Endoscopic scoring system utilization for inflammatory bowel disease activity assessment: A multicenter real-world study from Argentina / Uso de puntajes endoscopicos para la medicion de la actividad mucosa en pacientes con enfermedades inflamatorias intestinales: un estudio de vida real multicentrico de la Argentina

Background The frequency and patterns of use of scores for the assessment of endoscopic activity in inflammatory bowel disease patients are not known. Aim To describe the prevalence of adequate use of endoscopic scores in IBD patients who underwent colonoscopy in a real-life setting. Materials and methods A multicenter observational study comprising six community hospitals in Argentina was undertaken. Patients with a diagnosis of Crohn's disease or ulcerative colitis who underwent colonoscopy for endoscopic activity assessment between 2018 and 2022 were included. Colonoscopy reports of included subjects were manually reviewed to determine the proportion of colonoscopies that included an endoscopic score report. We determined the proportion of colonoscopy reports that included all of the IBD colonoscopy report quality elements proposed by BRIDGe group. Endoscopist's specialty, years of experience as well as expertise in IBD were assessed. Results A total of 1556 patients were included for analysis (31.94% patients with Crohn's disease). Mean age was 45.94±15.46. Endoscopic score reporting was found in 58.41% of colonoscopies. Most frequently used scores were Mayo endoscopic score (90.56%) and SES-CD (56.03%) for ulcerative colitis and Crohn's disease, respectively. In addition, 79.11% of endoscopic reports failed to comply with all recommendations on endoscopic reporting for inflammatory bowel disease. Conclusions A significant proportion of endoscopic reports of inflammatory bowel disease patients do not include the description of an endoscopic score to assess mucosal inflammatory activity in a real-world setting. This is also associated with a lack of compliance in recommended criteria for proper endoscopic reporting. (AU)

Introduccion La frecuencia y el patrón de uso de puntajes para evaluar la actividad endoscópica en pacientes con enfermedades inflamatorias intestinales no se conoce bien. Objetivo Describir la prevalencia de uso adecuado de puntajes de actividad endoscópica en colonoscopias de pacientes con enfermedades inflamatorias intestinales en la vida real. Materiales y métodos Se realizó un estudio multicéntrico observacional en seis hospitales de comunidad en Argentina. Se incluyeron pacientes con enfermedad de Crohn o colitis ulcerosa sometidos a colonoscopia para evaluación de la actividad endoscópica entre 2018 y 2022. Se revisaron los reportes de colonoscopias de sujetos incluidos evaluando la proporción de reportes que incluyeron algún puntaje de actividad endoscópica. Se evaluó la proporción de reportes que incluyeron los elementos de calidad en reporte de colonoscopia en enfermedades inflamatorias intestinales sugeridos por el grupo BRIDGe. Se evaluó la especialidad de los operadores, sus años de experiencia y su experiencia en el manejo de enfermedades inflamatorias intestinales. Resultados Se incluyeron 1556 pacientes (31.94% con enfermedad de Crohn). La edad promedio fue de 45.94±15.46. El reporte de algún puntaje endoscópico se identificó en el 58.41% de las colonoscopias. Los puntajes más utilizados fueron el puntaje endoscópico de Mayo (90.56%) y el SES-CD (56.03%). El 79.11% de los reportes de colonoscopias no contaban con todas las recomendaciones para el correcto reporte de colonoscopias en enfermedades inflamatorias intestinales. Conclusiones Una proporción signifivativa de reportes de colonoscopias en sujetos con enfermedades inflamatorias intestinales no incluyen puntajes endoscópicos de actividad. (AU)

Management of colorectal cancer screening backlog due to the COVID-19 pandemic: A retrospective analysis of the use of a colorectal cancer screening clinical-decision support tool in Argentina

Background The COVID-19 pandemic created a backlog in colorectal cancer (CRC) screening and surveillance colonoscopies. The real impact in Argentina is not fully known. Goal To estimate the impact of the COVID-19 pandemic on CRC prevention by comparing the number of CRC screening and surveillance consults in a clinical decision support-tool used in Argentina before, during and after pandemic lockdown. Methods We analyzed data from May 2019 to December 2021 from CaPtyVa, a clinical decision support tool for CRC screening and surveillance. Queries were divided in pre-pandemic (May 2019 to March 2020), lockdown (April 2020 to December 2020), and post-lockdown (January 2021 to December 2021). The number of CRC monthly screening and surveillance visits were compared among the three periods and stratified according to CRC risk. Results Overall, 27,563 consults were analyzed of which 9035 were screening and 18,528 were surveillance. Pre-pandemic, the median number of screening consults was 346 per month (IQR25–75 280–410). There was a decrease to 156 (80–210)/month (p < 0.005) during lockdown that partially recovered during post-lockdown to 230 (170–290)/month (p = 0.05). Pre-pandemic, the median number of surveillance consults was 716 (560–880)/month. They decreased to 354 (190–470)/month during lockdown (p < .05) and unlike screening, completely recovered during post-lockdown to 581 (450–790)/month. Conclusions There was a >50% decrease in the number of CRC screening and surveillance consults registered in CaPtyVa during lockdown in Argentina. Post-lockdown, surveillance consults recovered to pre-pandemic levels, but screening consults remained at 66% of pre-pandemic levels. This has implications for delays in CRC diagnoses and patient outcomes (AU)

Antecedentes La pandemia de COVID-19 provocó atraso en las colonoscopias de detección y vigilancia del cáncer colorrectal (CCR). Objetivo Estimar el impacto de la pandemia de COVID-19 en la prevención del CCR comparando el número de consultas de pesquisa y vigilancia del CCR en una herramienta digital de apoyo a la decisión clínica utilizada en Argentina antes, durante y después del confinamiento. Métodos Analizamos datos entre mayo 2019 a diciembre 2021 de CaPtyVa, una herramienta digital de apoyo a la toma de decisiones clínicas para la pesquisa y vigilancia del CCR. Las consultas se dividieron en prepandemia (mayo 2019- marzo 2020), confinamiento (abril 2020- diciembre 2020) y post-confinamiento (enero 2021-diciembre 2021). El número de visitas mensuales de pesquisa y vigilancia de CCR se comparó entre períodos y se estratificó según riesgo de CCR. Resultados Prepandemia, la mediana de consultas de detección fue 346 mes (IQR25-75 280-410). Hubo una disminución a 156 (80-210)/mes (p<0,005) durante el confinamiento que ascendió a 230 (170-290)/mes (p=0,05) en el post-confinamiento. Prepandemia, la mediana de consultas de vigilancia fue 716 (560-880)/mes. Disminuyeron a 354 (190-470)/mes durante el confinamiento (p<0,05) y se recuperaron por completo durante el post-confinamiento. Conclusiones Hubo una disminución >50% en el número de consultas de detección y vigilancia de CCR registradas en CaPtyVa durante el confinamiento en Argentina. Post-confinamiento, las consultas de vigilancia se recuperaron a niveles prepandemia, pero las consultas de detección se mantuvieron en el 66 % de niveles históricos. Esto tendría implicaciones en los diagnósticos y pronósticos de CCR (AU)

Colorectal Cancer Prevention: Is Chat Generative Pretrained Transformer (Chat GPT) ready to Assist Physicians in Determining Appropriate Screening and Surveillance Recommendations?

OBJECTIVE: To determine whether a publicly available advanced language model could help determine appropriate colorectal cancer (CRC) screening and surveillance recommendations. BACKGROUND: Poor physician knowledge or inability to accurately recall recommendations might affect adherence to CRC screening guidelines. Adoption of newer technologies can help improve the delivery of such preventive care services. METHODS: An assessment with 10 multiple choice questions, including 5 CRC screening and 5 CRC surveillance clinical vignettes, was inputted into chat generative pretrained transformer (ChatGPT) 3.5 in 4 separate sessions. Responses were recorded and screened for accuracy to determine the reliability of this tool. The mean number of correct answers was then compared against a control group of gastroenterologists and colorectal surgeons answering the same questions with and without the help of a previously validated CRC screening mobile app. RESULTS: The average overall performance of ChatGPT was 45%. The mean number of correct answers was 2.75 (95% CI: 2.26-3.24), 1.75 (95% CI: 1.26-2.24), and 4.5 (95% CI: 3.93-5.07) for screening, surveillance, and total questions, respectively. ChatGPT showed inconsistency and gave a different answer in 4 questions among the different sessions. A total of 238 physicians also responded to the assessment; 123 (51.7%) without and 115 (48.3%) with the mobile app. The mean number of total correct answers of ChatGPT was significantly lower than those of physicians without [5.62 (95% CI: 5.32-5.92)] and with the mobile app [7.71 (95% CI: 7.39-8.03); P < 0.001]. CONCLUSIONS: Large language models developed with artificial intelligence require further refinements to serve as reliable assistants in clinical practice.

Management of colorectal cancer screening backlog due to the COVID-19 pandemic: A retrospective analysis of the use of a colorectal cancer screening clinical-decision support tool in Argentina.

BACKGROUND: The COVID-19 pandemic created a backlog in colorectal cancer (CRC) screening and surveillance colonoscopies. The real impact in Argentina is not fully known. GOAL: To estimate the impact of the COVID-19 pandemic on CRC prevention by comparing the number of CRC screening and surveillance consults in a clinical decision support-tool used in Argentina before, during and after pandemic lockdown. METHODS: We analyzed data from May 2019 to December 2021 from CaPtyVa, a clinical decision support tool for CRC screening and surveillance. Queries were divided in pre-pandemic (May 2019 to March 2020), lockdown (April 2020 to December 2020), and post-lockdown (January 2021 to December 2021). The number of CRC monthly screening and surveillance visits were compared among the three periods and stratified according to CRC risk. RESULTS: Overall, 27,563 consults were analyzed of which 9035 were screening and 18,528 were surveillance. Pre-pandemic, the median number of screening consults was 346 per month (IQR25-75 280-410). There was a decrease to 156 (80-210)/month (p<0.005) during lockdown that partially recovered during post-lockdown to 230 (170-290)/month (p=0.05). Pre-pandemic, the median number of surveillance consults was 716 (560-880)/month. They decreased to 354 (190-470)/month during lockdown (p<.05) and unlike screening, completely recovered during post-lockdown to 581 (450-790)/month. CONCLUSIONS: There was a >50% decrease in the number of CRC screening and surveillance consults registered in CaPtyVa during lockdown in Argentina. Post-lockdown, surveillance consults recovered to pre-pandemic levels, but screening consults remained at 66% of pre-pandemic levels. This has implications for delays in CRC diagnoses and patient outcomes.

Endoscopic scoring system utilization for inflammatory bowel disease activity assessment: A multicenter real-world study from Argentina.

BACKGROUND: The frequency and patterns of use of scores for the assessment of endoscopic activity in inflammatory bowel disease patients are not known. AIM: To describe the prevalence of adequate use of endoscopic scores in IBD patients who underwent colonoscopy in a real-life setting. MATERIALS AND METHODS: A multicenter observational study comprising six community hospitals in Argentina was undertaken. Patients with a diagnosis of Crohn's disease or ulcerative colitis who underwent colonoscopy for endoscopic activity assessment between 2018 and 2022 were included. Colonoscopy reports of included subjects were manually reviewed to determine the proportion of colonoscopies that included an endoscopic score report. We determined the proportion of colonoscopy reports that included all of the IBD colonoscopy report quality elements proposed by BRIDGe group. Endoscopist's specialty, years of experience as well as expertise in IBD were assessed. RESULTS: A total of 1556 patients were included for analysis (31.94% patients with Crohn's disease). Mean age was 45.94±15.46. Endoscopic score reporting was found in 58.41% of colonoscopies. Most frequently used scores were Mayo endoscopic score (90.56%) and SES-CD (56.03%) for ulcerative colitis and Crohn's disease, respectively. In addition, 79.11% of endoscopic reports failed to comply with all recommendations on endoscopic reporting for inflammatory bowel disease. CONCLUSIONS: A significant proportion of endoscopic reports of inflammatory bowel disease patients do not include the description of an endoscopic score to assess mucosal inflammatory activity in a real-world setting. This is also associated with a lack of compliance in recommended criteria for proper endoscopic reporting.

Impact of an Educational Mobile App on Inflammatory Bowel Disease Colonoscopy Report Quality.

BACKGROUND: Inadequate endoscopic assessment of disease activity might lead to suboptimal treatment of patients with inflammatory bowel disease (IBD). AIMS: We aimed to determine if the implementation of an educational mobile app could help improving the quality of colonoscopy reports in patients with IBD. METHODS: We retrospectively analyzed a consecutive series of colonoscopy reports in patients with IBD during the period 2016-2023. The sample was divided into two groups: before and after the implementation of an educational mobile app (JEDII app ™). The main outcome was the inclusion of validated activity assessment scoring systems and previously stablished reporting required elements. RESULTS: A total of 883 IBD colonoscopy reports were included for analysis; 621 (70.3%) procedures were performed before the implementation of the app and 262 (29.7%) after. An IBD scoring system was included in 201 (32.4%) and 148 (56.5%) colonoscopy reports before and after the adoption of the mobile app, respectively (p < 0.001). The mean number of recommended elements for quality IBD colonoscopy reporting was significantly increased after the app implementation (4.3 vs. 1.9, p < 0.001). Diagnosis of ulcerative colitis, gastroenterologist as endoscopist, endoscopist with IBD clinical interest, and the implementation of the educational mobile app were independently associated with the inclusion of an IBD score in the colonoscopy report. CONCLUSION: The inclusion of scoring systems and recommended elements for quality IBD colonoscopy report significantly increased after the implementation of an educational mobile app. E-health technologies should be further explored to improve quality of care in patients with IBD.

Incidence and prevalence of inflammatory bowel diseases in a population from Buenos Aires, Argentina.

BACKGROUND: Inflammatory bowel diseases (IBD) incidence and prevalence in Latin America have experienced a significant shift in the last decades. There is paucity of IBD epidemiologic data in Argentina. AIM: To determine the incidence and prevalence of IBD between 2018 and 2022 of a population from the city of Buenos Aires. MATERIALS AND METHODS: From January 1st, 2018 to December 31st, 2022, the total population of two healthcare insurances were studied. 'Possible' IBD cases were identified using the following information sources: IBD-unit patient databases; electronic medical record; central laboratory electronic database; histopathology electronic database; pharmacy electronic database. Age-adjusted incidence and prevalence rates for Crohn's disease (CD), ulcerative colitis (UC) and IBD were estimated based on the number of patients compared with the at-risk population and expressed per 100,000 subjects. Trends in IBD incidence and prevalence were estimated as annual percentage changes; we used Poisson regression modeling to calculate significance in these trends over time. RESULTS: Information source analysis rendered 172 possible cases, of which 82 cases of IBD were finally confirmed: 27.16% were CD and 72.84% were UC. Mean age-standardized incidence across the study period for IBD, CD and UC was 11.93 (11.28-12.55), 2.88 (2.65-3.07) and 9.05 (8.83-9.2) respectively. Point prevalence on December 31st, 2022 for IBD, UC and CD was 134 (95%CI 132.3-135.6), 98 (96.95-99.52) and 36 (35.69-36.4) respectively. CONCLUSIONS: We found an incidence and prevalence of IBD in a population from Buenos Aires higher than those previously published in epidemiological studies in Argentina.

Endoscopically Active Ulcerative Colitis Is Associated With Asymptomatic Atherosclerotic Vascular Disease: A Case-Control Study.

BACKGROUND: Chronic inflammation in immune-mediated conditions has been associated with an increased risk in atherosclerotic disease. There is paucity of evidence regarding the prevalence of asymptomatic atherosclerosis in patients with ulcerative colitis (UC) and its association with disease activity. We sought to compare the prevalence of asymptomatic atherosclerotic disease between young patients with UC with and without mucosal healing (MH) and healthy control individuals. METHODS: An observational study was conducted in 2 hospitals in Buenos Aires, Argentina. Patients with UC 18 to 50 years of age with at least 1 previous colonoscopy in the last year were enrolled, along with age- and sex-matched healthy control individuals. Carotid and femoral ultrasound assessments were performed to determine the prevalence of atherosclerotic lesions and abnormal intima-media thickness (IMT). We compared the prevalence of atherosclerotic disease and the prevalence of abnormally increased IMT in at least 1 vascular territory. RESULTS: Sixty patients with UC and 60 healthy control individuals were enrolled. Mean age was 38 years and 53.33% were men. Although the prevalence of atherosclerotic lesions was similar in patients with UC without MH when compared with both patients with UC with MH and control individuals (3.7% vs 0% vs 6.67%; P = .1), we found a significant increase in abnormal IMT in at least 1 vascular territory in UC patients without MH when compared with healthy control individuals (48.15% vs 26.67%; P = .05). CONCLUSIONS: Patients with UC with active mucosal inflammation showed a significantly increased odds of asymptomatic femoral or carotid vascular disease when compared with control individuals.

Young patients with endoscopically active ulcerative colitis showed a significantly higher prevalence of abnormal intima-media thickness when compared with control individuals. Among patients with ulcerative colitis, age, disease duration, and C-reactive protein were associated with increased odds of asymptomatic vascular lesions.

Review article: Risk of cardiovascular events in patients with inflammatory bowel disease receiving small molecule drugs.

BACKGROUND: In the context of an ageing inflammatory bowel disease (IBD) population, cardiovascular comorbidities become particularly relevant. Novel small molecule drugs (SMDs) for the treatment of moderate-to-severe IBD have been recently approved, including Janus kinase (JAK) inhibitors and sphingosine-1-phosphate receptor (S1P) modulators. Data from rheumatoid arthritis population have raised concerns about the risk of cardiovascular events with the use of tofacitinib, which was extrapolated to other immune-mediated diseases and other JAK inhibitors. S1P receptor modulation has been associated with potential cardiovascular events, especially bradycardia and cardiac conduction abnormalities. AIM: To review the incidence of cardiovascular events with the use of SMDs in patients with IBD and to provide practical recommendations on mitigation strategies. METHODS: Published literature was reviewed; recommendations were synthesised by experts in both cardiovascular diseases and IBD. RESULTS: Evidence from the IBD population does not indicate a higher risk of cardiovascular events with tofacitinib and other JAK inhibitors. The risk is higher in patients with intermediate to high cardiovascular risk. S1P modulators may be associated with a dose-dependent, first-dose effect, transient risk of conduction abnormalities (bradycardia and AV block). Screening and monitoring of cardiovascular risk factors should be done in all patients with IBD. Risk stratification for cardiovascular disease should be performed before starting treatment with SMDs. CONCLUSIONS: Available evidence of both JAK inhibitors and S1P modulators indicates a reassuring safety profile of SMDs from the cardiovascular perspective in the overall IBD population. Efforts should be made to identify patients with IBD at a higher risk of cardiovascular events.

Impact of Saccharomyces boulardii CNCM I-745 on Bacterial Overgrowth and Composition of Intestinal Microbiota in Diarrhea-Predominant Irritable Bowel Syndrome Patients: Results of a Randomized Pilot Study.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is associated with diarrhea-predominant irritable bowel syndrome (IBS-D). Probiotics like Saccharomyces boulardii CNCM I-745 (Sb) may be efficacious in balancing the microbiota. This randomized open label study assessed the effect of Sb in patients with bacterial overgrowth associated with IBS-D and its impact on the intestinal microbiota. METHODS: Patients were randomized to receive Sb + dietary advice (Sb + DA) or dietary advice (DA) only for 15 days. SIBO was assessed by the lactulose hydrogen breath test (LHBT). Symptoms were assessed with the IBS Symptom Severity Scale (IBS-SSS) and stool consistency with the Bristol Stool Form Scale. Microbiota and mycobiota were analyzed by 16S rDNA and ITS2. RESULTS: 54 patients were included, among whom 48 (27 Sb + DA, 21 DA) were evaluated. Decrease of hydrogen excretion was slightly higher in Sb + DA group, 41% versus 29% in DA group, and IBS-SSS total score were reduced by -134 and -93, respectively. The proportion of patients with diarrhea was lower in the Sb + DA group than in the DA group (25.9% compared to 47.6%). Bacterial and fungal microbiota showed that Sb treatment was associated with several modifications. Interestingly, F. prausnitzii was more abundant in Sb-treated patients with marked clinical improvement. The safety of S. boulardii CNCM I-745 was excellent. CONCLUSIONS: In patients with SIBO, S. boulardii CNCM I-745 associated with dietary advice reduced bacterial overgrowth and improved digestive symptoms while restoring the intestinal microbiota. The increased abundance of F. prausnitzii coupled with symptom improvement merits further research.

Opportunistic Infections in Patients with Inflammatory Bowel Disease Treated with Advanced Therapies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND AND AIMS: Advanced therapies for inflammatory bowel disease [IBD] could potentially lead to a state of immunosuppression with an increased risk of opportunistic infections [OIs]. We aimed to provide an update on the incidence of OIs among adult IBD patients in randomized controlled trials [RCTs] of approved biologics and small-molecule drugs [SMDs]. Also, we aimed to describe OI definitions utilized in RCTs, to ultimately propose a standardized definition. METHODS: Electronic databases were searched from January 1, 1990, until April 16, 2022. Our primary outcome was incidence rate of overall OIs among IBD patients exposed and unexposed to biologics or SMDs. We also describe specific OIs reported in included trials, as well as definitions of OIs within studies when provided. RESULTS: Ninety studies were included. The incidence rates of reported OIs were 0.42 and 0.21 per 100 person-years in patients exposed to advanced therapies and placebo, respectively. This was highest for anti-tumour necrosis factors [0.83 per 100 person-years] and Janus kinase inhibitors [0.55 per 100 person-years] and lowest for anti-integrins and ozanimod. On meta-analysis, no increased risk of OIs was observed. None of the studies provided a detailed definition of OIs, or a comprehensive list of infections considered as OIs. CONCLUSION: Different mechanisms of action may have specific OI profiles. In the absence of a uniform definition of OIs, these estimates are less reliable. We propose a definition to be used in future studies to help provide standardized reporting. When using this definition, we saw significant differences in incidence rates of OIs across mechanisms of action.

Prolonged Intestinal Transit Time and Its Relation with Capsule Endoscopy Diagnostic Yield.

BACKGROUND: Capsule endoscopy is a gold standard diagnostic method for small bowel lesions. There is scarce evidence regarding vari- ables that may increase the odds of identifying small bowel lesions with this endoscopic method. The aim of this work is to describe variables associated with a higher probability of finding small bowel lesions on capsule endoscopy. METHODS: Cross-sectional study was performed using our Department's adult patients' capsule endoscopy database. The presence of any small bowel mucosal lesion was registered. Other variables were examined: age, gender, reason for referral, quality of bowel cleans- ing, and intestinal transit time. These variables were compared between those patients showing at least 1 lesion versus those without lesions. Univariate and multivariate analysis was performed to determine variables significantly associated with the presence of bowel lesions. RESULTS: In total, 140 studies were analyzed; 90% were performed due to occult gastrointestinal bleeding. Median age was 69 years (60-75); 54.29% were males. Bowel cleansing was adequate in 94.29%; 68.57% showed at least 1 lesion. Non-significant difference was observed in terms of age between groups of comparison (70 [61-76] vs 63 [59-74], P = .07). No difference was found comparing bowel cleansing, gender, or reason for referral. Intestinal transit time was significantly longer among those patients with a bowel lesion (359 minutes [257-427] vs 279 minutes [200-333], P = .05). On multivariate analysis, age and intestinal time were significantly associ- ated with the presence of at least one small bowel lesion (odds ratio 1.02 [1-1.06] and 1.09 [1.03-1.12], respectively). CONCLUSION: Age and intestinal transit time were significantly associated with the presence of abnormal findings on capsule endoscopy.

Efficacy and safety of biologics and small molecule drugs for patients with moderate-to-severe ulcerative colitis: a systematic review and network meta-analysis.

BACKGROUND: There is a growing armamentarium for the treatment of moderate-to-severe ulcerative colitis. We aimed to compare the relative efficacy and safety of biologics and small molecule drugs for the treatment of patients with moderate-to-severe ulcerative colitis. METHODS: In this systematic review and network meta-analysis, we searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials without language restrictions for articles published between Jan 1, 1990, and July 1, 2021. Major congresses' databases from Jan 1, 2018, to July 3, 2021, were reviewed manually. Phase 3, placebo-controlled or head-to-head randomised controlled trials (RCTs) assessing the efficacy and safety of biologics or small molecule drugs as induction or maintenance therapies for patients with moderate-to-severe ulcerative colitis were included. Phase 2 RCTs were excluded because of their small sample sizes and inclusion of doses not further explored in phase 3 RCTs. Summary data from intention-to-treat analyses were extracted from included reports by JSL and PAO. The primary outcome was the induction of clinical remission. A network meta-analysis was done under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs. The surface under the cumulative ranking (SUCRA) was used to rank the included agents for each outcome. Higher SUCRA scores correlate with better efficacy, whereas lower SUCRA scores correlate with better safety. Maintenance data on efficacy for treat-straight-through and randomised responder trials are also presented. This study is registered with PROSPERO, CRD42021225329. FINDINGS: Our search yielded 5904 results, from which 29 studies (four being head-to-head RCTs) fulfilled our inclusion criteria and were included. Of these, 23 studies assessed induction therapy with either a biologic or small molecule drug, comprising 10 061 patients with ulcerative colitis. A risk of bias assessment showed a low risk of bias for most of the included studies. Upadacitinib was significantly superior to all other interventions for the induction of clinical remission (infliximab [OR 2·70, 95% CI 1·18-6·20], adalimumab [4·64, 2·47-8·71], golimumab [3·00, 1·32-6·82], vedolizumab [3·56, 1·84-6·91], ustekinumab [2·92, 1·31-6·51], etrolizumab [4·91, 2·59-9·31], tofacitinib [2·84, 1·28-6·31], filgotinib 100 mg [6·15, 2·98-12·72], filgotinib 200 mg [4·49, 2·18-9·24], and ozanimod (2·70, 1·18-6·20), and ranked highest for the induction of clinical remission (SUCRA 0·996). No differences between active interventions were observed when assessing adverse events and serious adverse events. Vedolizumab ranked lowest for both adverse events (SUCRA 0·184) and serious adverse events (0·139), whereas upadacitinib ranked highest for adverse events (0·843) and ozanimod ranked highest for serious adverse events (0·831). INTERPRETATION: Upadacitinib was the best performing agent for the induction of clinical remission (the primary outcome) but the worst performing agent in terms of adverse events in patients with moderate-to-severe ulcerative colitis. Vedolizumab was the best performing agent for safety outcomes. With the paucity of direct comparisons in the published literature, our results might help clinicians to position drugs in treatment algorithms. FUNDING: None.

IgA Deficiency Is Not Systematically Ruled Out in Patients Undergoing Celiac Disease Testing.

BACKGROUND: Guidelines for celiac disease (CD) testing recommend total serum IgA determination alongside anti-transglutaminase IgA antibodies. It is not well known if lack of serum IgA determination is a common finding in clinical practice. AIM: To determine the prevalence of lack of serum IgA determination among patients screened for celiac disease. MATERIALS AND METHODS: We identified all subjects who underwent serum anti-transglutaminase IgA and/or other CD-related antibodies determination at a single teaching hospital in Buenos Aires from October 2019 to February 2020. Medical records were reviewed to select adult patients who were tested for celiac disease. The primary outcome was the proportion of patients with inadequate testing for celiac disease due to lack of serum IgA determination. We retrieved the following variables from each patient's record: age, gender, body mass index, symptoms present at screening, first-grade family history of CD, history of type-1 diabetes mellitus, autoimmune hypothyroidism, Down's syndrome. RESULTS: Overall, 1122 patients were included for analysis. Lack of serum IgA determination prevalence was 20.49%. Among patients who did have serum IgA determination, the prevalence of IgA deficiency was 5.16%. The following variables were independently associated with a significantly increased odds of serum IgA determination: diarrhea [OR 1.55 (1.01-2.34)] and abdominal pain [OR 2.28 (1.44-3.63)]; higher body mass index [OR 0.91 (0.85-0.98)], osteoporosis [OR 0.49 (0.28-0.89)], hypothyroidism [OR 0.18 (0.07-0.45)], arthralgia/arthritis [OR 0.47 (0.27-0.85)], or testing by endocrinologist [OR 0.46 (0.23-0.91)] and gynecologist [OR 0.14 (0.06-0.31)] were inversely associated. CONCLUSION: IgA deficiency is not systematically ruled out in a relatively high proportion of patients undergoing serological screening of celiac disease.

Safety of S1P Modulators in Patients with Immune-Mediated Diseases: A Systematic Review and Meta-Analysis.

INTRODUCTION: Sphingosine-1-phosphate modulators are approved for the treatment of multiple sclerosis and are under development for other immune-mediated conditions; however, safety concerns have arisen. OBJECTIVE: The objective of this systematic review was to investigate the safety profile of S1P modulators in patients with multiple sclerosis, ulcerative colitis, Crohn's disease, psoriasis, and systemic lupus erythematosus. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January, 1990 through 1 April, 2020. We also performed a manual review of conference databases from 2017 through 2020. The primary outcome was the occurrence of adverse events and serious adverse events. We also estimated the occurrence of serious infections, herpes zoster infection, malignancy, bradycardia, atrio-ventricular block, and macular edema. We performed a meta-analysis of controlled studies to assess the risks of such events. RESULTS: We identified 3843 citations; of these, 26 studies were finally included, comprising 9604 patients who were exposed to a sphingosine-1-phosphate modulator. A meta-analysis of randomized controlled trials showed an increased risk in herpes zoster infection [risk ratio, 1.75 (95% confidence interval 1.09-2.80)], bradycardia [2.64 (1.77-3.96)], and atrio-ventricular block [1.73 (1.03-2.91)] among subjects exposed to sphingosine-1-phosphate modulators as compared with a placebo or an active comparator. CONCLUSIONS: We found an increased risk of herpes zoster infection, and transient cardiovascular events among patients treated with sphingosine-1-phosphate modulators. CLINICAL TRIAL REGISTRATION: PROSPERO CRD42020172575.

Resección transmural endoscópica de adenoma colónico residual con fibrosis / Endoscopic full-thickness resection of residual colonic adenoma with fibrosis

Resumen La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

Abstract Endoscopic full-thickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

[Endoscopic full-thickness resection of residual colonic adenoma with fibrosis]. / Resección transmural endoscópica de adenoma colónico residual con fibrosis.

Endoscopic fullthickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

Treatment Adherence in Inflammatory Bowel Disease Patients from Argentina: A Multicenter Study.

METHODS: A multicenter cross-sectional study involving seven referral centers from three cities of Argentina was undertaken. Patients with a diagnosis of ulcerative colitis (UC), Crohn's disease (CD), or indeterminate colitis (IBDU/IC) were invited to answer an anonymous survey, which included a 5-point Likert scale to evaluate adherence to therapies. Independent variables associated with inadequate adherence were evaluated. RESULTS: Overall, 447 UC/IBDU and 135 CD patients were enrolled. Median age was 37 years (range 21-72); 39.8% were male; median time from diagnosis was 6 years (0.5-35). 91.4% were under treatment with at least one oral medication; 50.3% of patients reported inadequate adherence to oral medications. Patients with UC/IBDU had a lower risk of inadequate adherence when compared to patients with CD (OR 0.57 (0.37-0.87)). 21.8% reported inadequate adherence to biologics; subcutaneous administration was significantly associated with inadequate adherence to biologics (OR 4.8 (1.57-14.66)). CONCLUSION: Inadequate treatment adherence is common among patients with IBD, and potentially modifiable factors were identified.