The Addition of Endoscopic Sphincterotomy to Biliary Stent Placement and its Impact on the Risk of Adverse Events: An Updated Meta-Analysis of Randomized Controlled Trials.

BACKGROUND & AIMS: Endoscopic sphincterotomy (ES) is not mandatory before biliary stenting. The impact of ES before biliary stent placement remains uncertain. Previous studies have reported that ES can increase adverse event rates by up to 4.5 times compared to no ES. We aimed to assess the occurrence of post-ERCP adverse events following biliary stent placement with and without ES. METHODS: PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials. The primary outcome was post-ERCP pancreatitis (PEP). Subgroup analyses were performed with patients undergoing biliary drainage due to obstruction, using metal stents, and using plastic stents. Secondary outcomes included were post-procedure bleeding, perforation, stent/catheter occlusion, stent/catheter migration, and cholangitis. Heterogeneity was examined using I2 statistics, and a random-effects model was employed. Review manager 5.4 was used for statistical analyses. RESULTS: Seven RCTs with 1,022 patients were included. There was no significant difference between ES and non-ES groups (OR 0.46; 95% 0.19 to 1.09; p = 0.08; I2 = 59%) regarding PEP; however, a significant difference in bleeding rates was found between groups, favoring non-ES (OR 7.55; 95% CI 2.46 to 23.21; p = 0.0004; I2 = 0%). The analysis of the occurrence of cholangitis (OR 1.25; 95% CI 0.58 to 2.69; p = 0.56; I2 = 67%); perforation (OR 1.95; 95% CI 0.07 to 55.73; p = 0.70; I2 = 58%); stent/catheter migration (OR 1.95; 95% CI 0.07 to 55.73; p = 0.23; I2 = 6%); and stent/catheter occlusion (OR 0.90; 95% CI 0.37 to 2.19; p = 0.81; I2 = 0%) did not favor either group. CONCLUSION: Performing ES before biliary drainage does not impact the PEP rate but is associated with an increased postprocedure bleeding rate.

Vedolizumab versus ustekinumab in Crohn's disease with prior anti-tumor necrosis factor failure: an updated meta-analysis.

Ustekinumab and vedolizumab are key treatment options for Crohn's disease patients who fail anti-tumor necrosis factor (TNF) therapy. This updated meta-analysis aims to compare the efficacy and safety of these two drugs. We performed a systematic review in PubMed, Embase , and Cochrane databases searching for randomized and nonrandomized studies comparing vedolizumab versus ustekinumab in patients with Crohn's disease with previous anti-TNF failure or intolerance. The primary outcome was steroid-free clinical remission (SFR) at the pos-induction (12-16 weeks) and maintenance period (48-52 weeks). The odds ratio (OR) was used for binary outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I2 statistics. This meta-analysis included 11 studies and 2724 patients. There was a significant difference favoring ustekinumab in SFR at pos-induction (OR, 1.44; 95% CI, 1.11-1.88; P  = 0.006; I2  = 27%) and maintenance periods (OR, 1.86; 95% CI, 1.23-2.82; P  = 0.003; I2  = 80%), in clinical remission at pos-induction period (OR, 2.04; 95% CI, 1.58-2.63; P  < 0.001; I2  = 3%), and in treatment discontinuation due to adverse events (OR, 0.31; 95% CI, 0.16-0.60; P  < 0.001; I2  = 0%). In patients with Crohn's disease with prior anti-TNF failure, ustekinumab showed higher SFR during both the pos-induction and maintenance period and a lower rate of treatment discontinuation due to adverse events.

Could CD64 expression be used as a predictor of positive culture results in children with febrile neutropenia?

Background: Early recognition of infectious processes in neutropenic patients is hampered by the fact that these processes may have dissimilar and non-specific clinical presentations. CD64 is a neutrophil surface marker that is not expressed in non-sensitized neutrophils. When the neutrophil is exposed to tumor necrosis factor-alpha it is activated and is measured via the CD64 index. Methods: This paper evaluated the relationship between the index value of CD64 on the first day of febrile neutropenia and a positive blood culture. The correlations with white blood count, C-reactive protein and erythrocyte sedimentation rate were also evaluated. This case-control, prospective, diagnostic study included 64 episodes of neutropenia. Case group (n = 14) comprised positive blood cultures, and the control group (n = 50), negative blood cultures. Results: The median rates of CD64 were 2.1 (a ± 3.9) in the case group and 1.76 (a ± 5.02) in the control group. There was no correlation between the value of the CD64 index and blood cultures. The CD64 index was also not correlated with C-reactive protein positivity. Further- more, the CD64 index was not able to predict blood culture positivity. The sensitivity was 64.3%, the specificity was 42%, the positive predictive value was 23.7% and the negative predictive value was 80%. For C-reactive protein, the sensitivity, specificity, positive predictive value, and negative predictive value were 71.4%, 32%, 22.7%, and 80%, respectively. Conclusion: The CD64 index is not suitable for predicting the positivity of blood cultures in this specific population of patients with febrile neutropenia.