Food-Related Quality of Life and Its Predictors in Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) is associated with dietary restrictions and food- and drink-driven daily life limitations. Food-related quality of life (FR-QoL) is still an under-addressed issue in IBD. AIM: We aimed to study determinants of FR-QoL in an IBD cohort, namely objective measures of disease activity. METHODS: A cross-sectional case-control study was conducted in a Tertiary Hospital, including adult patients with IBD (cases) and blood donors or subjects referred for colorectal polypectomies (controls). Participants answered an anonymous multimodal questionnaire including sociodemographic and clinical data, the validated FR-QoL-29, and the SIBDQ tools. Patients' disease activity was previously assessed by a physician using symptom-based scores and biomarkers (Harvey-Bradshaw index, partial Mayo score, fecal calprotectin). RESULTS: A total of 239 patients with IBD and 126 controls were included. Patients with active disease had poorer FR-QoL than patients in remission (80.0 [56.0-99.0] vs. 103.5 [81.0-129.9], p < 0.001). Still, patients with IBD had significantly lower FR-QoL compared with controls (99.0 [76.0-126.0] vs. 126.0 [102.8-143.0], p < 0.001), irrespective of disease activity. FR-QoL correlated with health-related quality of life, measured by SIBDQ (r = 0.490, p < 0.001), and was significantly impaired by patients' depressive humor (84.0 [61.0-112.0] vs. 108.0 [88.0-130.5], p < 0.001). Globally, FR-QoL compromise was mostly related to persistent worries about food, concerns about food-related symptoms, and life disruption due to eating and drinking. CONCLUSIONS: Patients with IBD showed significant FR-QoL impairment, irrespective of disease type and activity. Related psychosocial factors, such as the patient's affective status and fear around eating, warrant a need for a multidisciplinary approach to IBD, including tailored nutritional counseling.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy.

OBJECTIVE: Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role. DESIGN: In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO2e) and 1 kg of RMW to 3kgCO2e was assumed. Paired samples t-tests for comparisons. RESULTS: From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO2e by 31.6% (138.8kgCO2e) was found (mean kgCO2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel. CONCLUSION: In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

Subclinical Persistent Inflammation as Risk Factor for Crohn's Disease Progression: Findings From a Prospective Real-World Study of 2 Years.

BACKGROUND AND AIMS: Subclinical intestinal inflammation is common in Crohn's disease (CD). We aimed to explore its impact in the disease progression of infliximab-treated patients and the usefulness of fecal calprotectin (FC) and C-reactive protein (CRP) as surrogate minimally invasive biomarkers. METHODS: The registry-based, prospective, observational, multicenter DIRECT (study to investigate the correlation of fecal calprotectin with serum Drug levels and development of an antI-dRug antibodiEs among adult patients with inflammatory bowel disease reCeiving anti-TNF-alfa treatment or vedoluzimab treatment) study followed infliximab-treated CD patients for 2 years in a tertiary care setting. Persistent inflammation definition was based on FC (>150 µg/g, >250 µg/g, or >350 µg/g) or serum CRP (>3 µg/mL) concentrations over 2 consecutive or at least 3 visits. Patients were categorized according to a composite outcome reflecting disease progression that incorporated surgery; hospitalizations; new fistulae, abscess, or stricture; and treatment escalation. RESULTS: Of 322 DIRECT study patients, 180 asymptomatic, infliximab treated on maintenance regimen were included in the analysis. Patients developing the composite endpoint (n = 96) presented higher median levels of FC (205 [interquartile range, 98-515] µg/g; P = .045) but not of CRP (2.50 [interquartile range, 0.80-6.00] µg/mL; P = .895). Biomarker-defined persistent subclinical inflammation prevalence ranged from 24% to 81%. Considering FC >250 µg/g in 2 consecutive visits, prevalence was 50%, odds of achieving the endpoint were increased 3-fold (odds ratio, 2.996 [95% confidence interval, 1.557-5.776]), and time-to-outcome occurrence was significantly lower among subjects with persistent inflammation (median time: 11 months). Both clinical-related and treatment-related components were significantly associated with persistent inflammation. Definitions based on CRP >3 µg/mL, FC >150 µg/g, FC >350 µg/g, double biomarkers (FC >250 µg/g and/or CRP >3 µg/mL), or more visits did not improve predictive ability. CONCLUSIONS: Persistent inflammation, defined simply and readily by FC >250 µg/g over 2 consecutive visits, was associated with a significantly higher risk and shorter time to occurrence of a composite outcome reflecting disease progression in asymptomatic infliximab-treated CD patients.

Gynecological history to diagnosis and pregnancy outcomes in diagnosed Wilson's disease patients under therapy - A bicentric matched-control cohort study.

INTRODUCTION: most studies narrowly focus on pregnancy outcome comparisons between Wilson's disease (WD) patients on and off treatment. We aimed to identify menses irregularities in untreated WD, and to evaluate pregnancy outcomes in treated WD patients as compared to matched controls (with and without liver disease). METHODS: females with WD, hepatitis C (liver disease controls), and other gastrointestinal conditions (controls without liver disease) were identified at two tertiary hospital gastroenterology departments. Gynecological and obstetric data were retrospectively collected. A comparison of gynecological and obstetric outcomes was performed between the groups, and regression models were used to further assess obstetric outcomes. RESULTS: a total of 18 females with WD were identified, comprising 19 pregnancies under treatment in 11 patients, and 20 females were included in each control group. Age and liver disease stage were adjusted between groups. The incidence of menses irregularities was higher for WD (late menarche, 83 % vs. 10 % vs. 10 %, p < 0.01; irregular cycles, 100 % vs. 20 % vs. 20 %, p < 0.01; amenorrhea, 67 % vs. 10 % vs. 5 %, p < 0.01). Logistic regression models identified WD as a predictor of miscarriage and low birth weight (OR: 6.0; CI: 1.1-33.3; p < 0.05) but not of birth defects. Neither therapies (D-penicillamine 300 mg or zinc acetate 150 mg) nor disease presentation (hepatic and/or neurological) were associated with obstetric complications in WD subjects. CONCLUSION: there was a higher incidence of menses irregularities in untreated females with WD. In addition, our data suggest that treated WD still carries a higher risk of spontaneous abortion and low birth weight when compared to matched control groups with and without liver disease.

Short Inflammatory Bowel Disease Questionnaire: translation and validation to the Portuguese language.

BACKGROUND: The Short Inflammatory Bowel Disease Questionnaire (SIBDQ) is a widely used instrument to assess Health-related Quality of Life (HRQoL) among inflammatory bowel disease (IBD) patients. Our aim was to translate and adapt the SIBDQ so that it could be adequately used in Portugal. METHODS: This is a prospective design cohort study undertaken at a tertiary hospital. This study took place simultaneously with the first part of the SexIDI study, a study aiming to assess the impact of IBD on patients' sexual QoL. The original SIBDQ was translated by two independent translators and adapted by an IBD expert panel following the opinions of a convenient sample of 5 IBD patients. Afterwards, IBD patients from the outpatient clinic were consecutively invited to fill the Portuguese version of the questionnaire (SIBDQ-PT) at three different timepoints (0, 2, 4 weeks). Ninety-two patients completed the SIBDQ-PT at baseline, whereas 33 did so after 2 and 4 weeks (approximately). Statistical analysis was performed using SPSS version 25, and the following aspects were analysed: reliability (through internal consistency, test-retest and intraclass correlation), validity (through exploratory factor analysis [EFA], and Pearson correlation coefficient for linear correlations), score distribution, and responsiveness analysis (through t-student tests). RESULTS: Overall, SIBDQ-PT was shown to have a high internal consistency (Cronbach's α = 0.80) and a high test-retest reliability (0.80 [CI 0.74-0.86] and 0.69 [CI 0.50-0.82]). EFA detected four dimensions-bowel, social, emotional and systemic. As expected, an overall SIBDQ-PT score was positively correlated with sexual satisfaction (r = 0.27; p < 0.05) and negatively correlated with depression (r = - 0.63; p < 0.01). Moreover, SIBDQ-PT was found to have an adequate score distribution, and to be responsive, as there was a significant subscore change for patients who reported an "overall worsening in general well-being" (0.93 ± 0.13 decrease; p < 0.01). CONCLUSIONS: The Portuguese version of the SIBDQ hereby presented is a reliable, valid and responsive instrument that can be used to measure HRQoL among Portuguese IBD patients.

Methylation patterns in dysplasia in inflammatory bowel disease patients.

Background and aims: Inflammatory Bowel Disease (IBD) with colonic involvement increases colorectal cancer risk. However, the distinction between IBD related and sporadic dysplasia in IBD patients is difficult. Some data favors the importance of abnormal DNA methylation in IBD-related carcinogenesis. We aimed to define methylation patterns in patients with colonic cancer or dysplasia diagnosis following an IBD diagnosis.Methods: Multicentric cross-sectional study-91 samples from colonic mucosa with/without dysplasia from 9 patients with IBD-related dysplasia/cancer and 26 patients with IBD and sporadic dysplasia/cancer were included. Methylation patterns of CpG islands in the promoter regions of 67 genes were studied by Methylation-specific Multiplex Ligation-dependent Probe Amplification.Results: Mean age at IBD diagnosis: 42 ± 16 years;at dysplasia diagnosis: 56 ± 14 years. Twenty-ninepatients had ulcerative colitis. Twenty-five patients had at least 1 lesion endoscopically described as adenoma-like, 4 at least 1 non-adenoma like, 3 had cancer and 3 had dysplasia in flat mucosa. No patient had both adenoma-like and non-adenoma-like lesions. Patients with an IBD-related lesion were significantly younger at IBD diagnosis (p = .003) and at dysplasia/cancer diagnosis (p = .039). Promoter methylation of IGF2, RARB, ESR1, CHFR, CDH13, WT1, GATA5, WIF1genes was significantly associated to dysplasia/cancer; methylation of MSH6, TIMP3 was significantly associated to IBD-related dysplasia/cancer. Promoter methylation of MSH6, MSH3, RUNX3, CRABP1, TP73, RARB, CDH13, PAX5, WT1, THBS1, TP53, SFRP1, WIF1, APAF1, BCL2 genes was significantly associated to active IBD.Conclusions: Methylation analysis, namely of MSH6, may contribute to the classification of dysplastic lesions in IBD- to be further tested in prospective studies.

The influence of subclinical active inflammation on IFX pharmacokinetic modeling and disease progression assessment: findings from a prospective real-world study in inflammatory bowel disease patients.

BACKGROUND AND AIMS: Effective management of inflammatory bowel disease (IBD) relies on a comprehensive understanding of infliximab (IFX) pharmacokinetics (PK). This study's primary goal was to develop a robust PK model, identifying key covariates influencing IFX clearance (CL), while concurrently evaluating the risk of disease progression during the maintenance phase of IBD treatment. METHODS: The multicenter, prospective, real-world DIRECT study was conducted in several care centers, which included 369 IBD patients in the maintenance phase of IFX therapy. A two-compartment population PK model was used to determine IFX CL and covariates. Logistic and Cox regressions were applied to elucidate the associations between disease progression and covariates embedded in the PK model. RESULTS: The PK model included the contributions of weight, albumin, antidrug antibody (ADA), and fecal calprotectin (FC). On average, higher ADA, FC concentration and weight, and lower albumin concentration resulted in higher IFX CL. In the multivariate regression analyses, FC levels influenced the odds of disease progression in all its different definitions, when adjusted for several confounding factors. Additionally, alongside FC, both IFX and CL demonstrated a significant impact on the temporal aspect of disease progression. CONCLUSION: In this 2-year real-world study, readily available clinical covariates, notably FC, significantly impacted IFX availability in IBD patients. We demonstrated that subclinical active inflammation, as mirrored by FC or CRP, substantially influenced IFX clearance. Importantly, FC emerged as a pivotal determinant, not only of IFX pharmacokinetics but also of disease progression. These findings underscore the need to integrate FC into forthcoming IFX pharmacokinetic models, amplifying its clinical significance.

Impact of Crohn's Disease Therapies on Histology in Randomized Controlled Trials: Systematic Review With Meta-analysis.

BACKGROUND: The effectiveness of Crohn's disease treatments for inducing histological outcomes has not been addressed systematically. We performed a systematic review and meta-analysis of randomized controlled trials in Crohn's disease to assess the impact of therapies on mucosal histopathology. METHODS: Databases (MEDLINE, CENTRAL, Web of Science, EMBASE) were searched for randomized controlled trials including adult patients and evaluating histological outcomes. Risk of bias was evaluated using the Critical Appraisal Skills Programme. Histological outcomes, pooled frequencies, pooled odds ratios, and standard mean differences of the histological scores were compared between the intervention and placebo groups using a random-effects model. RESULTS: Out of 2070 records, 10 studies were included. The quality of the studies ranged from moderate to high, but they were clinically and methodologically diverse. All interventions were superior to placebo. Histological response was achieved by 68% of patients, and 38% achieved remission. Pooled odds ratio for histological remission in patients receiving intervention vs placebo was 4.14 (95% CI, 2.28-7.50; I2 0%; P < .01). Heterogeneity in histological response estimates was significant, and subgroup analysis of the odds ratio results was limited by the low number of studies per group. The standard mean difference of histological scores was higher for patients receiving intervention in both induction and maintenance studies (-2.95; 95% CI, -4.17 to -1.74; I2 83% P < .00; and -2.58; 95% CI, -3.89 to -1.27; I2 56% P < .00). CONCLUSIONS: Crohn's disease therapies are effective for achieving histological outcomes. Adherence to recently published consensus on histopathology harmonization assessment in Crohn's disease would facilitate adequate comparison between studies in the future.

We performed a systematic review and meta-analysis of randomized controlled trials in Crohn's disease with the primary objective of assessing therapeutic histologic outcomes (response and remission). Our results show that CD therapies are effective in achieving these outcomes.

Has the therapeutical ceiling been reached in Crohn's disease randomized controlled trials? A systematic review and meta-analysis.

BACKGROUND AND AIMS: The availability of biological agents for inflammatory bowel disease has increased over the past years. In this systematic review and meta-analysis, we aimed to explore time trends in clinical response and clinical remission rates in Crohn's disease (CD) patients treated with biologics while discussing the need for new strategies. METHODS: MEDLINE, Cochrane, and ISI Web of Science databases were searched for randomized placebo-controlled trials with biological agents in moderate-to-severe CD patients. Sub-group and meta-regression analyses compared treatment and placebo by calculating the pooled odds ratios of clinical remission and clinical response, across time categories and publication year. We also estimated the proportion of patients achieving clinical remission and clinical response by comparing both groups according to the publication year. RESULTS: Twenty-five trials were included in the systematic review, which enrolled 8879 patients between 1997 and 2022. The clinical remission and clinical response odds, in induction and maintenance, have been constant over time, as no statistically significant differences were found between time categories (interaction p-values: clinical remission [induction, p = 0.19; maintenance, p = 0.24]; clinical response [induction, p = 0.43; maintenance, p = 0.59]). In meta-regression analyses, publication year did not influence these outcomes (clinical remission [induction, OR 1.01{95% CI 0.97-1.05}, p = 0.72; clinical response [induction, OR 1.01{95% CI 0.97-1.04]; p = 0.63; maintenance, OR 1.03{95% CI 0.98-1.07}; p = 0.21]), with the exception of clinical remission in maintenance studies, which presented a decreased effect (odds ratio 0.97{95% CI 0.94-1.00}, p = 0.03]). CONCLUSIONS: Our review highlights that the odds of clinical outcomes in CD patients receiving biological treatment relative to placebo have been stable in the last decades.

Thiopurines have no impact on outcomes of Crohn's disease patients beyond 12 months of maintenance treatment with infliximab.

BACKGROUND: The emergence of new treatments the inflammatory bowel diseases (IBD) raised questions regarding the role of older agents, namely thiopurines. AIMS: To clarify the benefits of combination treatment with thiopurines on Crohn's disease (CD) patients in the maintenance phase of infliximab. METHODS: In this analysis of the 2-year prospective multicentric DIRECT study, patients were assessed in terms of clinical activity, faecal calprotectin (FC), C-reactive protein (CRP), and infliximab pharmacokinetics. A composite outcome based on clinical- and drug-related items was used to define treatment failure. RESULTS: The study included 172 patients; of these, 35.5 % were treated with combination treatment. Overall, 18 % of patients achieved the composite outcome, without statistically significant differences between patients on monotherapy and on combination treatment (21.6% vs 11.5 %, p = 0.098). Median CRP, FC, and infliximab pharmacokinetic parameters were similar in both groups. However, in the sub-analysis by infliximab treatment duration, in patients treated for less than 12 months, the composite outcome was reached in fewer patients in the combination group than in the monotherapy group (7.1% vs 47.1 %, p = 0.021). CONCLUSION: In CD patients in maintenance treatment with infliximab, combination treatment does not seem to have benefits over infliximab monotherapy beyond 12 months of treatment duration.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe.

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

How many biomarker measurements are needed to predict prognosis in Crohn's disease patients under infliximab?-A prospective study.

BACKGROUND: Timely stratification of Crohn's disease (CD) is essential for patients' management. The use of noninvasive accurate biomarkers is key to monitor treatment and to pursue mucosal healing, the ultimate treatment endpoint in CD. OBJECTIVE: We aimed to evaluate the performance of readily available biomarkers and develop risk matrices to predict CD progression. METHODS: Data from 289 CD patients receiving infliximab (IFX) maintenance therapy for 2 years was collected; those patients were included in DIRECT, a prospective multicenter observational study. Disease progression was evaluated using two composite outcomes incorporating clinical and drug-related factors, the first including IFX dose and/or frequency adjustments. Univariate and multivariable logistic regressions were used to calculate the odds ratios (OR) and to develop risk matrices. RESULTS: The isolated presence of anemia at least once during follow-up was a significant predictor of disease progression (OR 2.436 and 3.396 [p ≤ 0.001] for composite outcomes 1 and 2, respectively) regardless of confounding factors. Isolated highly elevated C-reactive protein (CRP; >10.0 mg/L) and fecal calprotectin (FC; >500.0 µg/g) in at least one visit were also significant predictors, while milder elevations (3.1-10.0 mg/L and 250.1-500.0 µg/g) were only relevant when detected in at least two visits (consecutive or not). The combination of biomarkers in risk matrices had good ability to predict progression; patients simultaneously presenting anemia, highly elevated CRP and FC at least once had 42%-63% probability of achieving the composite outcomes. CONCLUSION: The combined evaluation of hemoglobin, CRP, and FC in at least one time point and their incorporation into risk matrices seems to be the optimal strategy for CD management, as data from additional visits did not meaningfully influence the predictions and may delay decision-making.

Exploring the Ways of "The Great Imitator": A Case Report of Syphilitic Hepatitis.

Introduction: Syphilis is a chronic infection caused by Treponema pallidum. Manifestations of this disease are vast, and syphilitic hepatitis is a rarely depicted form of secondary syphilis. Case Presentation: We report the case of a 63-year-old man with worsening jaundice, maculopapular rash and perianal discomfort. Proctological examination with anoscopy revealed a perianal gray/white area with millimetric pale granules along the anal canal. Liver function tests showed a mixed pattern. Venereal Disease Research Laboratory, T. pallidum hemagglutination assay and IgM fluorescent treponemal antibody absorbance were positive. The patient was successfully treated with a single dose of penicillin G. Discussion/Conclusion: Syphilitic hepatitis is scarcely reported in the literature. Secondary syphilis with mild hepatitis rarely leads to hepatic cytolysis and jaundice. Many signs of secondary syphilis including syphilitic hepatitis may be linked to immune responses initiated during early infection. Over the past decades, evidence has emerged on the importance of innate and adaptive cellular immune responses in the immunopathogenesis of syphilis. This report raises awareness to a clinical entity that should be considered in patients at risk for sexually transmitted diseases, who present with intestinal discomfort or liver dysfunction, as it is a treatable and fully reversible condition.

Introdução: A sífilis é uma infeção crónica provocada pelo Treponema pallidum. As manifestações desta doença são vastas e a hepatite sifilítica é uma forma de sífilis secundária raramente descrita. Caso Clínico: Apresentamos o caso de um doente de 63 anos com icterícia de agravamento progressivo, rash maculopapular e desconforto perianal. O exame proctológico complementado por anuscopia revelou uma região perianal cinzenta-esbranquiçada com grânulos pálidos milimétricos ao longo do canal anal. Testes de função hepática revelaram um padrão misto e o Venereal Disease Research Laboratory, T. pallidum hemagglutination assay e IgM fluorescent treponemal antibody absorbance foram positivos. O doente foi tratado com sucesso com uma dose única de penicilina G. Discussão/Conclusão: São raros os casos de hepatite sifilítica descritos na literatura. Sífilis secundária com hepatite ligeira raramente conduz a citólise hepática e icterícia. Muitos dos sinais de sífilis secundária, incluindo a hepatite sifilítica, parecem estar associados a respostas imunitárias iniciadas durante o período de infeção precoce. Ao longo das últimas décadas, têm surgido evidências crescentes sobre a importância das respostas imunes inata e adaptativa na patogénese da sífilis. Este caso clínico descreve uma entidade nosológica que deve ser considerada em doentes em risco de contraírem doenças sexualmente transmissíveis, que se apresentem com desconforto intestinal ou disfunção hepática, visto tratar-se de uma condição tratável e totalmente reversível.

Rectal Perforation by a Balloon Spacer: A Rare Cause of Rectal Perforation Addressed Endoscopically.

Prostate cancer is the second most frequent cancer in men worldwide. Dose escalation is currently the standard of care for the treatment of prostate cancer with radiation therapy. However, the rectum tends to be the dose-limiting structure when treating prostate cancer, given its proximity. The injection of biodegradable spacers between the prostate and the rectum may optimize radiotherapy treatment delivery for patients with localized disease. Nevertheless, although the overall complication rate of spacers is marginal, the benefits of spacer technologies need to be evaluated against the complication risks such as rectum perforation/necrosis. We report a case of a 59-year-old man with a diagnosis of prostate adenocarcinoma for whom hormonal treatment followed by intensity modulated radiation therapy (IMRT) was proposed. A biodegradable and expandable balloon (BioProtect®) was injected into the perirectal space without detectable immediate complications. One month later, the patient presented with a 3-day persistent rectal bleeding. The investigation confirmed a rectal perforation by the balloon spacer system.

O cancro da próstata é atualmente, em todo o mundo, o segundo cancro mais frequente no homem. As recomendações atuais indicam o uso doses de radiação progressivamente maiores ao longo do processo de radioterapia no tratamento do cancro da próstata. Contudo, a proximidade anatómica do reto é um fator limitante na dose de radiação usada ao longo do tratamento. A colocação de espaçadores biodegradáveis entre a próstata e o reto pode otimizar o tratamento de radioterapia em doentes com doença localizada. No entanto, embora a taxa de complicações dos espaçadores seja reduzida, o benefício desta técnica precisa de ser contrabalançada com o risco de complicações, como perfuração/necrose do reto. Apresentamos o caso de um paciente do sexo masculino de 59 anos com diagnóstico de adenocarcinoma da próstata para o qual foi proposto tratamento hormonal seguido de radioterapia com intensidade modulada (IMRT). Um balão biodegradável e expansível (Bio-Protect®) foi injetado no espaço peri-retal sem complicações imediatas detetáveis. Após um mês, o paciente apresentou hematoquézias persistentes durante três dias. A investigação confirmou tratar-se de uma perfuração retal pelo balloon spacer.

The new simplified MARIA score applies beyond clinical trials: A suitable clinical practice tool for Crohn's disease that parallels a simple endoscopic index and fecal calprotectin.

BACKGROUND: A simplified magnetic resonance enterography (MRe) index (sMARIA) for Crohn's disease (CD) was recently developed and validated. OBJECTIVE: Our aims were (a) to assess sMARIA's accuracy in a sample other than the validation cohort; (b) to evaluate its correlation with a simpler endoscopy index (SES-CD) and fecal calprotectin (FC); and (c) to assess the need of an expert radiologist to reliably use sMARIA. METHODS: Patients with CD who underwent MRe, ileocolonoscopy and FC within 2-4 weeks had their MRe retrospectively reviewed by two blinded raters. Disease activity was evaluated through sMARIA, SES-CD and FC. sMARIA's accuracy, indices correlation, and interrater reliability were assessed. RESULTS: In total, 84 patients were included, comprising 420 intestinal segments evaluations. sMARIA ≥1 accurately identified segments with active disease (90% sensitivity, 98% specificity; area under the curve 0.94, 95% confidence interval (CI) 0.91-0.97; p < 0.01). sMARIA correlated with endoscopy, both for ileal and colonic segments (R = 0.94 and R = 0.82; p < 0.01). Per patient, there was a strong correlation between sMARIA, endoscopy (R = 0.95; p < 0.01) and FC (R = 0.91; p < 0.01). Interrater agreement was excellent (intraclass correlation coefficient 0.95; 95% CI 0.94-0.96; p < 0.01). CONCLUSION: sMARIA accurately measured CD activity using SES-CD as standard of reference, and exhibited high correlation with a simple endoscopic index and a biomarker. The interrater reliability between a radiology resident and an expert was excellent.

Sexual Quality of Life in Inflammatory Bowel Disease: A Multicenter, National-Level Study.

BACKGROUND: The impact of inflammatory bowel disease (IBD) on sexual health is a leading concern among patients. Most studies focus on sexual dysfunction rather than patient-perceived sexual quality of life (SQoL). We aimed to assess SQoL in IBD patients compared with healthy controls. METHODS: This is a multicenter, cross-sectional study of IBD patients (n = 575 with Crohn's disease and n = 294 with ulcerative colitis), compared with healthy controls (n = 398), that used an anonymous self-administered questionnaire. This multimodal questionnaire included sociodemographic data and 4 validated instruments: Short IBD Questionnaire, Social Desirability Scale, Sexual QoL Questionnaire-Male/Female, Nine-item Patient Health Questionnaire. RESULTS: Inflammatory bowel disease patients reported lower SQoL (men: 77.29 vs 83.83; P < 0.001; women: 70.40 vs 81.63; P < 0.001) compared with controls. Among IBD patients, SQoL was positively correlated with health-related quality of life (HRQoL) and negatively correlated with depression symptoms. Perianal disease was associated with lower HRQoL and higher incidence of depression, but only impacted SQoL in men. In linear regression analysis for men, SQoL was associated with age, marital status, and depression (ß, -2.101; 95% confidence interval [CI], -2.505 to -1.696; P < 0.001). In women, SQoL was associated with depression (ß, -1.973; 95% CI, -2.313 to -1.632; P < 0.001) only. CONCLUSIONS: Patients with IBD had impaired SQoL compared with healthy controls. Age, widow status, and depression were independent predictors of SQoL in men with IBD, whereas in women depression was the only independent predictor. Emotional and self-esteem issues were the main concerns reported by IBD patients regarding sexual health.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.

Background and study aims Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

A Narrative Review on Anti-Tumor Necrosis Factor α Therapies in Inflammatory Bowel Disease During Pregnancy: Immunoglobulin Placental Translocation and its Impact.

INTRODUCTION: Inflammatory bowel disease activity is associated with adverse pregnancy outcomes. Anti-tumor necrosis factor α therapy is often required to treat flares and to maintain disease remission. However, there are concerns regarding treatment with these agents during pregnancy, as they actively cross the placental barrier. MATERIAL AND METHODS: Studies regarding anti-tumor necrosis factor α therapy during pregnancy were identified from PubMed from 1958 to January 2018. The reference lists of the selected studies were reviewed to identify complementary publications. RESULTS AND DISCUSSION: Anti-tumor necrosis factor α agents are efficient treatments for moderate-to-severe inflammatory bowel disease and may ensure remission during pregnancy. Although these drugs cross the placenta, they are considered safe for both the mother and the fetus. Furthermore, up-to-date guidelines support therapy continuation during pregnancy aiming for disease control. The same guidelines also consider stopping treatment during the third trimester to limit maternal-fetal drug transfer. However, data shows that this strategy does not completely prevent fetus exposure. In addition, stopping treatment incurs in risk of disease flare and threatens subsequent therapy response. Fetus drug exposure has not showed an association with adverse childhood development. However, as infant drug levels could be detected up to seven months after birth, postponement of live virus vaccination is recommended. CONCLUSION: There should be no disagreement among the medical community as to the need to maintain therapy aiming for disease remission during gestation in inflammatory bowel disease. Anti-tumor necrosis factor α agents are safe for both the mother and the fetus.

Introdução: O melhor preditor de complicações durante a gravidez, na doença inflamatória intestinal, é a atividade da doença. A terapêutica com agentes anti-tumor necrosis factor α atravessa a barreira placentária o que levanta questões relativamente à sua segurança durante a gravidez. Material e Métodos: Revisão bibliográfica suportada a partir de artigos indexados na PubMed (1958 a 01/2018) sobre a terapêutica anti-tumor necrosis factor α durante a gravidez na doença inflamatória intestinal. Resultados e Discussão: Os agentes anti-tumor necrosis factor α são eficazes na doença inflamatória intestinal e podem garantir a remissão clínica durante a gravidez. Estes fármacos atravessam a barreira placentária, mas são seguros para a mãe e feto. Neste sentido, as orientações atuais defendem a manutenção terapêutica durante a gravidez para assegurar a remissão clínica. Paralelamente, as mesmas orientações consideram a suspensão terapêutica durante o terceiro trimestre para limitar a exposição fetal ao fármaco. No entanto, esta estratégia não só não previne totalmente a exposição fetal, como aumenta o risco de agudização da doença e da perda de resposta à terapêutica após o seu reinício. Esta exposição fetal não está associada a alterações do desenvolvimento in utero ou neonatal. Ainda assim, uma vez que é possível dosear fármaco no recém-nascido até aos sete meses de vida, recomenda-se adiar a administração de vacinas vivas em recém-nascidos expostos. Conclusão: Não deve haver discordância na comunidade médica quanto à necessidade de garantir a remissão da doença inflamatória intestinal durante a gestação. Os agentes anti-tumor necrosis factor α devem ser vistos como opções terapêuticas seguras para mãe e feto durante a gravidez.