistically significant differences in FC, CRP, and ESR between colon and small intestinal Crohn′s disease. FC has a high predictive value for disease activity and mucosal healing in patients with small intestinal Crohn′s disease and has certain clinical application value.

Mechanism of Acupuncture and Moxibustion on Promoting Mucosal Healing in Ulcerative Colitis / 中国结合医学杂志

The latest guideline about ulcerative colitis (UC) clinical practice stresses that mucosal healing, rather than anti-inflammation, is the main target in UC clinical management. Current mucosal dysfunction mainly closely relates to the endoscopic intestinal wall (mechanical barrier) injury with the imbalance between intestinal epithelial cells (IECs) regeneration and death, as well as tight junction (TJ) dysfunction. It is suggested that biological barrier (gut microbiota), chemical barrier (mucus protein layer, MUC) and immune barrier (immune cells) all take part in the imbalance, leading to mechanical barrier injury. Lots of experimental studies reported that acupuncture and moxibustion on UC recovery by adjusting the gut microbiota, MUC and immune cells on multiple targets and pathways, which contributes to the balance of IEC regeneration and death, as well as TJ structure recovery in animals. Moreover, the validity and superiority of acupuncture and moxibustion were also demonstrated in clinic. This study aims to review the achievements of acupuncture and moxibustion on mucosal healing and analyse the underlying mechanisms.

Current drug research on intestinal mucosal healing in inflammatory bowel disease based on macrophage regulation / 药学学报

Complete healing of the intestinal mucosa is the most ideal goal in the treatment of inflammatory bowel disease (IBD). The intestinal mucosa healing not only significantly alters the course of the disease and relieves clinical symptoms, but also markedly reduces the occurrence of complications and prevents recurrence of IBD. As chronic inflammation associated with peptic ulcer damage is the main pathological feature of IBD, clinical treatment is mainly based on anti-inflammatory therapy, but such therapy cannot promote the healing of the intestinal mucosa of patients. Therefore, how to achieve long-term remission of IBD is still an urgent challenge. In the process of intestinal mucosal repair, the polarization of macrophages maintains the homeostasis of the intestinal microenvironment, which is a representative process that promotes mucosal inflammatory-repair. It is a key part of initiating tissue regeneration that should not be underestimated. In this paper, we reviewed the literature of the past decade, focusing on the promotion of intestinal mucosal healing in IBD. The discussion will highlight the importance and feasibility of regulating macrophages to promote intestinal mucosal repair. Following this thought, we discuss the shortcomings of current clinical treatments and summarize the relevant drugs which have potential to promote intestinal mucosal repair. The aim is to provide effective potential drugs and therapeutic targets for the treatment of IBD.

Guía de práctica clínica para el tratamiento de la enfermedad de Crohn en población adulta / Clinical practice guidelines for the treatment of Crohn's disease in the adult population

Resumen Objetivo: La enfermedad de Crohn es un trastorno inflamatorio idiopático de etiología desconocida con características genéticas, inmunológicas e influencias del medio ambiente. La incidencia y la prevalencia de la enfermedad de Crohn han aumentado en Colombia. El tratamiento de estos pacientes no es fácil y ha evolucionado en los últimos años; por lo tanto, es necesario desarrollar una guía de práctica clínica en Colombia, orientada al tratamiento de esta compleja enfermedad, para unificar criterios. Materiales y métodos: Esta guía fue desarrollada por un equipo multidisciplinario con apoyo de la Asociación Colombiana de Gastroenterología, el Grupo Cochrane ITS y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas clínicas relevantes a la entidad y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías existentes fueron evaluadas en términos de calidad y aplicabilidad. El Grupo Cochrane realizó la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas usando la metodología GRADE. Resultados: Se realizó una guía de práctica clínica basada en la evidencia, para el tratamiento tanto médico como quirúrgico de la enfermedad de Crohn en población adulta en Colombia. Se diseñaron algoritmos de manejo teniendo en cuenta la actividad, el comportamiento y la localización de la enfermedad. Conclusiones: Se estableció que una adecuada evaluación clínica, endoscópica e imagenológica, así como una estratificación de riesgo individual son importantes para el manejo, y se especificaron las indicaciones para el adecuado tratamiento tanto médico como quirúrgico de estos pacientes.

Abstract Objective: Crohn's disease is an idiopathic inflammatory disorder of unknown origin, influenced by genetic, immunological, and environmental factors. The incidence and prevalence of Crohn's disease have increased in Colombia. The treatment of these patients is not easy and has improved in recent years. Therefore, it is necessary to develop the Colombian Clinical Practice Guideline to guide the treatment of this complex disease and unify criteria. Materials and methods: The present guideline was carried out by a multidisciplinary team with support from the Asociación Colombiana de Gastroenterología, the Cochrane ITS Team, and the Clinical Research Institute of the Universidad Nacional de Colombia. Clinical questions regarding this disease were developed, and national and international guidelines were searched in specialized databases. The existing guidelines were evaluated in terms of quality and applicability. The Cochrane Group conducted a systematic search of the existing literature. Evidence tables were elaborated, and recommendations were made using the GRADE methodology. Results: An evidence-based clinical practice guideline was developed for the medical and surgical treatment of Crohn's disease in the adult population in Colombia. Treatment algorithms were designed, taking into account the activity, behavior, and location of the disease. Conclusions: It was established that proper clinical, endoscopic, and imaging assessment, as well as individual risk stratification, are important for treatment. Also, the indications for adequate medical and surgical treatment of these patients were specified.

Guía para el manejo de colitis ulcerativa en población adulta (actualización) / Guidelines for the management of ulcerative colitis in the adult population (update)

Resumen Objetivo: desde 2015, la Asociación Colombiana de Gastroenterología, con el apoyo del Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia, realizó la guía de práctica clínica para el diagnóstico y tratamiento de colitis ulcerativa. Desde la publicación de esta guía, han aparecido nuevas alternativas terapéuticas y nuevos conceptos sobre los objetivos del tratamiento, por lo cual se consideró necesaria su actualización. Materiales y métodos: esta actualización fue realizada por un equipo multi-disciplinario con apoyo de la Asociación Colombiana de Gastroenterología y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas relevantes a nuevos tratamientos y vigilancia endoscópica de los pacientes adultos con colitis ulcerativa y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías fueron evaluadas en términos de calidad y aplicabilidad. El Grupo Cochrane llevó a cabo la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas usando la metodología GRADE. Resultados: se realizó una actualización de la guía para el tratamiento de la colitis ulcerativa en adultos en Colombia y se diseñaron nuevos algoritmos de tratamiento, teniendo en cuenta la extensión y la actividad de la enfermedad y los diferentes niveles de atención. Conclusiones: se estableció la importancia para el tratamiento de la evaluación clínica y endoscópica y se especificaron las indicaciones para el adecuado tratamiento de los pacientes con colitis ulcerativa. Adicionalmente, se dieron recomendaciones de vigilancia endoscópica de cáncer colorrectal y la importancia de la cromoendoscopia.

Abstract Objective: In 2015, the Asociación Colombiana de Gastroenterología (Colombian Association of Gastroenterology), with the support of the Institute of Clinical Research of the Universidad Nacional de Colombia, created the Clinical Practice Guideline for the diagnosis and treatment of ulcerative colitis. Since then, new therapeutic alternatives and concepts about treatment goals have emerged, making it necessary to update its contents. Materials and methods: The present update was carried out by a multidisciplinary team with support from the Asociación Colombiana de Gastroenterología and the Clinical Research Institute of the Universidad Nacional de Colombia. Questions regarding new treatments and endoscopic surveillance of adult patients with ulcerative colitis were developed, and national and international guidelines were searched in specialized databases. The guidelines were evaluated in terms of quality and applicability. The Cochrane Group conducted a systematic search of the existing literature, and evidence tables and recommendations were made using the GRADE methodology. Results: The guideline for the treatment of ulcerative colitis in adults in Colombia was updated, and new treatment algorithms were designed, taking into account the extent and activity of the disease and the different levels of care. Conclusions: The relevance of clinical and endoscopic assessment for treatment was established, and the indications for the proper management of patients with ulcerative colitis were specified. Furthermore, recommendations were made for endoscopic surveillance of colorectal cancer, and the importance of chromoendoscopy was established.

Advances in research on treat-to-target approach in ulcerative colitis / 西安交通大学学报(医学版)

Ulcerative colitis (UC) is a chronic, progressive and heterogeneous inflammatory bowel disease. Strategies for management of UC are shifting from simple control of symptoms toward clinical/patient-reported outcome remission (resolution of rectal bleeding and diarrhea/altered bowel habit) and endoscopic remission (mucosal healing), with the final aim of blocking the progression of the disease and promising better long-term outcomes. The therapeutic target for UC is a comprehensive one that combines subjective and objective goals as well as short-term and long-term goals. In order to achieve these goals, it is necessary to assess the severity of the disease first and predict the risk of UC progression, and then provide early intervention and individualized treatment for high-risk patients. The treatment should be timely tailored by close monitoring. Although the clinical implementation of UC treat-to-target (T2T) approach remains challenging, T2T strategy is the key-point for improving the quality of disease management.

Evaluative value of high-resolution microendoscopy on mucosal healing in ulcerative colitis / 中华消化内镜杂志

Objective To investigate the value of high resolution microendoscopy ( HRME ) for assessment of mucosal healing in patients with ulcerative colitis ( UC ) during clinical remission. Methods A total of 30 UC patients were randomly selected to collect HRME images. Pathological results were used as the gold standard to establish the diagnostic criteria of HRME on evaluation of colonic mucosal status. And then a prospective study was performed on 67 patients, who underwent standard endoscopy to evaluate colonic mucosal status and obtain biopsy specimens. The specimens were collected for HRME imaging. The accuracy of standard endoscopy and HRME in assessing ulcerative colonic mucosal healing was compared. Results According to the gland morphology, gland arrangement, gland opening and inflammatory cell infiltration, the HRME criteria for assessing UC mucosal status were formulated and divided into 0-3 grades with 4 levels. The prospective study of 67 patients with 113 sites showed that the sensitivity, specificity, positive predictive value, and negative predictive value of standard endoscopy for assessing mucosal healing in UC patients were 44. 68％ ( 21/47 ) , 90. 91％ ( 60/66 ) , 77. 78％ ( 21/27 ) , and 69. 77％ ( 60/86 ) , respectively, and the corresponding indicators of HRME imaging was 87. 23％ (41/47), 95. 45％ (63/66), 93. 18％ (41/44), and 91. 30％ (63/69), respectively. Compared with pathological results, the Kappa value of the consistency test of standard endoscopy and HRME imaging were 0. 379 and 0. 835, respectively ( both P<0. 05) . Conclusion HRME can achieve real-time virtual pathological imaging of colonic mucosa for UC patients, which is more accurate than standard endoscopy for assessing mucosal healing.

Stem cell-based therapy for inflammatory bowel disease

Inflammatory bowel disease (IBD) is an idiopathic, multi-etiological disease characterized by inflammation and mucosal destruction of the gastrointestinal tract. Despite the remarkable advance in immunomodulating therapies, there still remains a certain population of patients who are refractory to conventional as well as biologic therapies and fail to achieve mucosal healing. To improve the prognosis of those patients, at least 2 types of stem cells have been tested for their potential therapeutic use. Transplantation of hematopoietic stem cells or mesenchymal stem cells have been tested in several clinical studies, but their beneficial effect still remains controversial. In this review, we would like to overview the recent clinical challenges of stem cell-based therapies in IBD and also introduce our new therapeutic plan of intestinal stem cell transplantation for IBD, based on our ex vivo intestinal organoid culture technique.

The novel latex agglutination turbidimetric immunoassay system for simultaneous measurements of calprotectin and hemoglobin in feces

BACKGROUND/AIMS: Fecal calprotectin (Fcal) as well as the fecal immunochemical test (FIT) are useful biomarkers for detecting activity and mucosal healing in inflammatory bowel diseases. Here, we report the performance of simultaneous measurements of Fcal and FIT for ulcerative colitis (UC) patients using the newly-developed latex agglutination turbidimetric immunoassay (LATIA) system. METHODS: Fcal and hemoglobin were measured by the LATIA system in 152 UC patients who underwent colonoscopy. Fcal was also quantified with a conventional enzyme-linked immunosorbent assay (ELISA). Fecal markers were evaluated in conjunction with the mucosal status of UC, which was assessed via the Mayo endoscopic subscore (MES) classification. RESULTS: The LATIA system could quantify calprotectin and hemoglobin simultaneously with the same fecal samples within 10 minutes. The values of the Fcal-LATIA closely correlated with those of the Fcal-ELISA (Spearman rank correlation coefficient, r=0.84; P<0.0001). The values of Fcal for each assay and the FIT all significantly correlated with the MESs (Spearman rank correlation coefficient, Fcal-LATIA: r=0.58, Fcal-ELISA: r=0.55, and FIT: r=0.72). The mucosal healing predictability (determined by an MES of 0 alone) of the Fcal-LATIA, Fcal-ELISA, and FIT-LATIA with the cutoffs determined by receiver operating characteristic curve analysis was 0.79, 0.78, and 0.92 for sensitivity, respectively, and 0.78, 0.69, and 0.73 for specificity, respectively. CONCLUSIONS: The performance of the novel Fcal-LATIA was equivalent to that of the conventional Fcal assay. Simultaneous measurements with FITs would promote the clinical relevance of fecal biomarkers in UC.

Effect of Qingbaikuijietang enema on colonic mucosa healing and serum inflammatory factors in pa-tients with ulcerative colitis and large intestine damp-heat syndrome / 新乡医学院学报

Objective To investigate the effect and the mechanism of Qingbaikuijietang enema on colonic mucosa heal-ing and serum inflammatory factors in patients with ulcerative colitis(UC)and large intestine damp-heat syndrome. Methods A total of 120 patients with mild and moderate UC were selected from January 2014 to December 2015 in the Second Affilia-ted Hospital of Shaanxi University of Traditional Chinese Medicine. The patients were randomly divided into control group and observation group,with 60 cases in each group. The patients in the two groups were treated with mesalazine sustained release granules 1 g by oral,4 times a day for 4 weeks. Based on this,the patients in the observation group were given retention enema with Qingbaikuijietang,once a day for 4 weeks. The score of colonic mucosa healing under endoscopy were evaluated before and at 4 weeks after treatment. The levels of serum tumor necrosis factor-α(TNF-α)and interleukin-6(IL-6)were determined by enzyme linked immunosorbent assay,and the level of C-reactive protein(CRP)was determined by scattering turbidimetry be-fore and after 4 weeks of treatment. The endoscopic colonic lesions of all patients were scored by Rachmilewitz scoring standard before and after treatment. The clinical effect was evaluated by the standard set by the Cooperative Group of Inflammatory Bow-el Disease in Digestive Diseases Branch of Chinese Medical Association after 2 and 4 weeks of treatment. Results There was no significant difference in the score of colon mucosa healing between the two groups before treatment(P > 0. 05). The score of colonic lesions in the observation group was significantly lower than that in the control group after 4 weeks of treatment(P <0. 05). A total of 53 cases(88. 33％)in the observation group and 43 cases(71. 67％)in the control group were endoscopi-cally remission,the remission rate in the observation group was significantly higher than that in the control group(χ2 = 5. 208, P < 0. 05). There was no significant difference in serum IL-6,TNF-α and CRP levels between the two groups before treatment (P > 0. 05). The levels of serum IL-6,TNF-α and CRP after 4 weeks of treatment were significantly lower than those before treatment in the two groups(P < 0. 05). The levels of serum IL-6,TNF-α and CRP in the observation group were significantly lower than those in the control group after 4 weeks of treatment(P < 0. 05). The total effective rate in the control group and the observation group was 40. 00％ and 88. 34％ respectively after 2 weeks of treatment,and it was 86. 67％ and 96. 67％ respec-tively after 4 weeks of treatment,the total effective rate in the observation group was significantly higher than that in the control group after 2 and 4 weeks of treatment(χ2 = 30. 480,3. 927;P < 0. 05). Conclusion Qingbaikuijietang enema combined with mesalazine sustained release granules can reduce the levels of serum inflammatory inflammatory factors,inhibit the inflammato-ry reaction,promote the healing of colonic mucosa and alleviate the clinical symptoms in patients with UC.

Trough level of infliximab is useful for assessing mucosal healing in Crohn's disease: a prospective cohort study

BACKGROUND/AIMS: Decreased trough levels of infliximab (TLI) and antibodies to infliximab (ATI) are associated with loss of response (LOR) in Crohn's disease. Two prospective studies were conducted to determine whether TLI or ATI better correlates with LOR (Study 1), and whether TLI could become a predictor of mucosal healing (MH) (Study 2). METHODS: Study 1 was conducted in 108 patients, including those with LOR and remission to compare ATI and TLI in discriminating the 2 conditions based on receiver operating characteristic (ROC) curve analyses. Study 2 involved 35 patients who were evaluated endoscopically. RESULTS: In Study 1, there were no differences between the 2 assays in ROC curve analyses; the TLI cutoff value for LOR was 2.6 µg/mL (sensitivity, 70.9%; specificity, 79.2%), and the ATI cutoff value was 4.9 µg/mL (sensitivity, 65.5%; specificity, 67.9%). The AUROC (area under the ROC curve) of TLI was greater than that of ATI. AUROC was useful for discriminating between the 2 conditions. In Study 2, the TLI was significantly higher in the colonic MH group than in the non-MH group (2.7 µg/mL vs. 0.5 µg/mL, P=0.032). CONCLUSIONS: TLI is better than ATI for clinically diagnosing LOR, and a correlation was observed between TLI and colonic MH.

Evaluation of confocal laser endomicroscopy on pathological changes of intestinal mucosa repairing for patients with ulcerative colitis / 中华消化内镜杂志

Objective To evaluate the advantages of confocal laser endomicroscopy(CLE)for function repairing of ulcerative colitis(UC). Methods Thirty patients with UC who were diagnosed and treated in the First Affiliated Hospital of Zhejiang University Medical College between July 2014 and December 2016 were enrolled in the study group. The control group consisted of 10 patients who were diagnosed as having colonic polyps with colonoscopy and underwent polypectomy in the same period. Both groups were examined with white light endoscopy and CLE,then the fluorescein leakage score was compared. Results There were 10 out of 30 cases in the study group whose whole intestinal mucosa were judged as normal under white light endoscopy. In the other 20 cases,there were parts of intestinal mucosa being judged as abnormal. All of the 10 cases in the control group were with normal colon mucosa. There was a significant difference on fluorescein leakage score by CLE between the study group which showed normal by white light endoscopy and the control group(P<0.05). The fluorescein leakage score by CLE was significant difference between the abnormal intestinal segment and normal intestinal segment in 20 patients with active UC(P<0.05). Spearman correlation analysis showed that there was non-ranked correlation between the fluorescein leakage score of CLE and histopathological findings of biopsy in UC patients with normal mucosa of the left colon under white light endoscopy(rs=0.394,P>0.05). Conclusion In the process of mucosal healing of UC patients,structural repair can be found firstly through CLE. Mucosal healing under white light endoscopy cannot represent the functional recovery. CLE is more effective than the histopathology in the evaluation of mucosal barrier function.

An Elevated Platelet Count Increases the Risk of Relapse in Ulcerative Colitis Patients with Mucosal Healing

BACKGROUND/AIMS: Although mucosal healing (MH) has been considered a treatment goal for patients with ulcerative colitis (UC), the risk factors predictive of relapse in patients who achieve MH are unknown. Because the platelet count has been shown to be a marker of inflammation in inflammatory bowel diseases, this study aimed to assess whether the platelet count could predict relapse in UC patients with MH. METHODS: A prospective observational study was performed. UC patients with MH were consecutively enrolled in the study and monitored for at least 2 years or until relapse. The correlation between the incidence of relapse and the platelet count at the time of study enrollment was examined. RESULTS: In total, 43 patients were enrolled, and 14 patients (33%) relapsed. The median platelet count at the time of enrollment in the patients who relapsed significantly differed from that in the patients who did not relapse (27.2×104/μL vs 23.8×104/μL, respectively; p=0.016). A platelet count >25.0×104/μL was a significant risk factor for relapse based on a multivariate analysis (hazard ratio, 4.85; 95% confidence interval, 1.07 to 25.28), and according to the Kaplan-Meier analysis, this cutoff could identify patients susceptible to relapse (p=0.041, log-rank test). CONCLUSIONS: The platelet count could be used as a predictor of relapse in UC patients with MH.

Patient self-reported symptoms using visual analog scales are useful to estimate endoscopic activity in ulcerative colitis

BACKGROUND/AIMS: In clinical practice, colonoscopy has been regarded as the gold standard for the evaluation of disease severity as well as mucosal healing in ulcerative colitis (UC). Some activity indices incorporating patient symptoms as parameters have been shown to reflect the endoscopic activity of UC. The aim of this study was to examine whether self-reported symptoms with visual analog scales (VAS) can predict endoscopic activity. METHODS: A cross-sectional study of 150 UC patients who underwent colonoscopy with submission of VAS scores of 4 symptoms: general condition, bloody stools, stool form, and abdominal pain (0: no symptoms, 10: the most severe symptoms). Each VAS score was compared with colonoscopic activity assessed with the Mayo endoscopic subscore (MES). RESULTS: All VAS scores were significantly correlated with the endoscopic severity (Spearman correlation coefficients of general condition, bloody stools, stool form, and abdominal pain: 0.63, 0.64, 0.58, and 0.43, respectively). Mucosal healing defined as MES 0 alone was predicted by VAS score < 1.5 on general condition or 0 on bloody stools with sensitivity of 0.84 and 0.76 and specificity of 0.66 and 0.76, respectively. Additionally, VAS score < 2.5 on stool form predicted active lesions in distal colorectum alone with sensitivity of 0.67 and specificity of 0.66, suggesting that this item could predict the indication of topical therapy. CONCLUSIONS: Self-reported VAS scores on symptoms were correlated with endoscopic activity of UC. To clarify the relationship between VAS and mucosal healing, further validation studies are needed.

How to Optimally Use Currently Available Drugs in a Therapeutic Algorithm? / 대한소화기학회지

Recently, the incidence and prevalence of inflammatory bowel disease (IBD) have been increasing in worldwide, especially in Asian area. IBD is a chronic and progressive disease eventually causing bowel damage. The advance in the treatment of IBD over the past several decades has been achieved with the development of biologics. Furthermore, goals for management of IBD have been evolving from symptom-based management to mucosal healing, which can reduce the surgery rate and hospitalization. To treat the patients with IBD properly, identification of risk factors of patients should be preceded. In addition, the knowledge of several drugs, which are available in current situation is essential. In this review, optimal therapeutic approach with drugs including 5-aminosalicylate, steroid, immunomodulators and anti-TNF antagonists is discussed.

Early Biologic Treatment in Pediatric Crohn's Disease: Catching the Therapeutic Window of Opportunity in Early Disease by Treat-to-Target / 대한소아소화기영양학회지

The emergence of mucosal healing as a treatment goal that could modify the natural course of Crohn's disease and the accumulating evidence showing that biologics are most effective in achieving mucosal healing, along with the success of early treatment regimens for rheumatoid arthritis, have led to the identification of early Crohn's disease and development of the concept of catching the therapeutic window during the early disease course. Thus, an increasing number of pediatric gastroenterologists are adopting an early biologic treatment strategy with or without an immunomodulator. Although early biologic treatment is effective, cost and overtreatment are issues that limit its early use. Currently, there are insufficient data on who will benefit most from early biologics, as well as on who will not need early or even any biologics. For now, top-down biologics should be considered for patients with currently known high-risk factors of poor outcomes. For other patients, close, objective monitoring and accelerating the step-up process by means of a treat-to-target approach seems the best way to catch the therapeutic window in early pediatric Crohn's disease. The individual benefits of immunomodulator addition during early biologic treatment should be weighed against its risks and decision on early combination treatment should be made after comprehensive discussion with each patient and guardian.

Clinical outcome and patient satisfaction using biodegradable (NasoPore) and non-biodegradable packing, a double-blind, prospective, randomized study / Desfecho clínico e satisfação do paciente com o uso de tampão biodegradável (NasoPore) e não biodegradável: estudo prospectivo, duplo-cego e randomizado

Abstract Introduction Nasal packing after endoscopic sinus surgery is used as a standard procedure. The optimum solution to minimize or eliminate all disadvantages of this procedure may be accomplished using biodegradable packs. Objective The aim of this study was to compare patient satisfaction and clinical outcome associated with absorbable and non-absorbable packing after FESS. Methods In total, 50 patients were included in a prospective, double-blind, randomized trial. One side was packed with polyurethane foam, while the opposite side was packed with gauze packing. On the 2nd, 10th, and 30th postoperative day, the patients were questioned with the aid of a visual analog scale. The standardized questionnaires for bleeding, nasal breathing, feeling of pressure, and headache were used. The presence of synechiae, infection, or granulation was noted and recorded with the video-endoscopy. Results A significant difference according to lower pressure was found in the NasoPore group compared to the controls on day ten after surgery. The NasoPore packing had lower scores with respect to postoperative nose blockage on the 2nd and 10th days. Mucosal healing was better for the NasoPore group, both at day ten and 30 compared with the control group. Conclusion The overall patient comfort is higher when using NasoPore compared to non-resorbable traditional impregnated gauze packing. Intensive saline douches applied three to four times per day are mandatory after the operation to prevent synechiae formation and fluid resorption by the packing.

Resumo Introdução O tamponamento nasal após cirurgia sinusal endoscópica é procedimento de rotina. A solução ideal para minimizar ou eliminar as desvantagens desse procedimento pode ser alcançada com o uso de tampões biodegradáveis. Objetivo Comparar a satisfação do paciente e o desfecho clínico associados ao uso de tampões absorvíveis e não absorvíveis após a cirurgia funcional dos seios paranasais (FESS- Functional Endoscopic Sinus Surgery). Método Foram incluídos 50 pacientes neste estudo prospectivo, duplo-cego e randomizado. Um dos lados foi tamponado com espuma de poliuretano, enquanto no outro lado foi feito um tamponamento com gaze. Nos 2º, 10º e 30º dias após a operação, os pacientes foram perguntados com a ajuda de uma escala analógica visual. Foram empregados questionários padronizados para sangramento, respiração nasal, sensação de pressão e cefaleia. A presença de sinequias, infecção ou granulação foi registrada por videoendoscopia. Resultados Foi observada diferença significante, da sensação de pressão, menor no lado tratado com NasoPore vs. controles no 10º dia após a cirurgia. O tamponamento com NasoPore obteve escores mais baixos com respeito ao bloqueio nasal pós-operatório no 2º e 10º dias. A cicatrização da mucosa foi melhor no lado do NasoPore, mas no 10º e 30º dias os resultados foram comparáveis com os do lado de controle. Conclusão O conforto geral do paciente é maior com o uso de NasoPore vs. tamponamento tradicional com gaze besuntada não reabsorvível. O uso vigoroso de jatos de solução salina aplicados 3-4 vezes ao dia é um procedimento obrigatório após a cirurgia, para evitar a formação de sinequias e para uma absorção natural do tampão.

Treatment and outcomes: medical and surgical treatment for intestinal Behçet's disease

Behçet's disease (BD) is a chronic relapsing disease involving multiple organ systems. BD is characterized clinically by oral and genital aphthae, cutaneous lesions, and ophthalmological, neurological, and/or gastrointestinal manifestations. It is widely recognized that the presence of intestinal lesions may be a poor prognostic factor in intestinal BD, increasing the risk of surgery and decreasing the quality of life. Despite this, the management of intestinal BD has not been standardized. Empirical therapies including 5-aminosalicylic acid and corticosteroids have been used anecdotally to treat intestinal BD, but recent studies have provided evidence for the efficacy of anti-tumor necrosis factor α monoclonal antibodies. The development of agents targeting tumor necrosis factor α continues, it seems likely that they will change the therapeutic strategy and clinical outcomes of intestinal BD and inflammatory bowel disease. Monitoring disease activity such as endoscopic evaluation will become more important to obtain better outcomes. Here, we review current and future perspectives in the treatment and outcomes of intestinal BD.

Mucosal healing in ileocolonic Crohn′s diseases with short-term infliximab and immunosuppression combined therapy / 中华消化杂志

Objective To investigate the efficacy of short-term biological agent infliximab and immunosuppression combined therapy in patients with active ileocolonic Crohn′s diseases (CD)and to evaluate the mucosal healing.Methods From January 2013 to July 2014,forty hospitalized patients with active ileocolonic CD received at least six times scheduled infliximab injection were enrolled.At week 0, second,and sixth,infliximab 5 mg/kg was administered to induce remission.From the second week, immunosuppression was added.After that,infliximab 5 mg/kg was administered every eight weeks for maintenance treatment.The 36th week after treatment was the end point of follow-up.Before treatment and at the end point of follow-up,the levels of C-reactive protein (CRP),hemoglobin (Hb),clinical remission Crohn′s disease activity index (CDAI)2 ) and deep remission (achieved both clinical remission and mucosal healing)were compared.T test and Wilcoxon rank sum test were performed for comparison before and after treatment.Results At the 36 th week after treatment,the clinical remission rate was 95 .0% (38/40 ),mucosal healing rate,partial mucosal healing rate and deep remission rate were 62.5 % (25/40),35 .0% (14/40)and 62.5 % (25/40), respectively.The mucosal inflammation of only one case (2.5 %)was not improved.After treatment,the CDAI was 99.3 ±29.3,which was lower than that before treatment (301 .3 ±73.1 )and the difference was statistically significant (t = 17.2,P <0.01 ).Median blood CRP level was 0.8 mg/L(0.1 mg/L, 8.1 mg/L),which was lower than that before treatment (26.8 mg/L(16.1 mg/L,61 .0 mg/L)),the difference was statistically significant (Z = - 5 .3,P < 0.01 ).However,the level of Hb ((134.0 ± 16.0)g/L)was higher than that before treatment ((117.0 ±20.0)g/L),the difference was statistically significant (t=-6.3,P <0.01 ).The median SES-CD was 0 (0,5 ),which was lower than that before treatment (14(8,24)),and the difference was statistically significant (Z =-5 .4,P <0.01 ).Conclusion The short-term (36 weeks)infliximab and immunosuppression combined therapy can achieve high mucosal healing rate and deep remission rate in active ileocolonic CD patients.

Efficacy and safety of thalidomide in the treatment of 29 refractory Crohn's disease patients / 中华消化杂志

Objective To evaluate the efficacy and safety of thalidomide (100 to 200mg per day) in the treatment of adult refractory Crohn's disease (CD).Methods From July 2008 to February 2013,29 refractory CD patients were enrolled in thalidomide (100 to 200 mg per day)cohort study.The clinical activity was evaluated by simplified CD activity index.Patients in clinical remission underwent colon endoscope examination,and mucosal healing was assessed by simple endoscopic score for Crohn's disease (SES-CD).Adverse reactions (ADR) were also observed.Results Among the 29 CD patients,23 males and six females,the baseline of 19 patients (65.5％) were in clinical active period and 10 in clinical remission period.Among patients with baseline in clinical active period,three patients did not reach the target dose because of ADR,the left 16 patients were treated with thalidomide for one year and 14 patients achieved clinical remission.The median time of inducing clinical remission was one month.A totle of 24 patients with clinical remission induced by thalidomide and with baseline in clinical remission period were assessed in efficacy evaluation of mucosal healing.Thalidomide was withdrawn in three patients in six months because of ADR and colonoscopy evaluation did not complete,while the other 21 patients received colonoscopy evaluation among whom 33.3％ (7/21) achieved mucosal healing after two years of thalidomide treatment.Numbness of the hands,feet or mouth,somnolence and dermatitis were the top three ADR of thalidomide treatment.A total of nine patients withdrew the medication because of ADR (four (13.8％) with numbness of the hands,feet or mouth,four (13.8％) with dermatitis and one (3.4％) with leukopenia).Conclusions Thalidomide 100 to 200 mg per day can induce clinical remission and mucosal healing in refractory CD.However,it has some adverse reactions and close monitoring and follow up are required during treatment.