The implications of concomitant mucosal inflammation on clinical manifestations and outcomes of sinonasal inverted papilloma.

PURPOSE: This study examines the impact of concomitant mucosal inflammation on clinical manifestations and long-term outcomes of Inverted Papilloma (IP). METHODS: This retrospective cohort study was conducted in five tertiary medical centers. The included patients underwent an attachment-oriented surgical resection for IP with a minimum follow-up of 3 years. RESULTS: Of 185 patients with IP, 65 patients (35.1%) had synchronous mucosal inflammation with polypoid changes. The mean age was 56.7 years, and 69% were males. Most tumors originated from the maxillary sinus. Age, gender, Krouse stage, and tumor attachment site did not differ between the mucosal inflammation and IP-only groups. IP recurrence rate was twofold in the patients with mucosal inflammation (15.4% vs. 7.5%, p = 0.092). However, the difference was not significant, with a similar median time to recurrence between the two groups [15.5 (3-36) months vs. 16(6-96) months, p = 0.712]. In revision cases, IP recurred only in patients with mucosal inflammation (19% vs. 0%, p = 0.07). This group had a significantly worse 5-years recurrence-free survival than revision cases without mucosal inflammation (80.6% vs. 100%, p = 0.04). CONCLUSIONS: IP in the setting of mucosal inflammation might be associated with a higher recurrence rate, predominantly after revision surgery. Otolaryngologists should consider this during these patients' diagnosis, surgical planning, and follow-up.

Jejunal Inflammation in Crohn's Disease: Comparison between Diffusion Weighted Magnetic Resonance Imaging and Video Capsule Endoscopy.

BACKGROUND: Jejunal disease is associated with worse prognosis in Crohn's disease. The added value of diffusion weighted imaging for evaluating jejunal inflammation related to Crohn's Disease is scarce. OBJECTIVES: To compare diffusion weighted imaging, video capsule endoscopy, and inflammatory biomarkers in the assessment of Crohn's disease involving the jejunum. METHODS: Crohn's disease patients in clinical remission were prospectively recruited and underwent magnetic resonance (MR)-enterography and video capsule endoscopy. C-reactive protein and fecal-calprotectin levels were obtained. MR-enterography images were evaluated for restricted diffusion, and apparent diffusion coefficient values were measured. The video capsule endoscopy-based Lewis score was calculated. Associations between diffusion weighted imaging, apparent diffusion coefficient, Lewis score, and inflammatory biomarkers were evaluated. RESULTS: The study included 51 patients, and 27/51 (52.9%) with video capsule endoscopies showed jejunal mucosal inflammation. Sensitivity and specificity of restricted diffusion for video capsule endoscopy mucosal inflammation were 59.3% and 37.5% for the first reader, and 66.7% and 37.5% for the second reader, respectively. Diffusion weighted imaging was not statistically associated with jejunal video capsule endoscopy inflammation (P = 0.813). CONCLUSIONS: Diffusion weighted imaging was not an effective test for evaluation of jejunal inflammation as seen by video capsule endoscopy in patients with quiescent Crohn's disease.

A Novel Nonsurgical Technique for Correcting Congenital Auricular Anomalies.

Congenital ear anomalies are associated with psychological morbidity. Ear deformities can usually be corrected by nonsurgical techniques such as splinting or molding in the neonatal period, initiated before 6 weeks. Without early corrections, many will require otoplasty during childhood. We introduce a novel silicone-based custom mold technique for congenital ear anomalies. The highly malleable silicone was pushed into every part of the auricle, enabling the auricle to remain in the desired shape, with new molds made weekly. Of 31 newborns (18 males, 13 females), 54 ears were treated. Average age at treatment initiation was 26.8 days. The mean treatment duration was 43.2 days, with a median of 28 days. Normal appearance and parent's satisfaction were achieved in 30 patients with 49 deformed ears and also in four newborns older than 6 weeks. Three concha type microtia in two patients achieved great improvements and parents' satisfaction. No complications were reported. Marked aesthetic improvements and normal appearance were achieved for all deformed auricles treated, and improvements in the concha type microtia will partially alleviate future surgical corrections. The results are not inferior to other techniques. The advantages are as follows: cost-effective, time-saving, simple to master, no need for hair shaving, and easy use for parents. Patients older than 6 weeks of age achieved normal auricle appearance, enabling the correction in older newborns. Custom made silicone auricle molding offers a simple nonsurgical technique for correcting congenital ear anomalies, alleviating the need for future surgical corrections.

Assessment of patency capsule retention using MR diffusion-weighted imaging.

OBJECTIVES: Evaluate the ability of MR diffusion-weighted imaging (DWI) to predict patency capsule retention in Crohn's disease (CD). METHODS: Clinical and imaging data were prospectively reviewed for 80 CD patients following patency capsule administration and MR-DWI under institutional review board (IRB) approval with informed consent. Two radiologists separately assessed the presence/absence of restricted diffusion in the distal ileum. Apparent diffusion coefficients (ADC) from three regions of interest on the ileal wall were averaged. The association between restricted diffusion and retention, and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Ability of ADC to predict retention was assessed with receiver operating characteristic (ROC) curve analysis. RESULTS: Restricted diffusion in the distal ileum was associated with capsule retention (p = 0.001, p < 0.0001). Sensitivity, specificity, PPV and NPV of restricted diffusion for capsule retention were 100.0%, 46.2%, 30.0%, 100% and 100.0%, 56.9%, 34.9%, 100%, respectively, for two radiologists. Accuracy of ADC to predict retention was high (area under the curve = 0.851, p < 0.0001). An ADC of 1.47 mm2/s showed 90.0% sensitivity and 50.0% specificity for retention. CONCLUSIONS: Sensitivity and NPV of restricted diffusion for patency capsule retention were 100%, suggesting that DWI may predict gastrointestinal tract capability to pass video camera endoscopy. KEY POINTS: • Capsule endoscopy enables assessment of the gastrointestinal mucosa in Crohn's disease • Prior patency capsule administration is recommended to evaluate gastrointestinal tract patency • MR diffusion-weighted imaging may detect pathological constriction of the ileum • Restricted diffusion in the distal ileum was associated with capsule retention • MR-DWI may predict gastrointestinal tract capability to pass capsule endoscopy.

CT measurement of breast glandular tissue and its association with testicular cancer.

OBJECTIVES: To evaluate the associations between breast glandular tissues diameters as determined by CT and b-hCG levels, histological types, tumour spread and prognosis in patients with testicular germ cell tumour. METHODS: Ninety-four patients with pre-treatment CT scan and markers (b-hCG, AFP, LDH) were retrospectively collected. A radiologist measured diameters in all CT examinations and correlation between diameters and log (b-hCG) was assessed (Pearson's coefficient). The ability of measured diameters to predict lymphatic and distant haematogenous metastatic spread was evaluated (ROC curves). The associations between measured diameter cut-off values of 20 and 25 mm and International Germ Cell Cancer Collaborative Group (IGCCCG) classification, lymphatic and distant haematogenous metastatic spread and histological subtypes were evaluated (chi squared test). RESULTS: Breast glandular diameters correlated to log(b-hCG) (r = 0.579) and predicted distant haematogenous metastatic spread (AUC = 0.78). Worse prognosis (intermediate or poor IGCCCG) was shown for 20 mm (27.3 vs. 4.2 %, p = 0.005) and 25 mm (33.3 vs. 6.1 %, p = 0.014). A diameter of 25 mm was associated with non-seminoma (91.7 vs. 48.8 %, p = 0.005). CONCLUSION: Breast glandular tissue diameters correlated with log(b-hCG) and predicted distant haematogenous metastases. Twenty and 25 mm were associated with worse prognosis and 25 mm was able to distinguish between seminoma and non-seminoma. KEY POINTS: • CT breast glandular tissue diameter correlates with log(b-HCG) • Gynaecomastia in CT is associated with worse prognosis • Gynaecomastia in CT is associated with non-seminoma histological subtype.

Intraluminal Uterine Hypodensity in CT Scans of Postmenopausal Women: Recommendations for Interpretation.

OBJECTIVE: This study aims to investigate the association between intraluminal uterine hypodensity and uterine malignancy and establish thresholds that would minimize routine gynecological evaluation. METHODS: Two groups were recruited retrospectively: cancer group, which comprised 32 sequential endometrial cancer patients, and postmenopausal group, which comprised 63 women, with no known gynecologic malignancy.Two radiologists independently measured hypodensity, transversely in the axial plane and anterioposteriorly in the sagittal plane.The association between cancer and hypodensity was evaluated. Receiver operating characteristic curves were evaluated diameters predictive of cancer. RESULTS: Hypodensity was associated with cancer (cancer group, 93.8% vs. postmenopausal group, 38.1%; P < 0.0001). Hypodensity diameters correlated highly with prediction of cancer (transverse area under the curve, 0.899; anteroposterior area under the curve, 0.892). Diameters of 19.5 mm transverse and 6.0 mm anteroposterior yielded a sensitivity of 87% and 83% and specificity of 91% and 83%, respectively. CONCLUSIONS: Intrauterine hypodensity is a common finding in computed tomography scans of postmenopausal women. A transverse diameter of 19.5 mm and an anteroposterior diameter of 6.0 mm are suggested as thresholds for further gynecological sonographic evaluation.

Prediction of patency capsule retention in known Crohn's disease patients by using magnetic resonance imaging.

BACKGROUND AND AIMS: Evaluation of small-bowel patency is recommended before swallowing video capsule endoscopy to prevent capsule retention. This study aimed to evaluate the ability of magnetic resonance enterography (MRE) to predict patency capsule (PC) retention in patients with Crohn's disease and to identify the most predictive imaging features for retention. METHODS: Fifty-seven patients prospectively underwent MRE and PC. Two radiologists predicted PC retention. Interrater reliability was determined by using Cohen's κ coefficient. The sensitivity, specificity, and positive and negative predictive values were calculated for the predictions. Evaluation of the imaging features was done using the t test and receiver-operating characteristics; t-tests were also performed on the clinical parameters. RESULTS: The κ value for interrater reliability was 0.58. The sensitivity, specificity, PPV, and NPV for the predictions by the 2 radiologists were 92.3%, 59%, 40%, 96.3%, and 100%, 52.3%, 38.2%, 100%, respectively. The maximal stricture length (9.7 ± 3.66 cm vs 7.0 ± 3.08 cm, P = .04) and the number of prestenotic dilations (1.9 ± 1.07 vs 1.0 ± 1.38, P = .03) were associated with PC retention. The area under the receiver-operating characteristic curves was 0.69 for the maximal stricture length and 0.751 for the number of prestenotic dilations. The phenotype of the disease was the only clinical parameter significantly correlated with PC retention. CONCLUSIONS: MRE has a high NPV and sensitivity for PC retention. When capsule retention is suggested by MRE, PC should be performed before the video capsule endoscopy examination. The maximal stricture length and the number of prestenotic dilations were found to be the most predictive imaging features for PC retention.

Association between Enlarged Axillary Lymph Nodes and Silicone Breast Implant Ruptures seen on Magnetic Resonance Imaging.

BACKGROUND: Silicone breast augmentation is a common cosmetic surgery. Previous case reports demonstrated lymphadenopathy in the presence of implant ruptures. OBJECTIVES: To investigate the association between enlarged axillary lymph nodes and silicone implant ruptures as seen on breast magnetic resonance imaging (MRI). METHODS: Two groups were derived retrospectively from breast MRI reports in our institution for the period December 2011-May 2014. A search of our hospital records for "silicone" and "lymph node" was performed (group A), and the relationship between the presence of enlarged nodes and ruptures was evaluated. The prevalence of ruptures in the presence of nodes was calculated and the association between MRI imaging features and ruptures evaluated. A search for "silicone" and "implant rupture" was performed (group B) and, as for group A, the relationship between the presence of ruptures and nodes was evaluated and the prevalence of enlarged nodes in the presence of ruptures calculated. RESULTS: Group A comprised 45 women with enlarged nodes. Intracapsular ruptures were associated with nodes (P = 0.005), while extracapsular ruptures showed a trend of association with nodes (P = 0.08). The prevalence of ruptures in the presence of nodes was 31.4%. Nodes associated with ruptures showed a strong silicone signal (P = 0.008) and absent enhancement (P = 0.005). Group B comprised 73 women with ruptures. Enlarged nodes were associated with both intra- and extracapsular ruptures (P < 0.001 and P = 0.002 respectively). The prevalence of nodes in the presence of ruptures was 22.2%. CONCLUSIONS: Enlarged axillary nodes were associated with ruptures in two groups of patients. This finding can guide clinical decisions when either enlarged nodes or ruptures are encountered in patients with silicone implants. The association between silicone lymphadenopathy and implant rupture raises concerns regarding the role of rupture in silicone-induced systemic disease.

Detection of Small Bowel Mucosal Healing and Deep Remission in Patients With Known Small Bowel Crohn's Disease Using Biomarkers, Capsule Endoscopy, and Imaging.

OBJECTIVES: Mucosal healing (MH) and deep remission (DR) are associated with improved outcomes in Crohn's disease (CD). However, most of the current data pertain to colonic MH and DR, whereas the evidence regarding the prevalence and impact of small bowel (SB) MH is scarce. The aim of this study was to to evaluate the prevalence of SBMH and DR in quiescent SBCD. METHODS: Patients with known SBCD in clinical remission (CDAI<150) or with mild symptoms (CDAI<220) were prospectively recruited and underwent video capsule endoscopy after verification of SB patency. Inflammation was quantified using the Lewis score (LS). SBMH was defined as LS<135, whereas a significant inflammation was defined as LS>790. Clinico-biomarker remission was defined as a combination of clinical remission and normal biomarkers. DR was defined as a combination of clinico-biomarker remission and MH. RESULTS: Fifty-six patients with proven SB patency were enrolled; 52 (92.9%) patients were in clinical remission and 21 (40.4%) in clinico-biomarker remission. SBMH was demonstrated in 8/52 (15.4%) of patients in clinical remission. Moderate-to-severe SB inflammation was demonstrated in 11/52 (21.1%) of patients in clinical remission and in 1/21 (4.7%) of patients in clinical and biomarker remission. Only 7/52 (13.5%) patients were in DR. CONCLUSIONS: SB inflammation is detected in the majority of CD patients in clinical and biomarker remission. SBMH and DR were rare and were independent of treatment modality. Our findings represent the true inflammatory burden in quiescent patients with SBCD.

Clinical Outcomes of Surgery Versus Endoscopic Balloon Dilation for Stricturing Crohn's Disease.

BACKGROUND: Endoscopic balloon dilation and surgery are commonly practiced in stricturing Crohn's disease. Nonetheless, there are still scant data directly comparing these 2 strategies. OBJECTIVE: The aim of this study was to compare the short- and long-term outcomes of endoscopic balloon dilation versus surgical resection in symptomatic Crohn's strictures. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary center. PATIENTS: Seventy-nine patients were identified, 40 in the surgical group and 39 in the endoscopic balloon dilation group (mean age 42.8 ± 13.9 versus 38.5 ± 12.2 years). MAIN OUTCOME MEASURES: The outcomes of all patients referred for endoscopic balloon dilation were compared with patients referred to surgery because of stricturing disease between the years 2006 and 2013. The primary outcome was the need for reintervention (either endoscopic balloon dilation or surgery) for symptomatic Crohn's disease during follow-up. RESULTS: The proportion of patients who required any reintervention during follow-up was significantly lower in the surgical group versus the endoscopic balloon dilation group (OR = 5.62 (95% CI, 1.66-19.01); p = 0.005). The need for surgery/resurgery during follow-up was also significantly lower in the surgically treated group (OR = 3.53 (95% CI, 1.01-12.29); p = 0.047). Reintervention-free survival and surgery-free survival were both significantly shorter in the endoscopically treated group in a Kaplan-Mayer analysis. The rate of major complications was similar in the endoscopically and surgically treated groups (7.6% versus 7.5%; p = 0.7). LIMITATIONS: The small cohort and the retrospective data collection were limitations of this study. CONCLUSIONS: In our cohort of patients with fibrostenotic Crohn's disease, a direct comparison showed reduced need for reinterventions with a similar rate of immediate major complications after surgery compared with endoscopic balloon dilation.

Real-World Outcomes of Inoperable and Metastatic Cutaneous Head and Neck Melanoma Patients.

OBJECTIVE: This study aims to describe the overall survival (OS) and to identify associated prognostic factors in patients with inoperable and metastatic cutaneous melanoma of the head and neck (H&N) region, undergoing modern systemic treatments. METHODS: This is a retrospective single institutional study. Data on all consecutive H&N melanoma patients treated with systemic oncologic treatments between 2015 and 2022 were collected from electronic medical files. Kaplan-Meier curves were used to describe survival and Cox regression analysis was used to identify patient and tumor factors associated with prognosis. RESULTS: A total of 144 patients were included. Median OS was 45 months (95% confidence interval [CI] 28-65 m). On univariable analysis for OS, the primary disease site, specifically the nape and neck (hazard ratio [HR] 3.3, 95% CI 1.4-7.7, p = 0.007), high Eastern Cooperative Oncology Group Performance Status ([ECOG-PS], HR 2.5, 95% CI = 1.9-3.3, p < 0.001), high lactate dehydrogenase (LDH) levels (HR 2.8, 95% CI = 1.7-4.6, p < 0.001), and treatment with targeted therapy (TT) as compared with immunotherapy (HR 2.6, 95% CI = 1.06-6.3, p = 0.03) were all associated with shorter OS. High-grade adverse events (AEs) were associated with a longer OS (HR 0.41, 95% CI = 0.25-0.68, p = 0.001). On multivariable analysis for OS, the ECOG-PS, LDH levels, site of disease, and the development of moderate-severe AEs remained significant. CONCLUSIONS: In the era of modern oncologic treatments, the prognosis of inoperable and metastatic cutaneous H&N melanoma aligns with other cutaneous melanomas. Primary tumor site of the nape and neck region emerges as a significant prognostic factor. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2762-2770, 2024.

The Safety of Pediatric Bedside Tracheostomy.

OBJECTIVE: Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU. MATERIALS AND METHODS: A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019. RESULTS: During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups. CONCLUSIONS: Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

SARS-CoV-2 Omicron Induces Enhanced Mucosal Interferon Response Compared to other Variants of Concern, Associated with Restricted Replication in Human Lung Tissues.

SARS-CoV-2 Omicron variant has been characterized by decreased clinical severity, raising the question of whether early variant-specific interactions within the mucosal surfaces of the respiratory tract could mediate its attenuated pathogenicity. Here, we employed ex vivo infection of native human nasal and lung tissues to investigate the local-mucosal susceptibility and innate immune response to Omicron compared to Delta and earlier SARS-CoV-2 variants of concern (VOC). We show that the replication of Omicron in lung tissues is highly restricted compared to other VOC, whereas it remains relatively unchanged in nasal tissues. Mechanistically, Omicron induced a much stronger antiviral interferon response in infected tissues compared to Delta and earlier VOC-a difference, which was most striking in the lung tissues, where the innate immune response to all other SARS-CoV-2 VOC was blunted. Notably, blocking the innate immune signaling restored Omicron replication in the lung tissues. Our data provide new insights to the reduced lung involvement and clinical severity of Omicron.

Preoperative Maxillary Sinus Imaging and the Outcome of Sinus Floor Augmentation and Dental Implants in Asymptomatic Patients.

OBJECTIVES: Preoperative maxillary sinus imaging findings have been suggested to be associated with complications and outcomes of sinus lift and dental implant procedures; nonetheless the evidence is controversial. The aim of this study was to examine the association between preoperative maxillary sinus imaging findings and outcomes of sinus lift and dental implant procedures in asymptomatic patients. METHODS: We included all patients who underwent maxillary sinus lift and dental implant procedures between 2014 and 2017. Maxillary sinus imaging findings were extracted from pre-procedural dental computed tomography scans, and outcomes of the procedures were assessed. RESULTS: A total of 145 procedures were included. No sinonasal symptoms were reported preoperatively. In 46% of cases maxillary sinus imaging was abnormal. The most common imaging finding was peripheral mucosal thickening (38%). Sinus floor cyst/polyp was identified in 13% of the cases, of which 47% occupied more than 50% of the sinus volume. Partial or complete opacification of the maxillary sinus was documented in 3% of cases. The sinus ostium and ostiomeatal complex were obstructed in 7% and 1%, respectively. Mucosal perforation was documented in 22% of cases and was inversely related to mucosal thickening (P = 0.011). Other minor post-operative complications did not correlate with radiological findings. Post-surgical sinusitis was not observed in any of the patients regardless of pre-surgical imaging findings. CONCLUSIONS: Incidental maxillary sinus imaging findings such as mucosal swelling, cysts or polyps, regardless of their severity or size, and maxillary ostial obstruction may not need to be addressed prior to sinus augmentation and dental implant procedures in asymptomatic patients. Patients with complete sinus opacification should be referred to an otolaryngologist prior to surgery. Further controlled trials, in larger cohorts, are needed to corroborate our findings.

Rhabdomyosarcoma disease spread evaluation on CT scans: Association with primary tumor size and Ki-67 proliferation marker.

PURPOSE: Ki-67 is a marker of cellular proliferation that is commonly used for the assessment of rhabdomyosarcoma. The aim of this study was to investigate the associations between Ki-67 expression and primary tumor diameter with CT evidence of lymph node and solid organ metastatic spread in rhabdomyosarcoma. MATERIALS AND METHODS: An institutional review board approval was granted for this study. A retrospective search for rhabdomyosarcoma patients was conducted. Pathology reports were examined for Ki-67 expression. Chest-abdomen CT was assessed for radiological evidence of lymph node and metastatic spread. The maximal primary tumor diameter (termed tumor size) was also measured in different modalities CT, MRI, PET-CT and US. Ki-67 levels and primary tumor maximal diameters were compared to CT evidence of lymph node and organ metastatic spread. RESULTS: Twenty-four patients with rhabdomyosarcoma were included. CT evidence of lymph node spread was associated with Ki-67 levels (AUC = 0.896, p = 0.006) and to a lesser extent with tumor size (AUC = 0.790, p = 0.030). However, organ metastatic spread was associated only with tumor size (AUC = 0.854, p = 0.006) and not with Ki-67 levels (AUC = 0.604, p = 0.469). A combination of tumor size ≥50 mm and Ki-67 levels ≥60% was significantly associated with CT evidence of lymph node spread (p = 0.004). CONCLUSION: In conclusion, this study demonstrates radiological-pathological correlation in RMS. Lymph node spread detected by radiological images is associated with Ki-67 values. Lymph node and metastatic spread are associated with primary tumor size.

Identifying Diabetes in Clinical Notes in Hebrew: A Novel Text Classification Approach Based on Word Embedding.

NimbleMiner is a word embedding-based, language-agnostic natural language processing system for clinical text classification. Previously, NimbleMiner was applied in English and this study applied NimbleMiner on a large sample of inpatient clinical notes in Hebrew to identify instances of diabetes mellitus. The study data included 521,278 clinical notes (one admission and one discharge note per patient) for 268,664 hospital admissions to medical-surgical units of a large hospital in Israel. NimbleMiner achieved overall good performance (F-score =.94) when tested on a gold standard human annotated dataset of 800 clinical notes. We found 15% more patients with diabetes mentioned in the clinical notes compared with diagnoses data. Our findings about underreporting of diabetes in the coded diagnoses data highlight the urgent need for tools and algorithms that will help busy providers identify a range of useful information, like having a diabetes.

Assessment of small bowel mucosal healing by video capsule endoscopy for the prediction of short-term and long-term risk of Crohn's disease flare: a prospective cohort study.

BACKGROUND: The optimal monitoring strategy for predicting disease course in Crohn's disease remains undefined. We aimed to evaluate the accuracy, safety, and tolerability of an intensive monitoring strategy designed to predict the future course of Crohn's disease in patients with quiescent disease. METHODS: In a prospective observational cohort study, we recruited patients older than 18 years with quiescent (for 3-24 months) Crohn's disease involving the small bowel with confirmed small bowel patency from three tertiary medical centres in Israel. Enrolled patients underwent baseline magnetic resonance enterography (MRE) and patency capsule, clinical or biomarker assessment every 3 months, and video capsule endoscopy (VCE) at baseline and every 6 months for 2 years or until a clinical flare (the primary outcome, defined as an increase in the Crohn's disease activity index score by 70 points or more) or disease worsening necessitating treatment intensification. We assessed the ability of the different Crohn's disease monitoring methods used to predict the occurrence of a flare during the 24-month follow-up period. FINDINGS: Of 90 screened patients, 29 were excluded (17 because of non-patent small bowel). Of the 61 patients enrolled between July 3, 2013, and Feb 1, 2015, 17 (28%) had a flare during the 24-month follow-up. No clinicodemographic parameter predicted future flare. A baseline VCE Lewis score of 350 or more identified patients with future flare (area under the curve [AUC] 0·79, 95% CI 0·66-0·88; p<0·0001; hazard ratio 10·7, 3·8-30·3). C-reactive protein at baseline had an AUC of 0·73 (0·6-0·84; p=0·0013) for predicting flare. The AUC of baseline faecal calprotectin for the prediction of flare occurring within 2 years was 0·62 (0·49-0·74; p=0·17), but progressively improved for shorter timespans and reached an AUC of 0·81 (0·76-0·85) for the prediction of flare occurring within 3 months. Of four MRE-based indices, only MRE global score correlated with 2-year flare risk (AUC 0·71, 0·58-0·82; p=0·024). During follow-up, a Lewis score increase of 383 points or more from baseline predicted imminent disease exacerbation within 6 months (AUC 0·79, 0·65-0·89; p=0·011). The safety and tolerability of the 231 VCEs ingested was excellent, with none being retained. INTERPRETATION: In patients with quiescent Crohn's disease involving the small bowel, faecal calprotectin predicts short-term flare risk, whereas VCE predicts both short-term and long-term risk of disease exacerbation. If corroborated by additional studies, protocols incorporating VCE could expand the scope of available methods for monitoring disease activity and predicting outcomes in small bowel Crohn's disease. FUNDING: The Leona M & Harry B Helmsley Charitable Trust.

A review of magnetic resonance enterography-based indices for quantification of Crohn's disease inflammation.

Magnetic resonance enterography (MRE) is a leading radiological modality in Crohn's disease (CD) and is used together with laboratory findings and endoscopic examinations for the evaluation of patients during initial diagnosis and follow up. Over the years, there has been great progress in the understanding of CD and there is a continuous strive to achieve better monitoring of patients and to develop new modalities which will predict disease course and thus help in clinical decisions making. An objective evaluation of CD using a quantification score is not a new concept and there are different clinical, endoscopies, radiological and combined indices which are used in clinical practice. Such scores are a necessity in clinical trials on CD for evaluation of disease response, however, there is no consensus of the preferred MRE score and they are not routinely used. This review presents MRE-based indices in use in the last decade: the Magnetic Resonance Index of Activity (MaRIA), the Clermont score, the Crohn's Disease Magnetic Resonance Imaging (MRI) Index (CDMI), the Magnetic Resonance Enterography Global Score (MEGS) and the Lemann index. We compare the different indices and evaluate the clinical research that utilized them. The aim of this review is to provide a reference guide for researchers and clinicians who incorporate MRE indices in their work. When devising future indices, accumulated data of the existing indices must be taken into account, as each of the current indices has its own strengths and weakness.

Capsule Endoscopy Validation of the Magnetic Enterography Global Score in Patients with Established Crohn's Disease.

BACKGROUND AND AIMS: Capsule endoscopy [CE] and magnetic resonance enterography [MRE] are prime modalities for evaluation of the small bowel in Crohn's disease [CD]. Detection of proximal small bowel [SB] inflammation in CD by MRE is challenging. Currently available quantitative MRE scores do not incorporate proximal SB data. The MRE global score [MEGS] was designed for quantitative evaluation of the entire digestive tract; its accuracy in the proximal SB has not previously been evaluated. This study compared the evaluation of the small bowel inflammation by MEGS and CE-derived quantitative score (the Lewis score[LS]). METHODS: CD patients in stable clinical remission were prospectively recruited and underwent MRE and CE; faecal calprotectin [FC] levels were obtained. MEGS was calculated for each SB segment and the entire SB [SBMEGS]. SB inflammation on CE was quantified using LS. A cumulative Lewis score [C-LS] was calculated based on summation of three tertiles scores. RESULTS: Fifty patients were included. There was a significant correlation of SBMEGS with LS and C-LS [r = 0.61 and 0.71, both p = 0.001]. The correlation with FC was stronger for MEGS than for LS or C-LS [r = 0.68 vs r = 0.46 vs r = 0.53, all p = 0.001]. The correlation between the proximal LS and MEGS was significant [r = 0.55, p = 0.001]; median MEGS was significantly different in patients, with LS values consistent with mucosal healing, mild and moderate-to-severe inflammation. CONCLUSIONS: MEGS provides accurate evaluation of the SB and strongly correlates with FC; the main advantage of MEGS is the accurate quantification of proximal SB inflammation unavailable for alternative MRE scores.

Diffusion-weighted magnetic resonance enterography for prediction of response to tumor necrosis factor inhibitors in stricturing Crohn's disease.

BACKGROUND AND AIMS: Distinguishing between fibrotic and inflammatory strictures in Crohn's disease (CD) is still challenging. The capacity of diffusion-weighted (DWI) magnetic resonance (MRE) to identify intestinal fibrosis was recently demonstrated; however, the therapeutic implications of this association have never been evaluated. The aim of the current study was to identify imaging features, including DWI, which can predict response to anti-inflammatory treatment in patients with stricturing CD. METHODS: Consecutive CD patients with intestinal strictures that initiated treatment with anti-tumor necrosis alpha (anti-TNF) between June 2012 and April 2017 with MRE adjacent to treatment onset were retrospectively collected. The primary outcome was treatment failure, defined as drug discontinuation, CD-related surgery, or endoscopic dilatation of the stricture. Clinical, demographic, and imaging data were compared between patients who did and did not develop treatment failure within 12 months of anti-TNF treatment initiation. RESULTS: A total of 21 patients were included in the study; 9/21 (42.8%) developed treatment failure. None of the clinical/demographic parameters were associated with the risk of treatment failure. Among imaging parameters, only ADC value (< 1 × 10-3 mm2/s) was significantly associated with the risk of treatment failure (AUC = 0.81, 66% vs. 0%, p = 0.015). CONCLUSIONS: Our results suggest that ADC value on DWI MRE may predict the risk of treatment failure in stricturing CD. If replicated in larger studies, these results may guide therapeutic decisions and suggest avoiding anti-TNF treatment.