Deep learning model using stool pictures for predicting endoscopic mucosal inflammation in patients with ulcerative colitis.

OBJECTIVES: Stool characteristics may change depending on the endoscopic activity of ulcerative colitis (UC). We developed a deep learning model using stool photos of patients with UC (DLSUC) to predict endoscopic mucosal inflammation. METHODS: This was a prospective multicenter study conducted in six tertiary referral hospitals. Patients scheduled to undergo endoscopy for mucosal inflammation monitoring were asked to take photos of their stool using smartphones within 1 week before the day of endoscopy. DLSUC was developed using 2161 stool pictures from 306 patients and tested on 1047 stool images from 126 patients. The ulcerative colitis endoscopic index of severity (UCEIS) was used to define endoscopic activity. The performance of DLSUC in endoscopic activity prediction was compared with that of fecal calprotectin (Fcal). RESULTS: The area under the receiver operating characteristic curve (AUC) of DLSUC for predicting endoscopic activity was 0.801 (95% confidence interval [CI] 0.717-0.873), which was not statistically different from the AUC of Fcal (0.837 [95% CI, 0.767-0.899, DeLong's P=0.458]). When rectal sparing cases (23/126, 18.2%) were excluded, the AUC of DLSUC increased to 0.849 (95% CI, 0.760-0.919). The accuracy, sensitivity, and specificity of DLSUC in predicting endoscopic activity were 0.746, 0.662, and 0.877 in all patients and 0.845, 0.745, and 0.958 in patients without rectal sparing, respectively. Active patients classified by DLSUC were more likely to experience disease relapse during a median 8-month follow-up (log-rank test, P=0.002). CONCLUSIONS: DLSUC demonstrated a good discriminating power similar to that of Fcal in predicting endoscopic activity with improved accuracy in patients without rectal sparing. This study implies that stool photos are a useful monitoring tool for typical UC.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos).

BACKGROUND AND AIMS: Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes. METHODS: This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes. RESULTS: Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization. CONCLUSIONS: This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Protaetia Brevitarsis-Derived Protein Hydrolysate Reduces Obesity-Related Colitis Induced by High-Fat Diet in Mice through Anti-Inflammatory Pathways.

Ulcerative colitis is an inflammatory bowel disease characterized by inflammation in the mucosal and submucosal layers of the colon. Obesity is closely related to the occurrence and progression of colitis. The most plausible mechanism linking obesity and colitis is an excessive adipogenesis-related inflammatory response, which causes mucosal dysfunction. Obesity and colitis are linked by several etiologic mechanisms, including excessive adipogenesis, lipotoxicity, pro-inflammatory adipokines/cytokines, macrophage polarization, oxidative stress, endoplasmic reticulum (ER) stress, and gut microbiota. These low-grade enteric inflammations cause mucosal layer damage, especially goblet cell dysfunction through mucin 2 (MUC2) misfolding, ultimately leading to colitis. Inhibiting the inflammatory response can be the most effective approach for treating obesity-related colitis. We focused on the anti-inflammatory effects of polyphenols in Protaectia brevitas larvae. The P. brevitas was prepared as a low molecular protein hydrolysate (PHPB) to increase the concentration of anti-inflammatory molecules. In the current study, we investigated the anti-inflammatory effect of PHPB in an obesity-induced colitis mouse model. Compared with the high-fat diet (HFD) group, the group treated with PHPB exhibited reduced body/organ/fat weight, appetite/food intake inhibition, hypolipidemic effect on ectopic fat, and anti-adipogenic mechanism through the AMPK signaling pathway. Furthermore, we observed attenuated expression of PPARγ and C/EBPα, inhibition of pro-inflammatory molecules, stimulation of anti-inflammatory molecules, probiotic-like effect against obesogenic gut microbiota, inhibition of macrophage polarization into M1, suppression of oxidative/ER stress, and reduction of Muc2 protein misfolding in colon. These diverse anti-inflammatory responses caused histological and functional recovery of goblet cells, eventually improving colitis. Therefore, our findings suggest that the protein hydrolysate of Protaetia brevitarsis can improve obesity-related colitis through its anti-inflammatory activities.

Comparison of 1-Year Colectomy Risk Between the US and Korean Patients with Acute Severe Ulcerative Colitis: A Propensity Score Matching Analysis.

BACKGROUND: Colectomy risk after acute severe ulcerative colitis (ASUC) has not been compared between Eastern and Western countries. We compared the 1-year colectomy risk after ASUC between Korea and the USA. METHODS: Data on patients admitted for ASUC to five tertiary referral hospitals in Korea and Mount Sinai Hospital, New York, the USA, between January 2015 and January 2019 were reviewed retrospectively. For comparability between groups, a 1:1 propensity score matching (PSM) was performed. The primary outcome was colectomy, and secondary outcomes were mortality, readmission, and venous thromboembolism (VTE) within 1-year of the index admission for ASUC. The risk of each outcome was compared using Cox proportional hazards model in pre-matched cohort and Kaplan-Meier analysis with log-rank test in post-matched cohort. RESULTS: 290 ASUC patients were included in the study (121 Korea, 169 the USA). After PSM, 56 patients were selected in each group with no significant differences in baseline variables. At 1 year after ASUC, colectomy was less common in Korea than in the USA [3 (5.4%) vs. 24 (42.9%), p < 0.001]. The cumulative colectomy risk was significantly higher in the USA than in Korea in pre-matched cohort [adjusted hazard ratio 7.89, 95% confidence interval 3.23 to 19.22] and in post-matched cohort (log-rank p < 0.001), while there was no difference in cumulative risk of mortality, readmission, and VTE. CONCLUSION: Colectomy risk within 1 year of ASUC is significantly higher in the USA than in Korea. We observed no differences in mortality, readmission, and VTE between the two groups.

Plant Alkaloid Tetrandrine Is a Nuclear Receptor 4A1 Antagonist and Inhibits Panc-1 Cell Growth In Vitro and In Vivo.

The orphan nuclear receptor 4A1 (NR4A1) is highly expressed in human pancreatic cancer cells and exerts pro-oncogenic activity. In a previous study, we demonstrated that fangchinoline (FCN), a natural inhibitor of nuclear NR4A1, induces NR4A1-dependent apoptosis in human pancreatic cancer cells. In this study, we evaluated FCN and its structural analogs (berbamine, isotetrandrine, tetrandrine, and tubocurarine) for their inhibitory effects on NR4A1 transactivity, and confirmed that tetrandrine (TTD) showed the highest inhibitory effect in pancreatic cancer cells. Moreover, in a tryptophan fluorescence quenching assay, TTD directly bound to the ligand binding domain (LBD) of NR4A1 with a KD value of 10.60 µM. Treatment with TTD decreased proliferation and induced apoptosis in Panc-1 human pancreatic cancer cells in part through the reduced expression of the Sp1-dependent anti-apoptotic gene survivin and induction of ROS-mediated endoplasmic reticulum stress, which are the well-known NR4A1-dependent proapoptotic pathways. Furthermore, at a dose of 25 mg/kg/day, TTD reduced tumor growth in an athymic nude mouse xenograft model bearing Panc-1 cells. These data show that TTD is an NR4A1 antagonist and that modulation of the NR4A1-mediated pro-survival pathways is involved in the antitumor effects of TTD.

Low Bone Mineral Density in Young Patients Newly Diagnosed with Inflammatory Bowel Disease.

BACKGROUND: The prevalence and risk factors of low bone mineral density (BMD) in Asian patients newly diagnosed with inflammatory bowel disease (IBD) have not been fully suggested. AIMS: We aimed to examine the prevalence and risk factors of low BMD in young Korean patients newly diagnosed with IBD. METHODS: We prospectively enrolled 132 patients aged less than 50 years and newly diagnosed with IBD from six tertiary referral centers in Korea between November 2014 and April 2017. BMD was measured by dual-energy X-ray absorptiometry, and then the Z-score was determined. We defined low BMD as a Z-score ≤ - 1.0. RESULTS: Of 68 patients with ulcerative colitis (UC), 22 (32.4%) had low BMD. Also, of 64 patients with Crohn's disease (CD), 24 (37.5%) showed low BMD. Results from multivariate regression analysis identified the risk factors for low BMD as a high level of alkaline phosphatase (ALP) (≥ 140 U/L) (P = 0.010) in UC patients, and being underweight (body mass index ≤ 18.5 kg/m2) (P = 0.017) in CD patients. CONCLUSIONS: Our study showed that about one-third of newly diagnosed IBD Asian patients had low BMD. The clinical factors associated with low BMD were a high level of ALP in UC patients, and being underweight, in CD patients. Therefore, measurements of BMD in young patients should be considered at the diagnosis of IBD.

In Vitro and In Vivo Protective Effects of Lentil (Lens culinaris) Extract against Oxidative Stress-Induced Hepatotoxicity.

Excessive oxidative stress plays a role in hepatotoxicity and the pathogenesis of hepatic diseases. In our previous study, the phenolic extract of beluga lentil (BLE) showed the most potent in vitro antioxidant activity among extracts of four common varieties of lentils; thus, we hypothesized that BLE might protect liver cells against oxidative stress-induced cytotoxicity. BLE was evaluated for its protective effects against oxidative stress-induced hepatotoxicity in AML12 mouse hepatocytes and BALB/c mice. H2O2 treatment caused a marked decrease in cell viability; however, pretreatment with BLE (25-100 µg/mL) for 24 h significantly preserved the viability of H2O2-treated cells up to about 50% at 100 µg/mL. As expected, BLE dramatically reduced intracellular reactive oxygen species (ROS) levels in a dose-dependent manner in H2O2-treated cells. Further mechanistic studies demonstrated that BLE reduced cellular ROS levels, partly by increasing expression of antioxidant genes. Furthermore, pretreatment with BLE (400 mg/kg) for 2 weeks significantly reduced serum levels of alanine transaminase and triglyceride by about 49% and 40%, respectively, and increased the expression and activity of glutathione peroxidase in CCl4-treated BALB/c mice. These results suggest that BLE protects liver cells against oxidative stress, partly by inducing cellular antioxidant system; thus, it represents a potential source of nutraceuticals with hepatoprotective effects.

Fecal calprotectin is more accurate than fecal immunochemical test for predicting mucosal healing in quiescent ulcerative colitis: a prospective multicenter study.

Objective: Non-invasive stool tests, including the fecal immunochemical test (FIT) and fecal calprotectin (FC), are reliable biomarkers for mucosal healing (MH) in ulcerative colitis (UC). However, which fecal test is superior for predicting MH in inactive UC patients requires evaluation. We aimed to compare the accuracy of FIT and FC results for predicting MH in quiescent UC patients.Methods: This prospective, multicenter study was conducted at three tertiary hospitals. UC patients in clinical remission for at least three months underwent colonoscopy and MH was evaluated using the Mayo endoscopic sub-score (MES). The receiver operating characteristic (ROC) curve and cutoff value with the best accuracy for predicting MH were assessed.Results: Among 127 patients, 65 (51.2%) showed MH (MES = 0). The area under the curve (AUC) for predicting MH (MES = 0) was significantly higher for FC than for FIT (AUC 0.858 (95% confidence interval (CI) 0.784-0.913) vs. 0.707 (95% CI 0.620-0.784), p < .001); there was no difference when MH included MES = 1 (MES ≤ 1) (AUC 0.820 (95% CI 0.742-0.883) vs. 0.813 (95% CI 0.734-0.877), p = .891). When the cutoff value was 70 µg/g for FC and 10 ng/mL for FIT, the sensitivity, specificity, positive predictive value and negative predictive value were 89.2, 71, 76.3, and 86.3, respectively, for FC and 92.3, 50, 65.9, and 86.1, respectively, for FIT.Conclusion: FC is more accurate than FIT for predicting MH in quiescent UC patients. The superiority of FC might be related to the distinctive performance of FC in differentiating inflammatory levels, particularly in low-grade mucosal activity.

Sarcopenia Is a New Risk Factor of Nonalcoholic Fatty Liver Disease in Patients with Inflammatory Bowel Disease.

BACKGROUND AND AIM: Recently, sarcopenia has been proposed as an additional risk factor of nonalcoholic fatty liver disease (NAFLD), and there have been no studies in patients with inflammatory bowel disease (IBD). We aimed to analyze the clinical associations between sarcopenia and NAFLD in IBD patients. METHODS: From January 2004 to December 2017, a total of 488 IBD patients, with CT results, were classified according to the presence of NAFLD. Sarcopenia was assessed based on the muscle volume calculated by the total psoas muscle area in the third lumbar region divided by the square of the patient's height (m2). RESULTS: Among the 443 included patients, NAFLD was diagnosed in 49 patients (11.1%). Sarcopenia was noted in 34.9%; it was more common in the NAFLD group (51.0 vs. 33.0%; p = 0.019). In multivariate analysis, metabolic syndrome (odds ratio [OR], 8.63), hyperuricemia (OR, 4.66), small bowel resection (OR, 3.45), and sarcopenia (OR, 2.99) were significant risk factors of NAFLD in IBD patients. In addition, sarcopenia was an independent risk factor after adjustment for age, sex, and other metabolic factors (OR, 2.26). CONCLUSIONS: The prevalence of nonalcoholic fatty liver in IBD patients was 11.1%, and sarcopenia was an independent risk factor.

Predictors and clinical outcomes of follow-up loss in patients with inflammatory bowel disease.

BACKGROUND AND AIM: Nonadherence is a risk factor of disease worsening in inflammatory bowel disease (IBD). We analyzed the frequency, predictors, and clinical outcomes of patients with IBD who are lost to follow-up in outpatient clinics. METHODS: Medical records of 784 IBD patients visiting our IBD clinic between January 2010 and December 2015 were reviewed retrospectively. Overall, 285 newly diagnosed IBD patients who were followed up for at least 12 months were included in the analysis. RESULTS: For 285 IBD patients (161 ulcerative colitis and 124 Crohn's disease), the mean disease duration was 66.3 ± 34.0 months (7-137 months). Forty-two patients (14.7%; 27 ulcerative colitis and 15 Crohn's disease) were lost to follow-up. On multivariate regression analysis, travel time to clinic (odds ratio, 2.37; 95% confidence interval, 1.63-3.45; P = 0.01) and C-reactive protein levels at diagnosis (odds ratio, 0.63; 95% confidence interval, 0.43-0.68; P = 0.01) were significantly associated with follow-up loss. Among the 42 patients lost to follow-up, 36 (85.7%) revisited the clinic. The cause of revisit was disease flare-up in 22 patients (61.1%). Step-up treatment was needed in 15 patients (41.7%). Steroid was introduced in 14 patients (38.9%). Azathioprine and an antitumor necrosis factor agent were newly prescribed in three patients (8.3%) and one patient (2.8%), respectively. CONCLUSIONS: Follow-up loss rate for IBD patients in remission state was 14.7%, and the predictors were far from hospital and low C-reactive protein levels. Because most of follow-up loss patients experienced flare-up, clinicians need to try to encourage patients to keep their adherence.

Disease Activity Patterns Recorded Using a Mobile Monitoring System Are Associated with Clinical Outcomes of Patients with Crohn's Disease.

BACKGROUND: Usefulness of a mobile monitoring system for Crohn's disease (CD) has not been evaluated. We aimed to determine whether disease activity patterns depicted using a web-based symptom diary for CD could indicate disease clinical outcomes. METHODS: Patients with CD from tertiary hospitals were prospectively invited to record their symptoms using a smartphone at least once a week. Disease activity patterns for at least 2 months were statistically classified into good and poor groups based on two factors in two consecutive time frames; the degree of score variation (maximum-minimum) in each frame and the trend (upward, stationary, or downward) of patterns indicated by the difference in the mean activity scores between two time frames. RESULTS: Overall, 220 (82.7%) and 46 (17.3%) patients were included in good and poor groups, respectively. Poor group was significantly more associated with disease-related hospitalization (p = 0.004), unscheduled hospital visits (p = 0.005), and bowel surgery (p < 0.001) during the follow-up period than good group. In the multivariate analysis, poor patterns [odds ratio (OR) 2.62, p = 0.006], stricturing (OR 4.19, p < 0.001) or penetrating behavior (OR 2.27, p = 0.012), and young age at diagnosis (OR 1.06, p = 0.019) were independently associated with disease-related hospitalization. Poor patterns (OR 4.06, p = 0.006) and an ileal location (OR 5.79, p = 0.032) remained independent risk factors for unscheduled visits. Poor patterns (OR 15.2, p < 0.001) and stricturing behavior (OR 9.77, p = 0.004) were independent risk factors for bowel surgery. CONCLUSION: The disease activity patterns depicted using a web-based symptom diary were useful indicators of poor clinical outcomes in patients with CD.

Comparison of 4-L Polyethylene Glycol and 2-L Polyethylene Glycol Plus Ascorbic Acid in Patients with Inactive Ulcerative Colitis.

BACKGROUND: Although colonoscopy preparation may cause symptom flares in patients with ulcerative colitis (UC), little is known about the standard preparation regimen in this population. AIM: We aimed to compare 4L polyethylene glycol (4L-PEG) with 2L polyethylene glycol plus ascorbic acid (2L-PEG-Asc) in quiescent UC patients. METHODS: Patients with inactive UC undergoing colonoscopy for surveillance or checkup of mucosal healing were prospectively enrolled at 5 tertiary hospitals. They were randomly assigned to 4L-PEG and 2L-PEG-Asc groups. The Boston Bowel Preparation Scale (BBPS) was used for the preparation quality. Symptoms were assessed using the Simple Clinical Colitis Activity Index (SCCAI) before colonoscopy, at 1 and 4 weeks after the procedure. RESULTS: Overall, 109 patients were included in the study (4L-PEG group 53, 2L-PEG-Asc group 56, the mean age at diagnosis 42.25 years, male 77). The quality of preparation was comparable between the groups (BBPS ≥ 6, 96.2 vs. 92.9%, p = 0.679). Although 26 patients (23.8%) had increased SCCAI scores within 4 weeks after colonoscopy, resulting in a medication dose-up or add-on in 3 patients (2.7%), the rise in scores was not different between the groups. No serious adverse events during preparation were observed in either group. However, the 2L-PEG-Asc group was more likely to be willing to repeat the preparation with the same agent than the 4L-PEG group (82.1 vs. 64.2%, respectively, p = 0.034). CONCLUSION: PEG-based regimens with different volumes are equally effective and safe in inactive UC patients. 2L-PEG-Asc is more acceptable in this population as indicated by the willingness for further usage.

Volume of hospital is important for the prognosis of high-risk patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).

BACKGROUND AND AIM: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a potentially life-threatening hospital emergency requiring hemodynamic stabilization and resuscitation. This study is carried out to determine whether hospital volume can influence outcome in patients with NVUGIB. METHOD: This is a retrospective study with a prospective cohort database (KCT 0000514. cris.nih.go.kr). Eight teaching hospitals were divided into two different groups: high-volume centers (HVC, ≥60 NVUGIB patients/year, four clinics) and low-volume centers (LVC, <60 NVUGIB patients/year, four clinics). Baseline characteristics of patients, risk stratification, and outcomes between hospitals of different volumes were compared. From February 2011 to December 2013, a total of 1584 NVUGIB patients enrolled in eight clinics were retrospectively reviewed. The main outcome measurements consisted of continuous bleeding after treatment, re-bleeding, necessity for surgical/other retreatments, and death within 30 days. RESULTS: Similar baseline characters for patients were observed in both groups. There was a significant difference in the incidence of poor outcome between the HVC and LVC groups (9.06 vs. 13.69%, P = 0.014). The incidence rate of poor outcome in high-risk patients (Rockall score ≥8) in HVC was lower than that in high-risk patients in LVC (16.07 vs. 26.92%, P = 0.048); however, there was no significant difference in poor outcome in the lower-risk patients in either group (8.72 vs. 10.42%, P = 0.370). CONCLUSIONS: Significant correlation between hospital volume and outcome in NVUGIB patients was observed. Referral to HVC for the management of high-risk NVUGIB patients should be considered in clinical practice.

WEO position statement on hygiene in digestive endoscopy: Focus on endoscopy units in Asia and the Middle East.

The aim of this position statement is to reinforce the key points of hygiene in digestive endoscopy. The present article details the minimum hygiene requirements for reprocessing of endoscopes and endoscopic devices, regardless of the reprocessing method (automated washer-disinfector or manual cleaning) and the endoscopy setting (endoscopy suite, operating room, elective or emergency procedures). These minimum requirements are mandatory for patient safety. Both advanced diagnostic and therapeutic endoscopies should be carried out in an environment that is safe for patients and staff. Particular attention is given to contaminants. Procedural errors in decontamination, defective equipment, and failure to follow disinfection guidelines are major factors contributing to transmission of infection during endoscopy. Other important risk factors include inadequate cleaning, use of older endoscopes with surface and working channel irregularities, and contamination of water bottles or irrigating solutions. Infections by multidrug-resistant organisms have become an increasing problem in health-care systems worldwide. Since 2010, outbreaks of multidrug-resistant bacteria associated with endoscopic retrograde cholangiopancreatography have been reported from the USA, France, Germany, and The Netherlands. In many endoscopy units in Asia and the Middle East, reprocessing procedures have lagged behind those of Western countries for cultural reasons or lack of financial resources. This inconsistency in standards is now being addressed, and the World Endoscopy Organization has prepared this position statement to highlight key points for quality assurance in any endoscopy unit in any country.

Patients' beliefs and attitudes about their treatment for inflammatory bowel disease in Korea.

BACKGROUND AND AIMS: Adherence to medication during the treatment of inflammatory bowel disease (IBD) is important in terms of maintaining remission. According to studies on adherence to medication in other chronic diseases, non-adherence is associated with negative attitudes to treatment. The aims of this study were to assess adherence rates and IBD patients' beliefs and attitudes regarding medication using a questionnaire based approach. METHODS: Two hundred and eighty seven patients from three tertiary hospitals were enrolled and completed a questionnaire that addressed adherence (Medication Adherence Report Scale, MARS), beliefs, and attitudes to medication (Beliefs about Medications Questionnaire, BMQ). RESULTS: Using a cutoff score of 16/20 for MARS, 64 (22.3%) patients did not adhere to medication. According to attitude analysis conducted using the BMQ, 41.8% of the 287 study subjects felt high necessity but low concern for the medication ("accepting") and 34.8% felt high necessity and concern ("ambivalent"). Multivariate analysis showed significantly lower adherence to medication among younger patients, patients with experience of adverse effects to medication, patients with demanding jobs, and for those with an "indifferent" or "skeptical" attitude regarding the benefits of medication. On the other hand, IBD patients with "accepting" attitude adhered to medication. CONCLUSION: Twenty-two percent of IBD patients were non-adherent to medical treatment, and belief of the need for medication was found to significantly enhance adherence. Interventions, such as education about the efficacy and safety of medications, should be considered to facilitate adherence to medical treatment among IBD patients.

Crohn's disease prognosis and early immunomodulator therapy: Results from the CONNECT study.

BACKGROUND: It is unknown whether the treatment initiating time of immunomodulators such as thiopurines affects the course of Crohn's disease (CD). We evaluated the efficacy of early immunomodulator therapy (EIT) on the prognosis of patients with CD. METHODS: We retrospectively analyzed 1157 patients with CD who were enrolled in the CrOhn's disease cliNical NEtwork and CohorT study and received immunomodulator therapy. The patients were divided into an EIT group and a conventional therapy group based on whether immunomodulators were initiated within six months after being diagnosed with CD. We compared the rates of intestinal surgery, bowel complications, and hospitalization because of CD between the groups. RESULTS: Patient age at diagnosis and sex were not significantly different between the two groups. The mean duration of follow-up was 105.8 ± 51.5 months. A Kaplan-Meier analysis identified that the EIT group was superior to the conventional therapy group in terms of delaying surgery (P = 0.017). In multivariate analysis, EIT was an independent predicting factor associated with delaying the onset of complications (P = 0.050). Patients were divided into two groups based on the year of CD diagnosis: from 1982 to 1999 (A) and from 2000 to 2008 (B). In group A, the time from diagnosis to the start of immunomodulatory therapy was longer (P < 0.001), and the time to first intestinal surgery was shorter than group B (P = 0.002). CONCLUSIONS: The early use of immunomodulators was associated with a good prognosis as defined by a need for surgery and the occurrence of complications in CD in our multicenter study.

Risk Factors Associated with Rebleeding in Patients with High Risk Peptic Ulcer Bleeding: Focusing on the Role of Second Look Endoscopy.

BACKGROUND: Re-bleeding after initial hemostasis in peptic ulcer bleeding can be life threatening. Identification of factors associated with re-bleeding is important. The aims of this study were to determine incidence of rebleeding in patients with high risk peptic ulcer bleeding and to evaluate factors associated with rebleeding. METHODS: Among patients diagnosed as upper gastrointestinal hemorrhage at seven hospitals in Daegu-Gyeongbuk, and one hospital in Gyeongnam, South Korea, from Feb 2011 to Dec 2013, 699 patients diagnosed as high risk peptic ulcer bleeding with Forrest classification above llb were included. The data were obtained in a prospective manner. RESULTS: Among 699 patients, re-bleeding occurred in 64 (9.2 %) patients. Second look endoscopy was significantly more performed in the non-rebleeding group than the rebleeding group (81.8 vs 62.5 %, p < 0.001). In multivariate analysis, use of non-steroidal anti-inflammatory agents, larger transfusion volume (≥5 units), and non-performance of second look endoscopy were found as risk factors for rebleeding in high risk peptic ulcer bleeding. CONCLUSION: In our study, rebleeding was observed in 9.2 % of patients with high risk peptic ulcer bleeding. Performance of second look endoscopy seems to lower the risk of rebleeding in high risk peptic ulcer bleeding patients and caution should be paid to patients receiving high volume transfusion and on medication with NSAIDs.

Risk Factors of Advanced Adenoma in Small and Diminutive Colorectal Polyp.

The aims of this study were to review the clinicopathological characteristics of diminutive (≤ 5 mm) and small polyps (> 5 mm but < 10 mm) and to evaluate the risk factors of advanced adenoma for polyps of diameter < 10 mm in the colon. The medical records of 4,711 patients who underwent first colonoscopy at outpatient clinics or health promotion center were reviewed retrospectively. We analyzed the presence and risk factors of advanced adenoma, which was defined as a villous or tubulovillous polyp, high-grade dysplasia or intramucosal carcinoma histologically. Total 5,058 polyps were detected in the 4,711 patients, and 93.0% (4,704/5,058) polyps were < 10 mm in size. Among them, advanced adenoma was noted in 0.6% (28/4,704) with a villous component in 19, high-grade dysplasia in 3, and adenocarcinoma in 6. Advanced and non-advanced adenomas differed significantly in age group, gender, and polyp size. Multivariate analysis showed that an advanced age (> 65 years), a male gender, and a polyp size of > 5 mm were risk factors of advanced adenoma. The incidence of advanced adenoma in polyps of < 10 mm was 0.6%. Polyp size, male gender, and age of > 65 years are independent risk factors of advanced adenoma.

Concomitant and hybrid therapy for Helicobacter pylori infection: A randomized clinical trial.

BACKGROUND AND AIMS: This study aimed to validate the equivalence of first-line concomitant and hybrid regimens for Helicobacter pylori infection in an era of increasing antibiotic resistance. The study also aimed to assess regimen compliance. METHODS: H. pylori-infected patients from six hospitals in Korea were randomly assigned to either concomitant or hybrid regimens. The concomitant regimen consisted of 20 mg of esomeprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg metronidazole, twice daily for 10 days. The hybrid regimen consisted of a 5-day dual therapy (20 mg of esomeprazole and 1 g of amoxicillin, twice daily) followed by a 5-day quadruple therapy (20 mg of esomeprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg of metronidazole, twice daily). RESULTS: Eradication rates for concomitant and hybrid therapy were 78.6% (187/238) and 78.8% (190/241) in the intention-to-treat analysis, and 89.8% (176/196) and 89.6% (181/202) in the per protocol analysis. For both analyses, 95% confidence intervals fell within the ± 8% equivalence margin. Adherence was better in the hybrid group (95.0%) than in the concomitant group (90.1%), a difference that was borderline significant (P = 0.051). Adverse event rates were higher in the concomitant group than in the hybrid group for nausea (15.8% vs 8.8%; P = 0.028) and regurgitation (17.6% vs 10.7%; P = 0.040). CONCLUSION: As compared with concomitant therapy, hybrid therapy offered similar efficacy, better compliance, and fewer adverse events. Hybrid therapy could be a reasonable first-line treatment option for H. pylori in areas with high antibiotics resistance.

Non-curative endoscopic resection does not always lead to grave outcomes in submucosal invasive early gastric cancer.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been widely performed for the treatment of early gastric cancer (EGC). The aim of this study is to examine the effectiveness of ESD in submucosal invasive gastric cancers (SM-GC), with a special focus on patients who underwent non-curative resection. METHODS: Data for 1,246 patients who underwent ESD for treatment of EGC at six medical centers in Daegu-Gyeongbuk, Korea, between February 2003 and May 2010 were collected. After retrospective analysis of ESD databases, 118 patients were enrolled and classified into three groups: (1) EGC with submucosal invasion less than 500 µm (SM1-GC) that met the expanded criteria (EC) (SM1 EC, n = 42); (2) SM1-GC that did not meet the EC (SM1 non-EC, n = 38); and (3) EGC with submucosal invasion greater than 500 µm (SM2-GC, n = 38). RESULTS: The en bloc and complete resection rates did not differ significantly among the three groups. However, the curative resection rate was significantly better in the SM1 EC group (69.0%) compared to that in SM1 non-EC and SM2-GC groups (0% in both cases). Out of a total of 118 patients, 89 (75.4%) underwent non-curative resection, and cancer recurrence was observed in 9 (9/89, 10.1%). We analyzed the survival rate in these non-curative patients and the overall survival and disease-free survival did not differ significantly between patients that were treated with additional surgical resection and those that were simply followed up after ESD. CONCLUSIONS: Non-curative resection in SM-GC does not always lead to cancer recurrence. Thus, if additional surgery cannot be performed because of the patient's unsuitable condition or refusal, a close follow-up with endoscopy can be considered as an alternative for carefully selected patients. Moreover, as the ESD technology continues to evolve, it might be possible to expand the criteria for curative ESD in patients with SM-GC.