Impact of the COVID-19 pandemic on inflammatory bowel disease care in Taiwan: A multicenter study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic had a great impact on healthcare system and patients. This study aimed to evaluate the effect of the COVID-19 pandemic on the perceptions of patients with inflammatory bowel disease (IBD). METHODS: This prospective multicenter study was conducted between July 2021 and December 2021. Patients with IBD answered a structured questionnaire, and their degree of anxiety was assessed using a visual analogue scale (VAS) before and after reading educational materials. RESULTS: A total of 225 (47.67%) patients with Crohn's disease, 244 (51.69%) with ulcerative colitis and 3 (0.64%) with indeterminate colitis were enrolled. Common concerns were adverse events from vaccination (20.34%), and higher risks of developing severe COVID-19 (19.28%) and COVID-19 infection (16.31%) than the general population. Medications deemed by the patients to increase the risk of COVID-19 were immunomodulators (16.10%), anti-tumor necrosis factor-α antagonists (9.96%), and corticosteroids (9.32%). Thirty-five (7.42%) patients self-discontinued IBD medication, of whom 12 (34.28%) had worse symptoms. Older age (>50 years) (OR 1.10, 95% CI 1.01-1.19, p = 0.03), IBD-related complications (OR 1.16, 95% CI 1.04-1.28, p = 0.01), education status below senior high school (OR 1.22, 95% CI 1.08-1.37, p = 0.001), and residing in north-central Taiwan (OR 1.21, 95% CI 1.10-1.34, p < 0.001) were associated with more anxiety. None of the enrolled patients contracted COVID-19. The anxiety VAS score (mean ± SD) improved after reading the educational materials (3.84 ± 2.33 vs. 2.81 ± 1.96, p < 0.001). CONCLUSION: The medical behavior of IBD patients was influenced by the COVID-19 pandemic, and their anxiety could be mitigated after education.

Ultrasound Color Pattern of Colonic Hamartomatous Polyps.

Colonic hamartomatous polyps are clinically benign tumors. Colonic hamartomas are polypoid lesions that are rare in adults and most commonly encountered in infants and children. We report an unusual case of giant colonic hamartomatous polyps that were found incidentally during a medical workup for acute lower gastrointestinal bleeding in a 26-year-old woman. We present the color Doppler ultrasound, computed tomography scan, and endoscopic pattern of colonic hamartomatous polyps.

Deep learning-based endoscopic anatomy classification: an accelerated approach for data preparation and model validation.

BACKGROUND: Photodocumentation during endoscopy procedures is one of the indicators for endoscopy performance quality; however, this indicator is difficult to measure and audit in the endoscopy unit. Emerging artificial intelligence technology may solve this problem, which requires a large amount of material for model development. We developed a deep learning-based endoscopic anatomy classification system through convolutional neural networks with an accelerated data preparation approach. PATIENTS AND METHODS: We retrospectively collected 8,041 images from esophagogastroduodenoscopy (EGD) procedures and labeled them using two experts for nine anatomical locations of the upper gastrointestinal tract. A base model for EGD image multiclass classification was first developed, and an additional 6,091 images were enrolled and classified by the base model. A total of 5,963 images were manually confirmed and added to develop the subsequent enhanced model. Additional internal and external endoscopy image datasets were used to test the model performance. RESULTS: The base model achieved total accuracy of 96.29%. For the enhanced model, the total accuracy was 96.64%. The overall accuracy improved with the enhanced model compared with the base model for the internal test dataset without narrowband images (93.05% vs. 91.25%, p < 0.01) or with narrowband images (92.74% vs. 90.46%, p < 0.01). The total accuracy was 92.56% of the enhanced model on the external test dataset. CONCLUSIONS: We constructed a deep learning-based model with an accelerated approach that can be used for quality control in endoscopy units. The model was also validated with both internal and external datasets with high accuracy.

Comparison Between Same-Day and Split-Dose Preparations with Sodium Picosulfate/Magnesium Citrate: A Randomized Noninferiority Study.

BACKGROUND: Sodium picosulfate/magnesium citrate (SPMC) is a small-volume bowel cleansing agent with similar efficacy to and better tolerability than polyethylene glycol. However, we found no data on which SPMC preparation (same-day vs. split-dose) provides better bowel cleansing efficacy for afternoon colonoscopy. AIMS: To compare bowel cleansing efficacy of different timing of the regimen. METHODS: This randomized, single-center, endoscopist-blinded, noninferior study compared same-day and split-dose SPMC preparations for afternoon colonoscopy in 101 and 96 patients, respectively. We also included a prospective observation group of 100 patients receiving morning colonoscopy to compare bowel preparation between morning and afternoon colonoscopies. Bowel cleansing efficacy was then evaluated by the Aronchick Scale, Ottawa Bowel Preparation Scale (OBPS), Boston Bowel Preparation Scale (BBPS), and the Bubble Scale. RESULTS: Same-day and split-dose preparations were similar in efficacy in all four scales. In the Aronchick Scale, the success rate (excellent and good cleanliness) was higher in same-day preparation than in split-dose preparation (100% vs. 92.8%). The same-day preparation also obtained a better OBPS score (1.4 vs. 2.1), but BBPS showed no difference between such groups (7.7 vs. 7.4). CONCLUSION: Same-day preparation with SPMC is not inferior to split-dose preparation for afternoon colonoscopy.

Development and validation of a deep learning-based algorithm for colonoscopy quality assessment.

BACKGROUND: Quality indicators should be assessed and monitored to improve colonoscopy quality in clinical practice. Endoscopists must enter relevant information in the endoscopy reporting system to facilitate data collection, which may be inaccurate. The current study aimed to develop a full deep learning-based algorithm to identify and analyze intra-procedural colonoscopy quality indicators based on endoscopy images obtained during the procedure. METHODS: A deep learning system for classifying colonoscopy images for quality assurance purposes was developed and its performance was assessed with an independent dataset. The system was utilized to analyze captured images and results were compared with those of real-world reports. RESULTS: In total, 10,417 images from the hospital endoscopy database and 3157 from Hyper-Kvasir open dataset were utilized to develop the quality assurance algorithm. The overall accuracy of the algorithm was 96.72% and that of the independent test dataset was 94.71%. Moreover, 761 real-world reports and colonoscopy images were analyzed. The accuracy of electronic reports about cecal intubation rate was 99.34% and that of the algorithm was 98.95%. The agreement rate for the assessment of polypectomy rates using the electronic reports and the algorithm was 0.87 (95% confidence interval 0.83-0.90). A good correlation was found between the withdrawal time calculated using the algorithm and that entered by the physician (correlation coefficient r = 0.959, p < 0.0001). CONCLUSION: We proposed a novel deep learning-based algorithm that used colonoscopy images for quality assurance purposes. This model can be used to automatically assess intra-procedural colonoscopy quality indicators in clinical practice.

Upper endoscopy photodocumentation quality evaluation with novel deep learning system.

OBJECTIVES: Visualization and photodocumentation during endoscopy procedures are suggested to be one indicator for endoscopy performance quality. However, this indicator is difficult to measure and audit manually in clinical practice. Artificial intelligence (AI) is an emerging technology that may solve this problem. METHODS: A deep learning model with an accuracy of 96.64% was developed from 15,305 images for upper endoscopy anatomy classification in the unit. Endoscopy images for asymptomatic patients receiving screening endoscopy were evaluated with this model to assess the completeness of photodocumentation rate. RESULTS: A total of 15,723 images from 472 upper endoscopies performed by 12 endoscopists were enrolled. The complete photodocumentation rate from the pharynx to the duodenum was 53.8% and from the esophagus to the duodenum was 78.0% in this study. Endoscopists with a higher adenoma detection rate had a higher complete examination rate from the pharynx to duodenum (60.0% vs. 38.7%, P < 0.0001) and from esophagus to duodenum (83.0% vs. 65.7%, P < 0.0001) compared with endoscopists with lower adenoma detection rate. The pharynx, gastric angle, gastric retroflex view, gastric antrum, and the first portion of duodenum are likely to be missed by endoscopists with lower adenoma detection rates. CONCLUSIONS: We report the use of a deep learning model to audit endoscopy photodocumentation quality in our unit. Endoscopists with better performance in colonoscopy had a better performance for this quality indicator. The use of such an AI system may help the endoscopy unit audit endoscopy performance.

The effectiveness and safety of vedolizumab induction for moderate to severe ulcerative colitis for Asia patient: A real practice observational study.

BACKGROUND: The use of biologic agents has become the cornerstone of therapy for moderate to severe IBD. Few studies have investigated the efficacy of vedolizumab (VDZ) induction for ulcerative colitis (UC) in Asian patients in a real practice setting. AIMS: To evaluate the efficacy and safety of VDZ induction therapy for moderate to severe UC in Taiwan. METHODS: This was a retrospective and observational study. Selected moderate to severe UC patients received VZD 300 mg i.v. at weeks 0, 2, and 6 as induction therapy. Mayo scores were calculated to evaluate the efficacy. RESULTS: A total of 37 patients with UC who received VDZ and completed the induction therapy at Chang Gung Memorial Hospital (2017/10-2021/5) were included. The mean age was 46.5 year-old and the male to female ratio was 1:1 (19/18). 81.8% of the patients were biologic-naive. At weeks 8-10, a clinical response, clinical remission and endoscopic remission with VDZ induction therapy were achieved in 56.8% (21/37), 32.4% (12/37) and 58.3% (7/12) of the patients, respectively. 54.1% (20/37) were able to taper off at week 8. Overall, only 10.8% (4/37) of the patients were primary non-responders during induction therapy. No obvious VDZ-related severe adverse events were noted. Overall, 58.9% (11/19) of the patients relapsed after stopping VDZ, and the relapse rate after VDZ discontinuation was 42.1% (8/19) within first 6 months and 52.6% (10/19) within the first year. CONCLUSION: In real-world experience, induction therapy with VDZ showed promising clinical benefits and safety profile for patients with UC.

Retrieval of lost patients in the system for hepatitis C microelimination: a single-center retrospective study.

BACKGROUND: Hepatitis C virus (HCV) is one of the major causes of chronic liver disease, cirrhosis, and liver cancer. Most of the infected people have no clinical symptoms. The current strategy for HCV elimination includes test and treatment. In this study, we aimed to evaluate the campaign for retrieving patients who were lost to follow-up, for subsequent re-evaluation. METHODS: From January 2020 to October 2020, patients who had prior tests for positive anti-HCV antibody in 2010-2018 in our hospital were enrolled for our patient callback campaign. Patients who had unknown HCV RNA status or no documented successful antiviral therapy history were selected for anti-HCV therapy re-evaluation. To facilitate patient referral in the hospital, we developed an electronic reminding system and called the candidate patients via telephone during the study period. RESULTS: Through the hospital electronic system, 3783 patients with positive anti-HCV antibody documentation were identified. Among them, 1446 (38.22%) had tested negative for HCV RNA or had anti-HCV therapy, thereby excluded. Of the 2337 eligible patients, 1472 (62.99%) were successfully contacted and called back during the study period for subsequent HCV RNA testing and therapy. We found that 42.19% of the patients had positive HCV RNA and 88% received subsequent anti-HCV therapy. CONCLUSIONS: A significant number of patients with positive HCV serology were lost for HCV confirmatory test or therapy in the hospital. Therefore, this targeted HCV callback approach in the hospital is feasible and effective in achieving microelimination.

Pitavastatin and metformin synergistically activate apoptosis and autophagy in pancreatic cancer cells.

Pancreatic cancer is the seventh leading cause of cancer-related deaths globally. Metformin is the standard first-line of treatment for hyperglycemia in Type 2 diabetes, whereas pitavastatin is a cholesterol-lowering drug used to prevent cardiovascular diseases. Both these agents evidently exert anticancer effects on pancreatic cancer; however, it remains unclear whether cotreatment using them has additive or synergistic anticancer effects on pancreatic cancer. Thus, we herein used the ASPC-1 and PANC-1 cells and treated them with metformin and/or pitavastatin. We performed the cell viability assay, transwell migration assay, and cell cycle analysis using flow cytometry. Western blotting was used to determine protein levels. We found that cotreatment with metformin (30 mM) and pitavastatin (10 µM) significantly reduced cell viability; caused G0/G1 cell cycle arrest; upregulated the expression levels of Bax, PCNA, cleaved PARP-1, cleaved caspase-3, LC3 II, and p27 Kip1 /p21Cip1 ; and inhibited cell migration. The combination index value for cell viability indicated a synergistic interaction between metformin and pitavastatin. Moreover, cotreating the cells with metformin (30 mM) and pitavastatin (10 µM) could preserve mitochondrial function, activate AMPK, and inhibit PI3K/mTOR than treatment with metformin or pitavastatin alone. These findings clearly indicated that metformin plus pitavastatin had a synergistic anticancer effect on pancreatic cancer cells, potentially caused due to the activation of AMPK and inhibition of PI3K/mTOR signaling. Altogether, our results provide that use of metformin plus pitavastatin maybe serve as a chemotherapeutic agent for human pancreatic cancer in future.

Superiority of NBI endoscopy to PET/CT scan in detecting esophageal cancer among head and neck cancer patients: a retrospective cohort analysis.

BACKGROUND: Second primary cancer of the esophagus is frequent in head and neck patients, especially in high-risk populations, and has a great impact on the prognosis. Although Positron emission tomography (PET)/computed tomography (CT) scan is commonly conducted in head and neck patients, its ability to detect early esophageal cancer is limited. Narrow-band imaging endoscopy is an accurate and convenient technique for esophageal examination. We aimed to compare PET/CT scan and narrow-band imaging endoscopy for the detection of esophageal cancer in head and neck cancer patients. METHODS: From November 2015 to November 2018, all head and neck cancer patients who underwent both PET/CT scan and narrow-band imaging endoscopy at Changhua Christian Hospital were retrospectively enrolled. Descriptive statistics, receiver operating characteristic curve analysis, logistic regression analysis, independent Student's t-test, and Kaplan-Meier survival analysis were conducted with MedCalc Statistical Software. RESULTS: A total of 147 subjects were included in the analysis; suspicious esophageal lesions were identified by PET/CT scan in 8 (5.44%) and by narrow-band imaging in 35 (23.81%). The final pathologic diagnoses were esophageal squamous cell carcinoma in 10 and high-grade dysplasia in 5. The respective sensitivity, specificity, and area under the curve for detecting suspicious esophageal lesions were 33.33, 97.73%, and 0.655 for PET/CT scan, and 100.0, 84.85%, and 0.924 for narrow-band imaging endoscopy. Hypopharyngeal or laryngeal location of the primary head and neck cancer was the only risk factor for developing second primary esophageal cancer. CONCLUSIONS: PET/CT scan was inferior to narrow-band imaging endoscopy in detecting second primary esophageal cancer in head and neck cancer patients. In addition to PET/CT scan, narrow-band imaging endoscopy should be considered in head and neck patients at high risk for developing second primary esophageal cancer.

Successful resuscitation with extracorporeal membrane oxygenation support for refractory ventricular fibrillation caused by left main coronary artery occlusion.

Refractory ventricular fibrillation with cardiac arrest caused by occlusion of the left main coronary artery may rapidly become fatal. In this report, we describe the case of a 70-year-old male who presented to emergency department with chest pain. Electrocardiogram showed ST-segment elevation in leads aVR and aVL and ST-segment depression in leads v3, v4, v5, v6, 2, 3, and aVF. Occlusion of the left main coronary artery was suspected. While waiting for percutaneous coronary intervention, the patient experienced sudden refractory ventricular fibrillation with cardiac arrest. In the emergency department, resuscitation of a patient with refractory ventricular fibrillation caused by occlusion of the left main coronary artery and ongoing cardiopulmonary resuscitation is a clinical challenge. Resuscitation with extracorporeal membrane oxygenation support was initiated approximately 35 min after prolonged conventional cardiopulmonary resuscitation. Emergency coronary angiography showed almost total occlusion of the left main coronary artery. Percutaneous coronary intervention with a stent restored coronary perfusion. The patient was discharged on day 6 without serious sequelae or neurological deficits.

A training program of a new simplified classification of magnified narrow band imaging for superficial esophageal squamous cell carcinoma.

BACKGROUND AND AIM: Optimal staging of the invasion depth of superficial esophageal squamous cell carcinoma is vital before endoscopic treatment. A new simplified magnified narrow-band imaging (M-NBI) classification system based on vascular architecture has recently been developed by the Japan Esophageal Society; however, its validity remains uncertain. METHODS: A total of 11 experienced and 11 inexperienced endoscopists were invited to join an endoscopic training program, which was composed of pretest, educational section, and post-test. The pretest and post-test sections included a set of endoscopic photos from 40 subjects with superficial esophageal squamous cell carcinoma with various invasion depths. Each subject appeared twice in the test, one with white-light imaging (WLI) only and the other with both WLI and M-NBI. The educational section included lectures and video demonstrations. RESULTS: The accuracy of WLI alone and combined with M-NBI at baseline were 0.53, 0.57 and 0.43, 0.41 for the experienced and inexperienced endoscopists, respectively, which then improved to 0.57, 0.63 and 0.49, 0.52 after training. Inter-observer agreement (k-value) of WLI alone and combined WLI and M-NBI for the experienced and inexperienced endoscopists also improved from 0.61, 0.61, and 0.61, 0.53 to 0.68, 0.71, and 0.71, 0.59, respectively. Multivariate analysis revealed that the educational course but not experience in endoscopy, NBI, or magnification significantly improved the diagnostic accuracy. M-NBI had a significant additional benefit to WLI, with an improvement in accuracy from 36% to 56% for the cases with m3/sm1 cancers (P < 0.05). CONCLUSIONS: A well-designed training program can improve the diagnostic accuracy in evaluating cancer invasion depth, with substantial agreement.

Incidence and clinical characteristics of hepatitis B virus reactivation in HBsAg-negative/HBcAb-positive patients receiving rituximab for rheumatoid arthritis.

OBJECTIVES: To analyse the incidence, clinical characteristics, and prognosis of patients with rheumatoid arthritis (RA) and hepatitis B virus (HBV) surface antigen negative/core antibody positive serostatus (HBsAg-/HBcAb+), who underwent rituximab therapy and developed HBV reactivation. METHODS: Medical records of RA patients with different HBV serostatus who received rituximab from January 2000 through January 2015 were reviewed. Case notes of four HBsAg-/HBcAb+ patients with RA who had HBV reactivation during treatment with rituximab were excerpted and summarised. We also searched the Medline (PubMed) database to identify published reports of other HBsAg-/HBcAb+ RA patients who likewise developed HBV reactivation during rituximab treatment. RESULTS: The study cohort comprised 54 RA patients who received rituximab, of whom 44 (81.5%) were HBsAg-/HBcAb+ whilst receiving rituximab. Four HBsAg-/HBcAb+ patients had HBV reactivations during rituximab therapy; thus, the incidence of HBV reactivation in the HBsAg-/HBcAb+ group was 9.1%. The literature search discovered another three cases, making a total of at least seven known rituximab-treated HBsAg-/HBcAb+ RA patients who have developed HBV reactivation. The mean duration from the first rituximab infusion to HBV reactivation was 25.4±4.6 months; no fatalities occurred. CONCLUSIONS: Approximately 9% of Taiwanese RA patients with HBsAg-/HBcAb+ serostatus had HBV reactivation around 2 years after starting regular rituximab therapy; they all had a relatively good prognosis.