A Swedish cost-utility analysis of ferric derisomaltose versus ferric carboxymaltose in the treatment of iron deficiency anemia in patients with inflammatory bowel disease

OBJECTIVES

Iron deficiency anemia (IDA) is a common extraintestinal manifestation of inflammatory bowel disease (IBD), driven by impaired iron absorption, inflammation of intestinal mucosa and blood loss due to intestinal bleeding. Exogenous iron is indicated to correct iron deficiency, with intravenous iron preferred in patients with malabsorption or intolerance of oral iron, active bleeding, systemic inflammation, or a need for rapid iron replenishment. The objective was to assess the cost-utility of two high-dose, rapid-infusion iron formulations-ferric derisomaltose (FDI) and ferric carboxymaltose (FCM)-in the treatment of patients with IBD and IDA in Sweden.

METHODS

The analysis used a previously-published micro-simulation model. Phosphate monitoring was modeled based on the product labelling, while iron need and disease-related quality of life (QoL) were modeled based on data from the PHOSPHARE-IBD randomized controlled trial. Cost-utility was evaluated from the national healthcare payer perspective over a five-year time horizon. Sensitivity and scenario analyses were performed.

RESULTS

For each iron treatment course, patients treated with FDI required 0.41 fewer infusions than those treated with FCM. The reduced number of infusions resulted in savings of SEK 9,876 over five years from iron administration costs alone (SEK 44,216 with FCM versus SEK 34,340 with FDI). Phosphate monitoring in patients treated with FCM cost SEK 2,776 over five years versus no monitoring costs with FDI. Total cost savings with FDI were SEK 14,962. FDI also resulted in a 0.076 quality-adjusted life year (QALY) improvement versus FCM driven primarily by the QoL improvements reported in PHOSPHARE-IBD, and FDI was therefore the dominant intervention.

LIMITATIONS

The analysis did not capture costs or outcomes associated with hypophosphatemic osteomalacia or fractures.

CONCLUSION

Relative to FCM, fewer infusions of FDI were required, there was no need for phosphate monitoring, and disease-related QoL was improved, while overall costs were reduced.

Uncovering de novo polyamine biosynthesis in the gut microbiome and its alteration in inflammatory bowel disease

Polyamines are important gut microbial metabolites known to affect host physiology, yet the mechanisms behind their microbial production remain incompletely understood. In this study, we developed a stable isotope-resolved metabolomic (SIRM) approach to track polyamine biosynthesis in the gut microbiome. Viable microbial cells were extracted from fresh human and mouse feces and incubated anaerobically with [U-13C]-labeled inulin (tracer). Liquid chromatography-high resolution mass spectrometry analysis revealed distinct 13C enrichment profiles for spermidine (SPD) and putrescine (PUT), indicating that the arginine-agmatine-SPD pathway contributes to SPD biosynthesis in addition to the well-known spermidine synthase pathway (PUT aminopropylation). Species differences were observed in the 13C enrichments of polyamines and related metabolites between the human and mouse microbiome. By analyzing the fecal metabolomics and metatranscriptomic data from an inflammatory bowel disease (IBD) cohort, we found significantly higher polyamine levels in IBD patients compared to healthy controls. Further investigations using single-strain SIRM and in silico analyses identified Bacteroides spp. as key contributors to polyamine biosynthesis, harboring essential genes for this process and potentially driving the upregulation of polyamines in IBD. Taken together, this study expands our understanding of polyamine biosynthesis in the gut microbiome and will facilitate the development of precision therapies to target polyamine-associated diseases.

Evaluating the cost-utility of ferric derisomaltose versus ferric carboxymaltose in patients with inflammatory bowel disease and iron deficiency anaemia in Norway

AIMS

Iron deficiency anemia (IDA) is among the most common extraintestinal sequelae of inflammatory bowel disease (IBD). Intravenous iron is often the preferred treatment in patients with active inflammation with or without active bleeding, iron malabsorption, or intolerance to oral iron. The aim of the present study was to evaluate the cost-utility of ferric derisomaltose (FDI) versus ferric carboyxymaltose (FCM) in patients with IBD and IDA in Norway.

MATERIALS AND METHODS

A published patient-level simulation model was used to evaluate the cost-utility of FDI versus FCM in patients with IBD and IDA from a Norwegian national payer perspective. Iron need was modelled based on bivariate distributions of hemoglobin and bodyweight combined with simplified tables of iron need from the FDI and FCM summaries of product characteristics. Patient characteristics and disease-related quality of life data were obtained from the PHOSPHARE-IBD trial. Cost-utility was evaluated in Norwegian Kroner (NOK) over a five-year time horizon.

RESULTS

Patients required 1.64 fewer infusions of FDI than FCM over five years (5.62 versus 7.26), corresponding to 0.41 fewer infusions per treatment course. The reduction in the number of infusions resulted in cost savings of NOK 5,236 (NOK 35,830 with FDI versus NOK 41,066 with FCM). The need for phosphate testing in patients treated with FCM resulted in further cost savings with FDI (no costs with FDI versus NOK 4,470 with FCM). Total cost savings with FDI were therefore NOK 9,707. FDI also increased quality-adjusted life expectancy by 0.071 quality-adjusted life years (QALYs) driven by reduced incidence of hypophosphatemia and fewer interactions with the healthcare system.

CONCLUSIONS

FDI resulted in cost savings and improved quality-adjusted life expectancy versus FCM in patients with IDA and IBD in Norway. FDI therefore represents the economically preferable iron formulation in Norwegian patients with IBD and IDA in whom it is indicated.

Synergistic Benefits of Dietary Strategies in the Management of IBD

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) patients commonly inquire about the role of diet in the onset and management of their disease process. This review sought to assess the impact of the inflammatory bowel diseases on the nutritional state of patients and evaluate the evidence supporting nutritional interventions as therapy.

RECENT FINDINGS

The role of nutrition has evolved from one of deficient nutrient and calorie replacement alone into a proactive therapeutic for treating active inflammatory disease symptoms. The realization that initiating total parenteral nutrition (TPN) in place of oral take could improve disease symptoms provided the first indication that food intake played a causative role in the IBD. The evolution of TPN to enteral nutrition improved tolerance and reduced side effects but clouded the role of oral intake in the pathophysiology of IBD. Advanced understanding of the role of the microbiota in IBD combined with recognition of the influence of nutrients on microbial composition have ushered in a new era of food as therapy. The role of nutrition in IBD has evolved significantly over the past 30-40 years. From complete elimination of oral intake to the carefully curated menu intended to mold the intestinal microbiota to a non-inflammatory milieu has revolutionized the approach to dietary intervention. Additional studies are warranted to optimize dietary intervention strategies.

A review of the effect of iron supplementation on the gut microbiota of children in developing countries and the impact of prebiotics

Iron is essential for many physiological functions of the body, and it is required for normal growth and development. Iron deficiency (ID) is the most common form of micronutrient malnutrition and is particularly prevalent in infants and young children in developing countries. Iron supplementation is considered the most effective strategy to combat the risk of ID and ID anaemia (IDA) in infants, although iron supplements cause a range of deleterious gut-related problems in malnourished children. The purpose of this review is to assess the available evidence on the effect of iron supplementation on the gut microbiota during childhood ID and to further assess whether prebiotics offer any benefits for iron supplementation. Prebiotics are well known to improve gut-microbial health in children, and recent reports indicate that prebiotics can mitigate the adverse gut-related effects of iron supplementation in children with ID and IDA. Thus, provision of prebiotics alongside iron supplements has the potential for an enhanced strategy for combatting ID and IDA among children in the developing world. However, further understanding is required before the benefit of such combined treatments of ID in nutritionally deprived children across populations can be fully confirmed. Such enhanced understanding is of high relevance in resource-poor countries where ID, poor sanitation and hygiene, alongside inadequate access to good drinking water and poor health systems, are serious public health concerns.

Dual role of hepcidin in response to pathogens

Hepcidin is the primary regulator of vertebrate iron homeostasis. Its production is stimulated by systemic iron levels and inflammatory signals. Although the role of hepcidin in iron homeostasis is well characterized, its response to pathogenic agents is complex and diverse. In this review, we examine studies that investigate the role of hepcidin in response to infectious agents. Interleukin-6 (IL-6) is a key factor responsible for the induction of hepcidin expression. During infection, hepcidin-mediated depletion of extracellular iron serves as a protective mechanism against a variety of pathogens. However, accumulation of iron in macrophages through hepcidin-mediated pathways may increase susceptibility to intracellular pathogens such as Mycobacterium tuberculosis. Prolonged elevation of hepcidin production can lead to anemia due to reduced iron availability for erythropoiesis, a condition referred to as anemia of inflammation. In addition, we highlight the role of hepcidin upregulation in several infectious contexts, including HIV-associated anemia, iron deficiency anemia in Helicobacter pylori infection, and post-malarial anemia in pediatric patients. In addition, we show that certain infectious agents, such as hepatitis C virus (HCV), can suppress hepcidin production during both the acute and chronic phases of infection, while hepatitis B virus (HBV) exhibits similar suppression during the chronic phase.

A Randomised, Double-Blind Trial to Compare the Efficacy, Safety, and Immunogenicity of the Biosimilar Ustekinumab FYB202 with Reference Ustekinumab in Patients with Moderate-to-Severe Plaque Psoriasis

INTRODUCTION

Biosimilars allow more patients access to affordable treatment options and help reduce the financial burden on healthcare systems. This multicentre trial compared the efficacy, safety, and immunogenicity of the approved biosimilar ustekinumab FYB202 with reference ustekinumab.

METHODS

Eligible patients were ≥ 18 years old with stable moderate-to-severe plaque psoriasis for ≥ 6 months and inadequate treatment response to or intolerance of ≥ 1 previous systemic treatment. Patients were randomised (1:1) to double-blind treatment with FYB202 or reference ustekinumab; patients in the reference group who achieved Psoriasis Area and Severity Index (PASI) 75 percent improvement at week 28 were re-randomised to FYB202 or reference product. The primary efficacy endpoint was percent improvement in PASI score from baseline to week 12. Therapeutic equivalence was demonstrated if, depending on the regulatory requirement with respect to the significance level, the two-sided 95% and 90% confidence intervals (CIs) were within the pre-defined equivalence intervals of ± 11% and ± 10%, respectively.

RESULTS

A total of 392 patients were randomised to FYB202 (n = 197) or reference ustekinumab (n = 195). Baseline characteristics were well balanced between groups. Mean percent improvement in PASI score at week 12 was equivalent between FYB202 and reference ustekinumab with an estimated least-squares mean treatment difference of 3.27% and the two-sided 95% (- 0.90%, 7.44%) and 90% (- 0.22%, 6.77%) CIs fully contained within the pre-defined equivalence margins. Safety and immunogenicity profiles were comparable between groups. Switching from reference product to FYB202 had no clinically relevant effect on efficacy, safety, or immunogenicity.

CONCLUSION

FYB202 demonstrated therapeutic equivalence to reference ustekinumab in patients with moderate-to-severe plaque psoriasis.

TRIAL REGISTRATION

NCT04595409; EudraCT 2019-004364-21.

Iron deficiency should not be accepted in patients with inflammatory bowel disease - a Scandinavian expert opinion

AIM

In this paper, we aim to explain the reason why iron deficiency (ID) is common in patients with inflammatory bowel disease (IBD), how to better apply diagnostic tools to uncover the state of ID as well as how to interpret the results, and not least, how to treat ID in this group of patients.

METHODS

This article is an expert review and opinion paper on a topic that is too often forgotten in clinical practice. We have not performed a systematic review, but we present the most important research allocated to the topic to substantiate an expert opinion.

RESULTS

This position paper summarises the pathophysiology of ID and gives recommendations on the monitoring and treatment of ID in IBD. ID with or without concurrent anaemia (IDA) is the most common systemic complication in patients with IBD, related to both disease activity and severity. It has consequences both for health-related quality of life and future course of disease of the IBD patient. Intravenous iron is an efficacious and well tolerated, but still underused, therapy for ID and IDA. Iron deficiency should be treated before symptoms of anaemia appear and quality of life is impacted. However, there is still limited awareness of how to detect and treat ID in clinical practice. Uncertainty regarding which diagnostic tests to use and how to interpret the results may also be responsible for variations in clinical practice. In addition, opinions on how to correct ID and IDA differ, in relation to both clinical efficacy and safety.

CONCLUSION

The consequences of ID in patients with IBD are significant. Guidelines on diagnosis, treatment and follow-up of ID should be implemented. IDA is a manifestation of severe ID and preventive strategies focusing on efficient treatment of ID regardless of the level of haemoglobin should therefore be explored.

Body weight-range based initial dosing of ustekinumab in Crohn's disease: Is it an ideal approach?

BACKGROUND & AIMS

The initial intravenous dose of ustekinumab (UST) for treating Crohn's disease (CD) is recommended based on body weight ranges for clinical convenience. However, patients whose body weight nears the upper threshold may receive a relatively lower dose (<6 mg/kg) based on current dosage calculations. We aimed to investigate whether the body weight-range based dosing calculation method for UST may lead to suboptimal therapeutic doses and then impact effectiveness, particularly in patients with borderline weight.

METHODS

A multi-center, observational, real-world cohort study was conducted in four centers. Patients with CD who received UST based on body weight-range dosing calculation were retrospectively enrolled. Participants were classified into two groups according to the initial induction dosage: the relatively higher dose (RHD) induction group (≥6 mg/kg) and the relatively lower dose (RLD) induction group (<6 mg/kg). Steroid-free remission, clinical remission, specific objective response and remission at week 24 were compared in the two groups using propensity score weighting. UST drug concentration was measured at week 24±4.

RESULTS

A total of 438 patients were included, with 176 patients in the RHD group and 262 patients in the RLD group. The RHD group demonstrated superior outcomes compared to the RLD group in achieving steroid-free remission (66.2 % vs. 54.9 %, P = 0.020, OR = 1.605, 95 % CI 1.082-2.395), clinical remission (66.7 % vs. 56.4 %, P = 0.032, OR = 1.546, 95 % CI 1.041-2.311) at week 24. In objective evaluation, the RHD group showed higher rates in ultrasound response (64.9 % vs. 52.1 %, P = 0.041, OR = 1.700, 95 % CI 1.027-2.844) and radiologic remission (25.1 % vs. 13.4 %, P = 0.022, OR = 2.163, 95 % CI 1.117-4.205). The drug concentration was significantly higher in the RHD group compared to the RLD group at week 24 [2.06 (1.36-3.17) µg/ml vs. 1.12 (0.25-1.52) µg/ml, P < 0.001]. Additionally, the RHD group required fewer treatment optimizations than the RLD group, but with no statistical difference (20.6 % vs. 24.9 %, P = 0.291, OR = 0.780, 95 % CI 0.488-1.231). The rate of adverse events was similar between the two groups (4.0 % vs 3.4 %, P = 0.767).

CONCLUSIONS

This study suggested that the current dose calculation method may result in inadequate induction doses of UST for CD patients whose body weight is close to the upper threshold, potentially impacting the effectiveness of induction.

LAY SUMMARY

A multi-center study suggests that the current body weight-range based dosing of ustekinumab for Crohn's disease may lead to insufficient induction doses for patients near the upper weight threshold, negatively impacting treatment effectiveness.

Chronically increased osteoclastogenesis in adult celiac disease patients does not hinder improvement in bone health induced by gluten-free diet: Role of vitamin D, OPG and IL-6

The etiology of bone loss in celiac disease (CeD) remains a clinical challenge, with uncertainties present such as the extent of involvement of malabsorption and inflammation-induced osteoresorption processes in development of osteopenia/osteoporosis (OPN/OP), or reasons for failure to achieve healthy bone mass (BMD) even after long-term gluten-free diet (GFD) treatment. This observational prospective study explores the in vitro osteoclastogenic potential of peripheral blood precursors originating from adult active (newly diagnosed and untreated) celiac disease patients (aCeD) and describes the longitudinal changes in osteoclastogenesis after long-term adherence to GFD. To find connections between in vitro observations and in vivo bone metabolism changes, serum levels of 25(OH)D3, PTH, bCTX, PINP, CRP, IL-6, RANKL and OPG were measured before and after GFD and levels of these markers were correlated with the rate of osteoclastogenesis in vitro. OPG and IL-6 showed associations with BMD and/or presence of OPN/OP. Patients after GFD (CeD-GFD) exhibited improved BMD and increased serum 25(OH)D3 levels, alongside reduced bCTX and PINP levels. Compared to healthy donors, aCeD osteoclast genesis in vitro was higher and, surprisingly, remained elevated even in CeD-GFD patients. Negative correlation was found between osteoclastogenesis rate and serum OPG in aCeD, while osteoclastogenesis rate positively correlated with PTH in CeD-GFD. These results highlight OPG as marker for risk of OPN/OP in CeD and suggest that improvement of BMD after GFD is a result of uncoupling between bone metabolism and osteoresorptive action of osteoclasts after GFD.

Comparative survival of sleeve gastrectomy versus Roux-en-Y gastric bypass in adults with obesity: a systematic review and meta-analysis

BACKGROUND

The difference in survival between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) remains controversial.

OBJECTIVE

To investigate the comparative survival difference between SG and RYGB in adults with morbid obesity.

SETTING

A meta-analysis.

METHODS

MEDLINE, EMBASE, and Cochrane Library Central Register of Controlled Trial were searched through June 30th, 2023 to identify studies comparing SG and RYGB. To minimize confounding, only adjusted outcomes were used from observational studies. The primary outcome was all-cause mortality during follow-up. Secondary outcomes were revision, reoperation, reintervention, hospitalization, endoscopic procedure, and emergency department visit.

RESULTS

Twenty-two studies (10 randomized controlled trials [RCTs] and 12 observational studies) met the inclusion criteria. Three RCTs and seven observational studies with 333,713 patients (SG, n = 172,909; RYGB, n = 160,804) were analyzed for all-cause mortality, with a weighted median follow-up of 34.4 months. SG was associated with decreased risks of all-cause mortality during follow-up (hazard ratio [HR]: .85; 95% confidence interval [CI]: .79 to .92), reoperation (HR: .69; 95% CI: .59 to .80), reintervention (HR: .74; 95% CI: .66 to .81), hospitalization (HR: .86; 95% CI: .77 to .97), and endoscopic procedure (HR: .55; 95% CI: 0.40-.76), whereas SG was associated with a higher risk of revision (HR: 2.18, 95% CI: 1.52 to 3.14). Meta-regression suggested consistent survival advantages of SG regardless of the proportion of patients with diabetes or follow-up duration.

CONCLUSION

In adults with morbid obesity undergoing bariatric surgery, SG was associated with a decreased risk of all-cause mortality during follow-up compared with RYGB. A large-scale randomized trial with long-term follow-up is still necessary for validation.

Gut Microbiome Signature in Predisease Phase of Inflammatory Bowel Disease: Prediction to Pathogenesis to Prevention

Advances in understanding the pathogenesis of inflammatory bowel disease (IBD) point toward a key role of the gut microbiome. We review the data describing the changes in the gut microbiome from IBD case-control studies and compare these findings with emerging data from studies of the preclinical phase of IBD. What is apparent is that assessing changes in the composition and function of the gut microbiome during the preclinical phase helps address confounding factors, such as disease activity and drug therapy, which can directly influence the gut microbiome. Understanding these changes in the predisease phase provides a means of predicting IBD in high-risk populations and offers insights into possible mechanisms involved in disease pathogenesis. Finally, we discuss strategies to use this information to design interventions aimed at modulating the microbiome as a means of preventing or delaying the onset of IBD.

The influence of fasting on abdominal ultrasound image quality - a randomized controlled trial

BACKGROUND

Many patients are instructed to fast before abdominal ultrasound examinations in order to obtain better image quality. However, the few available studies on this topic have so far failed to demonstrate an advantage of several hours of fasting. Prolonged fasting can lead to patient distress, hypoglycemia (e.g. in insulin-treated patients), and malnutrition. Therefore, unnecessary fasting should be avoided.

METHODS

For this prospective investigator-blinded study, we recruited 250 inpatients who were registered for abdominal ultrasonography in our hospital and randomized them into one of three groups: fasting for several hours, regular breakfast, or a liquid oral nutritional supplement. 215 patients could be evaluated. The sonographies were performed consecutively by inexperienced and experienced examiners who independently rated the image quality of seven anatomical structures (gallbladder, common hepatic duct [i.e., proximal part of the common duct], common bile duct [i.e., distal part of the common duct], pancreatic head, pancreatic body, pancreatic tail, and origin of the superior mesenteric artery) on a Likert scale from 1 to 5. The mean of these scores was calculated as a parameter for the diagnostic quality of the abdominal ultrasound examination.

RESULTS

No significant difference was found for sonographic image quality after eating breakfast vs. fasting in both experienced and inexperienced examiners. In inexperienced examiners, image quality was rated slightly better after intake of liquid nutritional supplements compared to a normal breakfast (p = 0.023) or fasting (p = 0.047). However, the effect size was small.

CONCLUSION

A general recommendation for several hours of fasting before abdominal sonography is not necessary.

Progress in understanding of relationship between blood concentrations of ustekinumab and clinical outcomes of inflammatory bowel disease

Ustekinumab is widely used in the treatment of immune diseases due to its well-established efficacy and safety profile. In recent years, studies have found that adjusting dosing strategies and optimizing drug concentrations during long-term therapy can significantly improve the prognosis of some patients. Therapeutic drug concentration monitoring (TDM) can measure the concentration of ustekinumab in vivo, thereby guiding personalized treatment strategy decisions. This review elaborates on the relationship between different drug concentrations of ustekinumab and clinical efficacy and outcomes, and explores the value of individualized treatment strategies based on TDM for clinical treatment based on the existing literature.

SLAM receptors regulate immune checkpoints via SAP and EAT- 2 in rheumatoid arthritis: association with disease activity

OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation and immune dysregulation. This study aimed to investigate the role of SLAM family receptors (SLAMF1 and SLAMF7), immune checkpoint molecules (PD- 1 and TIGIT), and SH2-containing adaptor proteins (SAP and EAT- 2) in rheumatoid arthritis (RA) and their association with disease activity.

METHODS

A total of 50 RA patients (30 inactive, 20 active) and 20 healthy controls were enrolled. Real-time ​polymerase chain reaction (PCR) was used to assess the expression of target genes in peripheral blood mononuclear cells (PBMCs). Gene expression profiling datasets (GSE77298, GSE206848, GSE236924, GSE15573) were analyzed to identify differentially expressed genes (DEGs). Correlation of gene expression with Disease Activity Score 28-joint count (DAS28) was evaluated.

RESULTS

SLAMF1, SLAMF7, SAP, and EAT- 2 expression levels were significantly elevated in RA patients compared to controls. SLAMF1 and SAP expression correlated positively with DAS28 (r = 0.319, p = 0.02; r = 0.460, p = 0.0008, respectively). PD- 1 expression was higher in RA patients but showed no correlation with DAS28, while TIGIT expression was not significantly different. Bioinformatics analysis revealed significant upregulation of SLAMF7 and TIGIT in synovial tissues from RA patients.

CONCLUSION

SLAMF1 and SLAMF7 appear to contribute to RA pathogenesis by modulating immune cell activity and cytokine production. Elevated PD- 1 levels suggest a role in immune dysregulation. The interplay between SLAM receptors, immune checkpoints, and adaptor proteins may exacerbate T cell overactivity and chronic inflammation, offering potential therapeutic targets. Key Points •RA patients showed significantly higher expression of SLAMF1, SLAMF7, PD- 1, SAP, and EAT- 2 compared to healthy controls. •SLAMF1 and SAP expression correlated with disease activity, with SLAMF1 levels higher in active RA cases. •PD- 1 overexpression suggested immune dysregulation, while TIGIT showed no significant difference in RA patients. •The interplay between SLAM receptors, immune checkpoints, and adaptor proteins may contribute to RA pathogenesis and serve as potential therapeutic targets.

Broad-Spectrum ROS/RNS Scavenging Catalase-Loaded Microreactors for Effective Oral Treatment of Inflammatory Bowel Diseases

Inflammatory bowel disease (IBD) such as ulcerative colitis (UC) is an autoimmune disease characterized by persistent inflammation along the gastrointestinal tract with excessive generation of reactive oxygen species (ROS)/reactive nitrogen species (RNS) generation. Here, catalase (CAT)-containing microreactor capsules with long-lasting broad-spectrum ROS/RNS-scavenging capability are developed for the treatment of IBD. In this design, CAT is encapsulated in the dense hydrogel network of calcium alginate (ALG) microspheres, which provides long-term protection of CAT activity in protease-rich intestinal environment. Afterward, the polydopamine (PDA) modification on the surface of CAT@ALG microspheres can provide them bioadhesiveness to achieve prolonged retention in the intestinal tract and broad-spectrum scavenging capability against various types of ROS/RNS beyond hydrogen peroxide. Enteric capsules are further used to protect the CAT@ALG-PDA microspheres from gastric fluid for selective release at the intestinal site. The combined action of PDA and CAT in CAT@ALG-PDA microreactors results in the broad-spectrum scavenging of excess ROS/RNS and regulates redox balance in acute UC rat model, showing satisfactory therapeutic effects superior to the mesalazine and adalimumab at clinically relevant doses without obvious side effects. This work highlights that these CAT@ALG-PDA capsules can act as long-acting broad-spectrum ROS/RNS reactors, promising for IBD treatment.

Advancements in the application of semi-solidified feeding in enteral nutrition for critically-ill patients: a comprehensive review

Introduction

Enteral nutrition represents the primary modality of nutritional support for critically ill patients. However, challenges such as gastroesophageal reflux, diarrhea, and abdominal distension often manifest during its administration. Enteral nutrition semi-solidified feeding has emerged as a promising alternative, demonstrating notable efficacy. This study systematically explores the literature on semi-solidified enteral nutrition, discussing its conceptual framework, classifications, relative merits, and drawbacks compared to traditional enteral nutrition. Additionally, it illustrates clinical application and associated complications, offering valuable insights for the implementation of semi-solidified enteral nutrition in critically ill patients.

Innate lymphoid cells, immune functional dynamics, epithelial parallels, and therapeutic frontiers in infections

Innate lymphoid cells (ILCs) have emerged as pivotal players in the field of immunology, expanding our understanding of innate immunity beyond conventional paradigms. This comprehensive review delves into the multifaceted world of ILCs, beginning with their serendipitous discovery and traversing their ontogeny and heterogeneity. We explore the distinct subsets of ILCs unraveling their intriguing plasticity, which adds a layer of complexity to their functional repertoire. As we journey through the functional activities of ILCs, we address their role in immune responses against various infections, categorizing their interactions with helminthic parasites, bacterial pathogens, fungal infections, and viral invaders. Notably, this review offers a detailed examination of ILCs in the context of specific infections, such as Mycobacterium tuberculosis, Citrobacter rodentium, Clostridium difficile, Salmonella typhimurium, Helicobacter pylori, Listeria monocytogenes, Staphylococcus aureus, Pseudomonas aeruginosa, Influenza virus, Cytomegalovirus, Herpes simplex virus, and severe acute respiratory syndrome coronavirus 2. This selection aimed for a comprehensive exploration of ILCs in various infectious contexts, opting for microorganisms based on extensive research findings rather than considerations of virulence or emergence. Furthermore, we raise intriguing questions about the potential immune functional resemblances between ILCs and epithelial cells, shedding light on their interconnectedness within the mucosal microenvironment. The review culminates in a critical assessment of the therapeutic prospects of targeting ILCs during infection, emphasizing their promise as novel immunotherapeutic targets. Nevertheless, due to their recent discovery and evolving understanding, effectively manipulating ILCs is challenging. Ensuring specificity and safety while evaluating long-term effects in clinical settings will be crucial.

Pancreatic Enzyme Replacement Therapy Improves Exclusive Enteral Nutrition Related Diarrhea in Crohn's Disease: A Prospective Randomized Trial

BACKGROUND & AIMS

Previous results showed that combined treatment of biologics and exclusive enteral nutrition (EEN) brought moderate-to-severe Crohn's disease patients significant improvements in clinical and endoscopic outcomes. Despite its essential role and favorable safety profile, EEN in the treatment of adult Crohn's disease is frequently underestimated because of lower compliance and several side effects, including EEN-related diarrhea (EEND).

METHODS

In this prospective, single-center randomized clinical trial, 147 eligible patients with actively moderate-to-severe Crohn's disease treated with biologics and concomitant 16-week EEN were included. Sixty-one patients without EEND were enrolled in the ND group (without EEN-related diarrhea), and other patients with EEND who received pancreatic enzyme replacement therapy (PERT) (43 patients) or not (43 patients) were recruited in PERT and NPERT groups, respectively. The clinical outcomes, biologic outcomes, and endoscopic outcomes were evaluated. Quality of life (QoL) and psychological status were also assessed at baseline and endpoints (week 16).

RESULTS

Bowel movements (daily frequency decreased by 5.3 times) and stool consistency (reduced watery and loose stool) were greatly improved in PERT group at week 16. At week 16, patients in the ND and PERT groups achieved similar clinical responses (93% in ND group and 94.7% in PERT group, p = 0.731) and clinical remission (86.0% in ND group and 86.8% in PERT group, p = 0.90) while patients in the NPERT group had significantly lower proportions of these clinical outcomes (67.9% clinical response and 57.1% clinical remission). No significant difference was observed in endoscopic outcomes between each group (p = 0.904). QoL and mental status including anxiety and depression in PERT group had great improvement compared with the NPERT group.

CONCLUSIONS

Our prospective results provided invaluable evidence that PERT supplementation efficiently improved EEND in Crohn's disease patients with combined treatment of biologics and 16-week EEN, which had a promising effect in active Crohn's disease induction.

TRIAL REGISTRATION

ChiCTR2200058343.

Evaluation of an Exercise Program in Patients with Inflammatory Bowel Disease: A Pilot Study

PURPOSE

Patients with inflammatory bowel disease (IBD) tend to be less physical active, while maintaining an active lifestyle has been associated with enhanced disease control, diminished fatigue, and improved quality of life. This study aimed to evaluate the feasibility and potential impact of an exercise program for patients with IBD.

METHODS

Patients with IBD participated in a 16-week personalized exercise program based on their individual fitness level. Outcome measures included body composition (BMI, muscle mass and fat percentage), physical fitness (based on the Fundamental Motor Skills), quality of life, fatigue, and disease control. For statistical analyses, a paired t test or Wilcoxon signed rank test was used.

RESULTS

In total 32 patients were included, mean age was 50.1 years (SD 12.3), 37.5% were male, and 50% had Crohn's disease. The program was completed by 75% of patients, and average rating of the program was 8.6 out of 10. The program significantly improved fatigue scores (P = 0.013). Quality of life scores improved by an average of 8 points, and disease control showed no significant difference. Additionally, muscle mass (P = 0.020), fat percentage (P = 0.003), lower body strength and coordination (P = 0.006), flexibility (P = 0.002), and speed and endurance (P < 0.001) improved significantly after the program.

CONCLUSION

This pilot study showed that a personalized exercise program could be feasible for patients with IBD and has the potential to have a positive effect on quality of life and fatigue. These findings underline the importance of physical activity and can be used as a step toward integrating an exercise program in standard IBD care.

Drug-induced Guillain-Barré Syndrome: a disproportionality analysis based on the US FDA adverse event reporting system

BACKGROUND

Guillain-Barré Syndrome (GBS) is a rare but severe neurological disorder often precipitated by infections, vaccines, and potentially by certain medications. Drug-induced GBS, though less commonly reported, presents significant diagnostic and therapeutic challenges. This study investigates the correlation between various medications and the onset of GBS.

RESEARCH DESIGN AND METHODS

We conducted a retrospective pharmacovigilance analysis using data from the FDA Adverse Event Reporting System (FAERS) from Q1 2004 to Q1 2024. The analysis focused on identifying drugs frequently associated with GBS and examining the time-to-onset and severity of these events.

RESULTS

From over 17 million adverse events, 1,869 cases were identified as drug-induced GBS. Monoclonal antibodies and immunomodulators were the most frequently implicated drug classes. The median time-to-onset for GBS was within the first 30 days following drug exposure. Approximately 51.8% of the cases resulted in severe outcomes, such as hospitalization or disability. Drugs such as brentuximab vedotin and efalizumab showed strong associations with GBS occurrences.

CONCLUSIONS

This study highlights the importance of monitoring for GBS symptoms following the administration of certain medications, particularly those that affect immune function, and underscores the need for healthcare providers to be aware of the potential neurological risks associated with these medications.

Obesity Is Associated with Inferior Clinical Treatment Outcomes in Inflammatory Bowel Disease: A Nationwide Dutch Registry Study

PURPOSE

To examine the impact of obesity on treatment outcomes in inflammatory bowel disease (IBD).

METHODS

Patients aged ≥ 16 years, with IBD, a documented baseline body mass index (BMI), and starting thiopurines and allopurinol, intravenous (iv) vedolizumab, subcutaneous (sc) vedolizumab, ustekinumab, ozanimod, filgotinib, or tofacitinib were selected from the Dutch Initiative on Crohn and Colitis (ICC) registry. Underweight patients (BMI < 18.5 mg/kg2) were excluded. The primary outcome was steroid-free clinical remission (i.e. Simple Clinical Colitis Activity Index (SCCAI) ≤ 2 for ulcerative colitis (UC) and IBD-unclassified (IBD-U), and Harvey Bradshaw Index (HBI) < 5 for Crohn's disease (CD)) at week 24. Remission rates were compared between normal weight (BMI 18.5-25 kg/m2), and overweight (BMI 25-30 kg/m2), and obese (BMI ≥ 30 kg/m2) patients using binary logistic regression analyses. Multivariable regression analysis was used to correct for possible confounders.

RESULTS

Among 1066 patients with IBD, 619 had normal weight, 303 were overweight, and 144 were obese. At week 24, obese patients achieved steroid-free clinical remission less frequently (35.3%, OR = 0.578, 95% CI: 0.380-0.879, p = 0.010), supported by multivariable analysis (OR = 0.537, 95% CI: 0.346-0.832, p = 0.005).

CONCLUSIONS

Obesity was associated with lower steroid-free clinical remission at week 24. Obese patients with IBD should be encouraged to lose weight not only to improve their overall health, but also to optimize their treatment outcomes.

Gastrointestinal Behҫet's disease mimicking appendicitis

A woman in her 40s of Chinese and African American ancestry with medical history of severe Behҫet's disease on immunosuppressive therapy presented with right lower quadrant abdominal pain. CT of the abdomen and pelvis suggested appendicitis. General surgery recommended bowel rest and antibiotics for treatment, considering her a high surgical risk due to her history of Behҫet's disease and immunosuppression. She again presented 2 weeks later with nausea, vomiting, worsening pain, fever, leucocytosis and elevated inflammatory markers. Colonoscopy was pursued with concern for appendicitis versus possible Behҫet's disease flare, which revealed colonic aphthous ulcers and a large caecal ulcer with associated oedema and ulceration of the appendiceal orifice, consistent with ileocaecal Behҫet's disease. Antibiotics were discontinued, and she was treated with systemic glucocorticoids with complete resolution of her presenting symptoms. Behҫet's disease may convincingly mimic appendicitis, and colonoscopy may prevent unnecessary appendectomy in patients with such a presentation.

A Diet Fortified with Anthocyanin-Rich Extract (RED) Reduces Ileal Inflammation in a Senescence-Prone Mice Model of Crohn's-Disease-like Ileitis

SAMP mice develop progressive Crohn's disease (CD)-like ileitis without spontaneous colitis that worsens over time without chemical, genetic, or immunological manipulation. Even growing in an identical vivarium and fed with the same diet, SAMP mice reveal a distinct fecal microbiome, metabolome, and lipidome profile compared to AKR mice, their non-inflamed parental control strain. Differences are already present in 5-week-old mice, with a tendency to increase in 15-week-old mice. SAMP and AKR mice metabolome and lipidome profiles were substantially different, belonging to two clusters in line with the progression of intestinal disease. Similarly, the 16S analysis confirmed differences between 15-week-old AKR and SAMP mice. The protective role of dietary polyphenols has been documented in inflammatory bowel diseases (IBD); thus, we supplemented the chow diet with an anthocyanin-rich extract (RED) to evaluate disease reduction in SAMP mice and changes in fecal microbiota/metabolome. Our data reveal that 10-week supplementation with anthocyanin-rich extract ameliorated disease severity in SAMP mice despite limited fecal microbiota/metabolome differences.

Antioxidants: a comprehensive review

Antioxidants had a growing interest owing to their protective roles in food and pharmaceutical products against oxidative deterioration and in the body and against oxidative stress-mediated pathological processes. Screening of antioxidant properties of plants and plant derived compounds requires appropriate methods, which address the mechanism of antioxidant activity and focus on the kinetics of the reactions including the antioxidants. Many studies have been conducted with evaluating antioxidant activity of various samples of research interest using by different methods in food and human health. These methods were classified methods described and discussed in this review. Methods based on inhibited autoxidation are the most suited for termination-enhancing antioxidants and, for chain-breaking antioxidants while different specific studies are needed for preventive antioxidants. For this purpose, the most commonly methods used in vitro determination of antioxidant capacity of food and pharmaceutical constituents are examined and also a selection of chemical testing methods is critically reviewed and highlighting. In addition, their advantages, disadvantages, limitations and usefulness were discussed and investigated for pure molecules and raw plant extracts. The effect and influence of the reaction medium on performance of antioxidants is also addressed. Hence, this overview provides a basis and rationale for developing standardized antioxidant capacity methods for the food, nutraceuticals, and dietary supplement industries. Also, the most important advantages and shortcomings of each method were detected and highlighted. The underlying chemical principles of these methods have been explained and thoroughly analyzed. The chemical principles of methods of 1,1-diphenyl-2-picrylhydrazyl (DPPH•) radical scavenging, 2,2'-azinobis-(3-ethylbenzothiazoline-6-sulphonate) radical (ABTS·+) scavenging, ferric ions (Fe3+) reducing assay, ferric reducing antioxidant power (FRAP) assay, cupric ions (Cu2+) reducing power assay (Cuprac), Folin-Ciocalteu reducing capacity (FCR assay), superoxide radical anion (O2·-), hydroxyl radical (OH·) scavenging, peroxyl radical (ROO·) removing, hydrogen peroxide (H2O2) decomposing, singlet oxygen (1O2) quenching assay, nitric oxide radical (NO·) scavenging assay and chemiluminescence assay are overviewed and critically discussed. Also, the general antioxidant aspects of the main food and pharmaceutical components were discussed through several methods currently used for detecting antioxidant properties of these components. This review consists of two main sections. The first section is devoted to the main components in food and their pharmaceutical applications. The second general section includes definitions of the main antioxidant methods commonly used for determining the antioxidant activity of components. In addition, some chemical, mechanistic, and kinetic properties, as well as technical details of the above mentioned methods, are provided. The general antioxidant aspects of main food components have been discussed through various methods currently used to detect the antioxidant properties of these components.

A comprehensive review of small molecules, targets, and pathways in ulcerative colitis treatment

Ulcerative colitis (UC), a chronic inflammatory bowel disease (IBD), poses significant clinical challenges because of its complex pathophysiology, long-term nature, and the limited efficacy of existing treatments. Small-molecule compounds, particularly those that are able to modulate inflammation-related signaling pathways and, in many cases, occur in nature, offer a promising alternative or supplement to conventional therapies. Studies on molecules for UC therapeutics reported in 1394 publications over the past 30 years were collected from the Web of Science (WOS) database. Only studies that verified therapeutic efficacy through animal experiments were included. Through an analysis of the molecular classes, structures, common targets, and pathways using network pharmacology, we identified 14 classes of compounds, 5 direct-target modules, and 3 crucial downstream pathways. Alkaloids, phenylpropanoids, flavonoids, and terpenes (and their derivatives) appeared most frequently and mainly targeted lipid metabolism, oxidative stress, immune regulation, signaling transduction, and cancer-related pathways. Notably, there has been an increasing trend of applying naturally sourced compounds in both preclinical and clinical trials, especially flavonoids, over the last five years. Although progress in UC research has been made, the majority of studies have focused on the overall therapeutic effects and biomarker alterations, with limited emphasis on the direct targets and underlying mechanisms. These findings highlight the need to explore novel small-molecule therapeutic strategies for UC, focusing on clearly defined targets and precise modes of action.

Preoperative weight loss by noninvasive approach in patients with obesity scheduled for bariatric and metabolic surgery: an update narrative review of indications and results available until 2024

Metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity and its metabolic complications. Currently, most MBSs are performed laparoscopically. However, high weight associated with an enlarged liver (especially the left lobe liver section, LLLS) may complicate the technical aspects of this surgery. Therefore, before MBS, moderate preoperative weight loss (PreopWL), and reduction in LLLS are desirable. Moreover, studies are inconclusive regarding which is the best approach to apply. This narrative review aimed to describe the current scientific evidence on the effect of a noninvasive approach, such as dietary or pharmacotherapy or space-occupying devices on PreopWL, peri-operative complications, hospital length of stay, and post-operative complications in patients with obesity scheduled for MBS. We conducted a literature search and screening for relevant publications from January 2010 to June 2024. We found that PreopWL before MBS is helpful for both patients and surgeons, as it leads to various benefits, such as a decrease in body weight and LLLS size, a lower risk of intra- and post-operative complications, shorter surgery times, and reduced hospital stays. In this context, concerning dietary approaches, several dietary protocols have been introduced over time, among which very low-calorie diets and very low energy ketogenic therapy are widely prescribed; however, larger randomized-controlled trials (RCTs) with well-defined dietary protocols are necessary to make definitive conclusions. Obesity management medications, such as the lipase inhibitor orlistat, phentermine/topiramate, naltrexone/bupropion, the glucagon-like peptide-1 receptor agonists (GLP-1RAs) liraglutide and semaglutide, and the novel dual glucose dependent insulinotropic peptide (GIP)/GLP-1 receptor agonist tirzepatide, has shown to be effective in promoting PreopWL before MBS; however, larger, well-designed RCTs are needed to establish optimal treatment protocols and assess their true benefits in patients scheduled for MBS. Space-occupying devices such as the swallowable intragastric balloon and hydrogel capsules, represent a promising tools but further research is essential to confirm their role.

Unveiling the influence of lipidomes on inflammatory bowel disease: a bidirectional mendelian randomization study

BACKGROUND

Plasma lipid homeostasis is pivotal in maintaining intestinal health. Inflammatory bowel disease (IBD), encompassing ulcerative colitis (UC) and Crohn's disease (CD) as distinct subtypes, manifests unique metabolic signatures. However, the specific roles of lipids in the pathogenesis and therapeutic targeting of IBD remain inadequately explored. This study aims to delineate the genetic influences of plasma lipids on IBD risk.

METHODS

We obtained genome-wide association study (GWAS) summary statistics of lipidomes and IBD (including UC and CD) from published studies to perform two-sample Mendelian randomization (MR) analyses. Outliers were removed using radial MR, followed by the application of the inverse-variance weighted (IVW) method to assess causal relationships. Sensitivity analyses were also conducted to validate the robustness of the primary results of the MR analyses. Additionally, reverse MR analyses were performed to evaluate the potential for reverse causality.

RESULTS

The MR analysis identified fourteen lipid species significantly associated with IBD, four with UC, and ten with CD. Phosphatidylcholine (PC; P < 0 .05) and lysophosphatidylcholine (OR = 0.83, P < 0.001) were instrumental in UC, while in CD, alongside these, cholesterol ester (OR = 0.86, P < 0.001), diacylglycerol (OR = 1.21, P = 0.004), and lysophosphatidylethanolamine (OR = 1.30, P < 0.001) also demonstrated causal links. Reverse MR analysis revealed no significant associations between IBDs and 179 lipid species.

CONCLUSION

This bidirectional MR study has uncovered genetic evidence of a causal relationship between lipidome and IBD, identifying potential therapeutic targets for IBD treatment. The findings suggest that elevated partial phosphatidylcholine, lysophosphatidylcholine, and cholesterol ester levels could reduce the risk of IBD, indicating a potential protective role for these lipid molecules. This study also underscores the critical role of lipidome variability in advancing our understanding of IBD's pathogenic processes and in developing targeted therapies.

Escherichia coli Nissle Improves Short-Chain Fatty Acid Absorption and Barrier Function in a Mouse Model for Chronic Inflammatory Diarrhea

BACKGROUND

Defects in SLC26A3, the major colonic Cl-/HCO3- exchanger, result in chloride-rich diarrhea, a reduction in short-chain fatty acid (SCFA)-producing bacteria, and a high incidence of inflammatory bowel disease in humans and in mice. Slc26a3-/- mice are, therefore, an interesting animal model for spontaneous but mild colonic inflammation and for testing strategies to reverse or prevent the inflammation. This study investigates the effect of Escherichia coli Nissle (EcN) application on the microbiome, SCFA production, barrier integrity, and mucosal inflammation in slc26a3-/- mice.

METHODS

In vivo fluid absorption and bicarbonate secretion were assessed in the gut of slc26a3+/+ and slc26a3-/- mice before and during luminal perfusion with 100 mM sodium acetate. Age-matched slc26a3+/+ and slc26a3-/- mice were intragastrically gavaged twice daily with 2 × 108 CFU/100 µL of EcN for 21 days. Body weight and stool water content were assessed daily, and stool and tissues were collected for further analysis.

RESULTS

Addition of sodium acetate to the lumen of the proximal colon significantly increased fluid absorption and luminal alkalinization in the slc26a3-/- mice. Gavage with EcN resulted in a significant increase in SCFA levels and the expression of SCFA transporters in the slc26a3-/- cecum, the predominant habitat of EcN in mice. This was accompanied by an increase in mucus-producing goblet cells and a decrease in the expression of inflammatory markers as well as host defense antimicrobial peptides. EcN did not improve the overall diversity of the luminal microbiome but resulted in a significant increase in SCFA producers Lachnospiraceae and Ruminococcaceae in the slc26a3-/- feces.

CONCLUSIONS

These findings suggest that EcN is able to proliferate in the inflamed cecum, resulting in increased microbial SCFA production, decreased inflammation, and improved gut barrier properties. In sufficient dosage, probiotics may thus be an effective anti-inflammatory strategy in the diseased gut.

Long-Term Outcomes of Intravenous Ustekinumab Maintenance Treatment in Patients With Loss of Response to Subcutaneous Dosing

BACKGROUND

Ustekinumab (UST) is commonly used to treat Crohn's disease and ulcerative colitis. However, some patients may experience diminishing response or require increased dosage. Intravenous (IV) UST maintenance is explored as a solution.

OBJECTIVES

We sought to evaluate IV UST maintenance effectiveness and safety in inflammatory bowel disease patients with partial or lost subcutaneous UST response.

METHODS

This was a multicenter retrospective study of inflammatory bowel disease patients on IV UST maintenance. Clinical response and remission at weeks 12 and 52, defined as Harvey-Bradshaw Index ≤4 for Crohn's disease or partial Mayo score ≤2 for ulcerative colitis. Objective markers reduction (fecal calprotectin, C-reactive protein), UST trough levels pre- and post-IV maintenance, and adverse events were assessed.

RESULTS

A total of 59 patients were included. Clinical remission at weeks 12 and 52 achieved by 47.5% and 64.3% respectively. 96.6% continued IV UST at follow-up. UST serum levels quadrupled. No adverse events reported.

CONCLUSIONS

IV UST maintenance effectively sustained remission in most patients at 52 weeks.

Iron Consumption and Colorectal Cancer in Korean Adults: A Prospective Cohort Study

Background/Objectives: Colorectal cancer (CRC) is a major health concern in Korea, with its increasing incidence emphasizing the urgent need to identify risk factors. Recent studies suggest that heme iron elevates CRC risk, but evidence remains conflicting. This study examined the associations between total, heme, and non-heme iron intake and the incidence of colorectal, colon, and rectal cancer in Koreans. Methods: Using the Korean Genome and Epidemiology Study Health Examinee (KoGES HEXA) cohort, a large community-based cohort of healthy Koreans, we constructed a database of iron content for foods listed in a validated food frequency questionnaire (FFQ) and assessed dietary iron intake for each participant. Colorectal, colon, and rectal cancer cases were identified via the national cancer registry up to 2018. The association between iron consumption and cancers was evaluated with hazard ratios (HRs) and 95% confidence intervals (95%CIs) using multivariable-adjusted Cox regression. Results: During the 9.1-year median follow-up of 109,908 participants (37,697 men and 71,401 women, median age: 53.8 years), 608 new CRC cases were identified. Moderate total iron consumption in the second quintile (5.00-6.27 mg/day) decreased CRC (HR: 0.75; 95%CI: 0.58-0.97) and colon cancer (HR: 0.71; 95%CI: 0.51-1.00) risk compared to the lowest consumption quintile (1.09-4.99 mg/day), as did non-heme iron intake in the second quintile (4.98-6.24 mg/day) compared to its lowest quintile (1.09-4.97 mg/day) (CRC HR: 0.75; 95%CI: 0.58-0.98; colon cancer HR: 0.70; 95%CI: 0.49-0.98). Conclusions: Moderate total and non-heme iron intake reduced colorectal and colon cancer risk in Koreans, possibly via the displacement of carcinogens and the increased intake of protective micronutrients from plant-based foods. Larger-scale studies may be instrumental in substantiating these results.

Real-world evaluation of an intravenous iron service for the treatment of iron deficiency with or without anemia

Intravenous (IV) iron is a guideline-recommended treatment for iron deficiency when oral iron is contraindicated, ineffective, or not tolerated, or when rapid iron delivery is necessary. However, evidence suggests that some patients receive less IV iron than needed. This retrospective audit assessed the effectiveness and safety of ferric derisomaltose (FDI), a high-dose IV iron, in 2,468 patients. Efficacy outcomes assessed at 4-12 weeks post-infusion included changes in hemoglobin (Hb) and ferritin, proportion of courses (a course was defined as the treatment episode required to administer one total dose) after which patients were non-anemic (Hb ≥ 130 g/L [men] or ≥ 120 g/L [women]), and response rate (proportion of courses after which patients were non-anemic or Hb increased by ≥ 20 g/L). Safety was assessed through adverse events. Across 2,775 FDI courses, the mean dose was 1,244 mg, but mean estimated iron need was 1,580 mg. At follow-up, mean Hb had increased by 20.9 g/L and mean ferritin by 188.8 µg/L. Patients were non-anemic after 33.4% (n = 494/1,478) of courses and responded after 65.1% (n = 962/1,478) of courses. One patient (n = 1/2,468; 0.04%) had a serious allergic reaction. Patients remained anemic after > 65% of courses, demonstrating the need to optimize dosing based on iron need.

Early detection and correction of preoperative anemia in patients undergoing colorectal surgery-a prospective study

INTRODUCTION

Preoperative anemia is an important target in preventing colorectal anastomotic leakage (CAL). However, it is not consistently detected and corrected in patients undergoing colorectal surgery. This study aimed to evaluate the impact of early detection and correction of preoperative anemia on perioperative outcomes and CAL.

METHODS

This was a prospective subanalysis of an international open-labeled trial, which implemented an enhanced care bundle to prevent CAL after elective colorectal surgeries. It introduced interventions for early detection and correction of preoperative anemia. Primary outcome was the incidence of preoperative anemia and the effect of early correction. Secondary outcomes included the impact on CAL, postoperative course, and mortality.

RESULTS

The study included 899 patients across eight European hospitals (September 2021-December 2023). Preoperative anemia was identified in 35.0% (n = 315) of participants, with 77.4% (n = 192) receiving iron therapy. Hemoglobin levels decreased in 4.2% (n = 13), remained stable in 45.8% (n = 143), and increased in 50.0% (n = 156) (p < 0.001). Perioperative hyperglycemia was more common among patients with anemia (7.8% versus 16.4%, p < 0.001). CAL occurred in 6.1% (n = 53) of patients. Anemia correction and changes in hemoglobin levels after iron treatment were not significantly associated with CAL, other complications, or mortality.

CONCLUSIONS

Early detection and correction of preoperative anemia is achievable. However, routine preoperative administration of iron alone, without concurrently optimizing other CAL risk factors, does not result in CAL prevention. Preoperative anemia indicates overall poor physiological fitness rather than being an isolated risk factor.

TRIAL NUMBER

NCT05250882 (20-01-2022).

Corticosteroid-sparing effects of risankizumab efficacy and safety in patients with moderately to severely active ulcerative colitis

BACKGROUND AND AIMS

This post hoc analysis evaluated the corticosteroid-sparing effects of risankizumab (RZB) therapy in patients with moderate-to-severe ulcerative colitis in the phase 3 induction and maintenance studies, INSPIRE and COMMAND.

METHODS

Patients were randomized (2:1) to 12 weeks of intravenous RZB or placebo (PBO) induction therapy; responders to intravenous RZB were randomized (1:1:1) to receive subcutaneous RZB 180 mg, 360 mg, or PBO (RZB withdrawal) maintenance therapy. Baseline corticosteroid doses were maintained during induction, with a mandatory taper beginning at maintenance week 0. Efficacy outcomes were evaluated by baseline corticosteroid use at induction week 12, while corticosteroid-free clinical and endoscopic outcomes were assessed at maintenance week 52 among the overall population and among patients on corticosteroids at baseline. Safety was also assessed.

RESULTS

At baseline, 35.7% (348/975) of patients were taking corticosteroids. At induction week 12, greater rates were observed for clinical, endoscopic, and patient-reported outcomes in RZB 1200 mg-treated patients compared with PBO, regardless of baseline corticosteroid use. RZB 180 mg and 360 mg treatment resulted in higher corticosteroid discontinuation rates (RZB 180 mg 64.9% [48/74]; RZB 360 mg 54.2% [32/59]; PBO [withdrawal] 36.8% [25/68], P ≤ .01) and corticosteroid-free clinical, endoscopic, and patient-reported outcomes at week 52, compared with PBO (withdrawal). The rates of treatment-emergent adverse events were similar regardless of baseline corticosteroid use during induction and maintenance.

CONCLUSIONS

The efficacy of RZB induction therapy was independent of corticosteroid use, with high rates of corticosteroid-free outcomes observed in the overall population and among patients with baseline corticosteroid use, reaffirming the potential of RZB to serve as a corticosteroid-sparing therapy for patients with ulcerative colitis.

CLINICALTRIAL.GOV NUMBERS

NCT03398148 and NCT03398135.

Utility of Fecal Biomarkers to Predict Invasive Nature of Acute Infectious Diarrhea in Indian Children

OBJECTIVE

To determine role of fecal calprotectin (FC) and fecal lactoferrin (FL) in diagnosis of invasive diarrhea.

METHODS

Stool samples from 75 children (≤ 12 years) with acute diarrhea were analysed using wet mount microscopy, culture, multiplex polymerase chain reaction, rapid tests for Rotavirus/ Adenovirus and quantitative ELISA for FC and FL.

RESULTS

The mean (SD) FC levels (μg/g) [774 (626.59) vs. 213 (251.48), P < 0.001] and FL levels (μg/g) [7.95 (4.72) vs. 4.22 (3.91), P = 0.004] were significantly higher in children with invasive diarrhea (n = 38) compared to those with non-invasive diarrhea (n = 37). Cut-off values of FC > 243 μg/g (sensitivity 81.57%, specificity 67.56%, AUC 0.813) and for FL > 6.02 μg/g (sensitivity 71.05%, specificity 81.08%, AUC 0.732) have diagnostic potential.

CONCLUSIONS

FC and FL can aid diagnosis of acute invasive diarrhea.

Comparative real-world effectiveness of ustekinumab versus anti-TNF in Crohn's disease: 12-month maintenance phase results from the prospective, observational RUN-CD study using propensity score adjustment

BACKGROUND

The prospective RUN-CD registry investigates the effectiveness of ustekinumab (UST) and other biologics in Crohn's disease (CD) across Germany. Based on data from the registry, this study presents the maintenance phase results of a 12-month real-world-evidence (RWE) comparison of CD patients initiating new biologic therapies with UST or anti-TNF.

METHODS

After excluding patients using biologics other than UST and anti-TNF and those with missing outcomes, the final sample consisted of 618 CD patients. Clinical remission (CR), defined as a Harvey-Bradshaw Index (HBI) ≤4, was the prespecified endpoint at 12 months. Switching to another biologic therapy was considered an outcome failure. Propensity score adjustment was used to reduce the effect of confounders.

RESULTS

The study included 343 CD patients treated with UST and 264 treated with anti-TNF. Over 12 months, the frequency of therapy switches was significantly higher for infliximab (28%) compared with UST (17%) and adalimumab (17%) (P =.045). There was no significant difference in CR rates at 12 months between the UST and anti-TNF groups (65.8% vs 60.0%, P =.262). However, in week-16 responders, CR rates at 12 months were significantly higher with UST (77.6%) versus anti-TNF (65.4%) (P =.041). The change in EQ-VAS (QoL) scores between UST and anti-TNF showed a 5.1-point difference favoring UST (P =.002).

CONCLUSIONS

In this 12-month RWE comparison, overall CR rates were similar between UST and anti-TNF. However, among week-16 responders, CR rates were significantly higher with UST. Additionally, UST was associated with a significantly greater improvement in QoL compared with anti-TNF.

Undernutrition in adult hospitalized patients and its impact on the length of stay, a 10-year repeated cross-sectional study analyzing 65,226 stays

BACKGROUND & AIMS

The prevalence of undernutrition in hospitalized patients and its impact on their length of stay (LOS) varies considerably depending on the population studied, the diagnosis criteria or the screening tools used. Previous reports using controlled data have been done on small populations while large cohorts have been studied on unverified declarative data. This study aims at determining the prevalence of undernutrition in a large population using verified anthropometric data and assessing its impact on the LOS.

METHODS

- For 10 years (2007-2017), a specialized nutritional assessment unit screened inpatients in a tertiary hospital for undernutrition, with the exception of those in emergency and intensive care, orthopedics, pediatrics and maternity wards. Within each unit, screening was carried out every two to three weeks. The diagnosis of undernutrition in adult inpatients was made using body mass index (BMI) (<18.5 kg/m2 for age <70 or < 21 kg/m2 for age ≥70) or weight loss (weight loss >5 % over a month or >10 % over 6 months). We retrospectively analyzed this database, looking at all adults (>18 years) hospitalized for at least one day. The analysis of the prevalence of undernutrition and its consequence on the LOS was performed on the entire population as well as by sex, age groups and diagnosis-related groups (DRGs). Statistics were performed using the chi-square test, T-test, ANOVA and mixed linear analysis. Age and gender were added as potential confounders, while DRG was included as a random effect.

RESULTS

The analysis included data from 65,226 stays. Mean age 65 years (min 18, max 113), 58.2 % male patients. The overall prevalence of undernutrition was 29.77 %, lower in the 40 to 70-year-old group than in the younger and older population. Undernutrition was present in all of the 53 surveyed DRGs, with a prevalence ranging from 12 % to 57.89 %. In the overall population, undernourished patients had a longer LOS than well-nourished patients, with a median increase of 5 days. In 42 of the 53 DRGs, representing 97.57 % of the total population, undernutrition significantly increased the LOS.

CONCLUSIONS

This large study of the prevalence of undernutrition diagnosed from verified anthropometric data in hospitalized adults does not confirm recent findings obtained from unverified data in hospital databases.

External Evaluation of Population Pharmacokinetic Models of Ustekinumab in Patients with Inflammatory Bowel Disease

BACKGROUND

Population pharmacokinetic (popPK) models are essential tools for optimizing ustekinumab (UST) dosing for the treatment of inflammatory bowel disease (IBD) through therapeutic drug monitoring. The external validation of these models is necessary to ensure their predictive performance and clinical utility. The aim of the study was to externally validate 4 published popPK models of UST in a real-world cohort of patients with IBD using prediction-based and simulation-based diagnostics, as well as Bayesian forecasting.

METHODS

Four popPK models of UST, identified through a systematic literature review, were evaluated using data from 99 patients with IBD and 374 serum UST concentrations. Predictive performance and Bayesian forecasting were assessed using statistical metrics, including mean prediction error, median prediction error (MDPE), and median absolute prediction error (MADPE). The acceptability criteria (MDPE ±20%, MADPE ≤30%, F20 ≥35%, and F30 ≥50%) were applied.

RESULTS

None of the models satisfied the predefined acceptability criteria. The Xu et al model demonstrated the best performance, achieving an MDPE of 19.55% and the lowest RMSPE (2.88 mcg/mL), but F20 (20.1%) and F30 (32.4%) values fell below thresholds. The model proposed by Adedokun et al showed strong results in simulation-based diagnostics, with only 5.6% of the observed concentrations outside the prediction interval.

CONCLUSIONS

The models developed by Xu et al and Adedokun et al exhibited the most promising predictive performance and potential clinical applicability for model-informed precision dosing. Refinements to these models and further research are required to enhance their use in personalized UST therapies for IBD.

PTPN2 Regulates Iron Handling Protein Expression in Inflammatory Bowel Disease Patients and Prevents Iron Deficiency in Mice

Anemia is the most common extraintestinal manifestation of inflammatory bowel disease (IBD). Iron deficiency is the most frequent cause of anemia in IBD; however, the mechanisms involved are still poorly understood. Here, we investigated the role of the IBD risk gene, protein tyrosine phosphatase non-receptor type 2 (PTPN2), in regulating iron homeostasis. Proteomic analyses were performed on serum from IBD patients genotyped for the IBD-associated loss-of-function rs1893217 PTPN2 variant. Constitutive Ptpn2 wild type (WT), heterozygous (Het), and knockout (KO) mice were analyzed for iron content, blood parameters, and expression of iron handling proteins. Iron absorption was assessed through radiotracer assays. Serum proteomic analyses revealed that the "iron homeostasis signaling pathway" was the main pathway downregulated in Crohn's disease (CD) patients carrying the PTPN2 risk allele, independent of disease activity. Ptpn2-KO mice showed characteristics of anemia, including reduced hemoglobin concentrations along with serum and tissue iron deficiency and elevated serum hepcidin levels vs. Ptpn2-WT and Het mice. 55Fe absorption via oral gavage was significantly impaired in Ptpn2-KO mice. Correspondingly, Ptpn2-KO mice showed reduced apical membrane expression of the iron transporter DMT1. CD patients with the PTPN2 loss-of-function rs1893217 variant display alterations in serum iron handling proteins. Loss of Ptpn2 in mice caused features of anemia, including iron deficiency associated with reduced apical membrane expression of DMT1. These findings identify an important role for PTPN2 in regulating systemic iron homeostasis.

Exploring the differences between percutaneous endoscopic gastrostomy and radiologically inserted gastrostomy tubes

Gastrostomy tubes are commonly used in people who are malnourished or at risk of malnutrition and require long-term artificial nutrition support but have a functional gastrointestinal tract. They generally provide a safe and effective access route for nutrition, hydration and medicine administration. This article describes the two main types of gastrostomy tubes seen in clinical practice, percutaneous endoscopic gastrostomy (PEG) tubes and radiologically inserted gastrostomy (RIG) tubes. The author explores the main differences between these tubes in terms of insertion technique, aftercare, replacement and removal, and outlines associated complications. To ensure patient safety and the delivery of high-quality care, it is essential that nurses involved in the care of patients with a PEG or RIG tube have a comprehensive understanding of these enteral feeding tubes and can recognise, and ideally prevent, potential complications.

Association Between 25-hydroxyvitamin D Levels and Adverse Pregnancy Outcomes in Systemic Lupus Erythematosus

OBJECTIVE

We evaluated the association of 25-hydroxyvitamin D (25(OH)D) levels with adverse pregnancy outcomes in systemic lupus erythematosus (SLE).

METHODS

The Hopkins Lupus Cohort includes visits of pregnant patients, including assessment of 25(OH)D levels at each visit. We examined the relationship between 25(OH)D levels and adverse pregnancy outcomes (miscarriage, preterm delivery, and small for gestational age). We also used a time-to-event analysis to assess whether time-varying of 25(OH)D levels were associated with time to miscarriage or preterm delivery.

RESULTS

In subgroups of patients defined by the average of 25(OH)D levels, we observed significantly different risks of miscarriage (P = 0.0045), preterm delivery (P = 0.0007), and the composite measure of all three adverse pregnancy outcomes (P = 0.011). The highest risks were observed among those with the lowest or highest levels of vitamin D. Nine of 10 pregnant patients with low vitamin D levels during the second trimester resulted in having a premature delivery. The time-to-event model confirmed the same U-shaped association after adjustment for SLE disease activity; however, the increased risk among those with highest levels of vitamin D was not statistically significant. Body mass index did not appear to be a confounding factor.

CONCLUSION

Our study is not able to prove causation, but the results strongly suggest an association of 25(OH)D at both lower and higher levels with adverse pregnancy outcomes. We recommend the monitoring of maternal serum 25(OH)D levels during SLE pregnancies, aiming for the ideal range of 40 to 59 ng/mL.

Emerging Technologies in Inflammatory Bowel Disease: A Minireview on Future Treatment Modalities

Inflammatory bowel disease (IBD) can present as either Crohn's disease or ulcerative colitis. Both phenotypes are inflammatory conditions of the gastrointestinal tract. Despite scientific advances, the overall incidence and morbidity of IBD continues to increase worldwide. Fortunately, we continue to develop novel therapies, in hopes of providing safer, more effective treatment options. Such therapies include cell therapy, exosome therapy, hyperbaric oxygen therapy, and central nerve stimulation. The aim of this review is to briefly highlight each of these novel therapeutic interventions as they relate to the treatment of IBD.

Zinc, copper, copper-to-zinc ratio, and other biometals in blood serum and tumor tissue of patients with colorectal cancer

The objective of the present study was to assess serum and cancerous tissue biometal levels in colorectal cancer (CRC) patients, and its relation to disease severity. A total of 90 CRC patients and 97 controls were involved in the present study. The level of biometals in blood serum and colon tissues (only in CRC cases) was evaluated by inductively-coupled plasma mass-spectrometry. CRC patients are characterized by lower serum Ca, Fe, Se, and Zn, as well as higher serum Co, Cu, Mg, V, and Cu/Zn ratio compared to healthy controls. The lowest serum Zn levels and the highest Cu concentration and Cu/Zn ratio were observed in patients with the largest tumor size. Regression analysis demonstrated that tumor size is a significant negative predictor of serum Se levels, being positively associated with serum Cu/Zn values. The degree of metastasis to regional lymph nodes was inversely associated with circulating Ca, Co, Mg, Zn, and Mn levels. Serum Mg and Mn levels were positively associated with the stage of the disease and tumor location, respectively. Cancerous tissue Ca and Mo levels were lower, while Mg content was higher compared to healthy adjacent tissues. In cancerous tissues a constant but non-significant trend to elevation of tissue Zn content with increasing tumor size was observed. In addition, serum Cu, Zn, and Cu/Zn values positively correlated with the respective tumor values. These findings demonstrate that altered biometal metabolism is associated with CRC, while systemic Cu/Zn ratio may be indicative of Cu and Zn imbalance in cancerous tissue.

Influence of gut microbiota on the pediatric endocrine system and associated disorders

The microbiota, a complex assembly of microorganisms residing in various body systems, including the gastrointestinal tract, plays a crucial role in influencing various physiological processes in the human body. The dynamic nature of gut microbiota is especially pronounced in children and is influenced by factors like breastfeeding and antibiotic use. Dysbiosis, characterized by alterations in microbiota composition or function, is associated with several pediatric endocrine disorders, such as precocious puberty, polycystic ovarian syndrome, and diabetes mellitus. This review focuses on the intricate relationship between gut microbiota and the pediatric endocrine system. The aim of this narrative review is to critically examine the existing literature to elucidate the impact of gut microbiota on the pediatric endocrine system and associated disorders. Additionally, potential interventions, such as probiotics and current gaps in knowledge, will be discussed. Despite emerging treatments like probiotics, further research is needed to understand and validate their effectiveness in treating pediatric endocrine disorders associated with dysbiosis.

[Position statement of the Spanish Society of Primary Care Physicians (SEMERGEN) and Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the management of inflammatory bowel disease in Primary Care]

Primary Care is the first point of contact for most patients after the onset of symptoms of inflammatory bowel disease (IBD). Establishing an initial diagnostic process based on compatible symptoms and agreed criteria and referral pathways, depending on the degree of suspicion and the patient's situation, can reduce diagnostic delays. Once the patient is referred to the Digestive specialist and the diagnosis of IBD is established, a treatment and follow-up plan is structured. The management of the patient must be shared with the participation of the family practitioners in the diagnosis and treatment of concomitant or intercurrent pathologies, the recognition of flare-ups or complications (of IBD or treatments), education tasks or adherence control. With the purpose of developing a comprehensive guide on the management of IBD aimed at Primary Care doctors, we have developed this positioning document collaboratively between the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU).

Plasminogen as a Marker for Assessing Thrombotic Risk During Hepatitis in Cameroon: Case-Control Study

Background and Aims

The liver synthesizes coagulation factors, anticoagulants, proteins involved in fibrinolysis, and the platelet production regulator, thrombopoietin, from megakaryocytes. Importantly, hepatic dysfunction that arises from hepatitis may perturb the clotting process. This study aims to determine these patients' plasminogen levels and hemostasis disorders to assess the thrombotic risk.

Methods

An analytical case-control study was carried out over 6 months. The study included hepatitis B, C, and D patients from Bafoussam Regional Hospital and Laquinitie Hospital in Douala-Cameroon, compared to healthy controls, to evaluate differences in hemostasis and thrombotic risk. Control tests were performed using the immunochromatographic and ELISA methods. Blood Count was performed by flow cytometry method. And determination of d-dimer and plasminogen by nephelometry and ELISA respectively; finally the evaluation of the enzymatic activity of alanine aminotransferase and aspartate aminotransferase (ALT and AST) by the spectrophotometric kinetic method. The results were recorded in an Excel spreadsheet and analyzed using the statistical software R version 4.1.1.

Results

The population size was 340 participants including 162 controls (47.7%) and 178 (52.3%) cases of which 136 cases of hepatitis B (76.4%), 26 cases of hepatitis C (14.6%), and 16 cases of hepatitis D (9%). The sex ratio was 3.15 in favor of men; including 1.7 in cases and 9.1 in controls. All patients had a thrombotic risk characterized by a decrease in plasminogen levels compared to controls (p < 0.001). 13.5% of the population had thrombocytopenia compared to none among controls (p < 0.001). The following parameters are associated with risk of developing thrombosis in this study in particular Hepatitis (aOR = 3; 95% CI [1.01-5.2]; p < 0.03), plasminogen decrease (aOR = 3; 95% CI [1.01-5.2]; p < 0.03), shortening cephalin time activator (CTA) (aOR = 1.5; 95% CI [1.1-5.2]; p < 0.04), and decreased hemoglobin (aOR = 2.1; 95% CI [1.1-5.1;]; p < 0.03).

Conclusion

This study shows a decrease in plasminogen in patients during hepatitis. It suggests it is an important element to evaluate the thrombotic risk although the exploration of other coagulation tests should be associated with it for a complete and exhaustive evaluation and a better final diagnosis.

Surveillance and Management of Dysplasia and Malignancy in Inflammatory Bowel Disease

The paradigm for surveilling and managing inflammatory bowel disease-associated colorectal dysplasia has changed as high-definition colonoscopy and chromoendoscopy have significantly improved the visualization of dysplasia, and endoscopic mucosal resection has made more lesions endoscopically resectable. However, these patients are at high risk of recurrent dysplasia and cancer and require intensive colonoscopic surveillance. Patients with invisible high-grade dysplasia, invisible multifocal low-grade dysplasia, and colorectal cancer should be considered for surgical resection. Total proctocolectomy removes all at-risk tissue. Subtotal colectomy with ileorectal anastomosis can be considered in select patients (ie, advanced age, poor functional status, and with no rectal inflammation or dysplasia).