Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Additional Yield of Random Biopsy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

There are limited clinical data regarding the additional yields of random biopsies (RBs) during colorectal cancer surveillance in patients with inflammatory bowel disease. To assess the additional yield of RB, a systematic review and meta-analysis was conducted.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies investigating the preferred colonoscopy surveillance approach for inflammatory bowel disease patients. The additional yield, detection rate, procedure time, and withdrawal time were pooled.

RESULTS

Thirty-seven studies (48 arms) were included in the meta-analysis with 9051 patients. The additional yields of RB were 10.34% in per-patient analysis and 16.20% in per-lesion analysis. The detection rates were 1.31% and 2.82% in per-patient and per-lesion analysis, respectively. Subgroup analysis showed a decline in additional yields from 14.43% to 0.42% in the per-patient analysis and from 19.20% to 5.32% in the per-lesion analysis for studies initiated before and after 2011. In per-patient analysis, the additional yields were 4.83%, 10.29%, and 56.05% for primary sclerosing cholangitis (PSC) proportions of 0% to 10%, 10% to 30%, and 100%, respectively. The corresponding detection rates were 0.56%, 1.40%, and 19.45%. In the per-lesion analysis, additional yields were 11.23%, 21.06%, and 45.22% for PSC proportions of 0% to 10%, 10% to 30%, and 100%, respectively. The corresponding detection rates were 2.09%, 3.58%, and 16.24%.

CONCLUSIONS

The additional yields of RB were 10.34% and 16.20% for per-patient and per-lesion analyses, respectively. Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating RB in the standard colonoscopy surveillance for inflammatory bowel disease patients, especially in those with PSC.

What is first-line and what is second-line therapy in adult patients with moderate to severe Crohn's disease?

Crohn's disease, a chronic inflammatory bowel disease, necessitates a comprehensive treatment approach tailored to the individual's specific disease characteristics and overall health. Treatment strategies aim to induce and maintain remission, alleviate symptoms, normalize biomarkers, improve the endoscopic appearance of the intestine, and improve quality of life. Key therapeutic options include pharmacotherapy, featuring corticosteroids, immunomodulators, monoclonal antibodies, and more recently Janus Kinase inhibitors (JAKi) which target different mechanisms of inflammation. Additionally, surgical interventions may be required for complications or when medical therapy fails. The recent introduction of novel therapies, such as the interleukin-23 (IL-23) anti-p19 inhibitor risankizumab and the selective JAKi upadacitinib, raises pertinent questions regarding the optimal sequencing of advanced therapeutic options. This review evaluates current data to address these questions and reflects the author's perspectives based on a presentation at the 27th Annual University of Manitoba Key Topics in Gastroenterology 2024.

Biological agents as attractive targets for inflammatory bowel disease therapeutics

Inflammatory bowel disease (IBD) refers to a group of chronic, recurrent intestinal inflammatory conditions with a complex cause and unclear underlying mechanisms. It includes two main types: Ulcerative colitis (UC) and Crohn's disease (CD). The conventional treatment of IBD mainly includes 5-aminosalicylates, glucocorticoids, and immunosuppressive drugs, which have their limitations. Recent advancements in IBD research have expanded treatment options, with biological agents playing a key role. Anti-tumor necrosis factor alpha has emerged as the first-line therapy for moderate to severe IBD. Anti-integrin antibodies have also become important for the treatment, and vedolizumab is often used in cases of anti-tumor necrosis factor-alpha failure and intolerance to other treatments. Other biological agents are being tested in clinical trials at different stages. This article reviews the efficacy and safety of the primary biological therapies for IBD and provides a comprehensive analysis of the current clinical challenges associated with the disease.

Approach to anaemia in gastrointestinal disease: A position paper by the ESPGHAN Gastroenterology Committee

Anaemia is a frequent consequence of many gastrointestinal (GI) diseases in children and it can even be the initial presenting symptom of underlying chronic GI disease. The definition of anaemia is age and gender-dependent and it can be classified based on pathophysiology, red cell morphology, and clinical presentation. Although nutritional deficiencies, including GI malabsorption of nutrients and GI bleeding, play a major role, other pathophysiologic mechanisms seen in chronic GI diseases, whether inflammatory (e.g., inflammatory bowel disease) or not (e.g., coeliac disease and dysmotility), are causing anaemia. Drugs, such as proton pump inhibitors, mesalamine, methotrexate and sulfasalazine, are also a potential cause of anaemia. Not uncommonly, due to a combination of factors, such as iron deficiency and a chronic inflammatory state, the underlying pathophysiology may be difficult to decipher and a broad diagnostic work-up is required. The goal of treatment is correction of anaemia by supplementation of iron and vitamins. The first therapeutic step is to treat the underlying cause of anaemia including bleeding control, restoration of intestinal integrity and reduction of inflammatory burden. The route of iron and vitamin supplementation is guided by the severity of anaemia.

Vitamin D and its analogs in immune system regulation

Vitamin D was discovered as the cure for nutritional rickets, a disease of bone growth arising from inadequate intestinal calcium absorption, and for much of the 20th century, it was studied for its critical role in calcium homeostasis. However, we now recognize that the vitamin D receptor and vitamin D metabolic enzymes are expressed in numerous tissues unrelated to calcium homeostasis. Notably, vitamin D signaling can induce cellular differentiation and cell cycle arrest. Moreover, the vitamin D receptor and the enzyme CYP27B1, which produces the hormonal form of vitamin D, 1,25-dihydroxyvitamin D (1,25D), are expressed throughout the immune system. In addition, CYP27B1 expression in immune cells is regulated by physiological inputs independent of those controlling its expression in calcium homeostatic tissues. These observations have driven the development of 1,25D-like secosteroidal analogs and nonsecosteroidal analogs to separate the effects of vitamin D on cell differentiation and function from its calcemic activities. Notably, some of these analogs have had considerable success in the clinic in the treatment of inflammatory and immune-related disorders. In this review, we described in detail the mechanisms of vitamin D signaling and the physiological signals controlling 1,25D synthesis and catabolism, with a focus on the immune system. We also surveyed the effects of 1,25D and its analogs on the regulation of immune system function and their implications for human immune-related disorders. Finally, we described the potential of vitamin D analogs as anticancer therapeutics, in particular, their use as adjuncts to cancer immunotherapy. SIGNIFICANCE STATEMENT: Vitamin D signaling is active in both the innate and adaptive arms of the immune system. Numerous vitamin D analogs, developed primarily to minimize the dose-limiting hypercalcemia of the active form of vitamin D, have been used widely in preclinical and clinical studies of immune system regulation. This review presents a description of the mechanisms of action of vitamin D signaling, an overview of analog development, and an in-depth discussion of the immunoregulatory roles of vitamin D analogs.

Preoperative intravenous versus oral iron supplementation for elective surgery: evidence based on 12 randomized trials

AIM

This study aims to clarify hematological parameters, transfusion requirements, and adverse events of preoperative intravenous (IVIS) versus oral iron supplementation (OIS) in elective surgery patients.

METHODS

We conducted a comprehensive literature search across multiple databases up to 10 December 2023. Twelve RCTs involving 930 participants met our eligibility criteria. Our analysis focused on post-treatment hemoglobin levels, changes in hemoglobin from baseline, ferritin levels, hemoglobin attainment rates, transfusion requirements, and adverse events. We employed the random-effects model for data synthesis, calculating pooled standard mean differences (SMD) or mean differences (MD) or risk ratios (RR) with 95% confidence intervals (CI). Methodological quality was assessed using the Cochrane ROB 2 tool. The GRADE approach evaluated the confidence in effect estimates.

FINDINGS

IVIS significantly improved post-treatment hemoglobin levels (MD = 0.77 g/dL, 95% CI [0.30 to 1.23]), hemoglobin increments (MD = 0.69 g/dL, 95% CI [0.01 to 1.37]), and ferritin levels (MD = 260.03 ng/mL, 95% CI [119.65 to 400.42]) compared to OIS. IVIS also led to a higher hemoglobin attainment rate (RR = 1.88, 95% CI [1.24 to 2.86]). No significant differences were noted in transfusion rates or volumes. IVIS was associated with fewer digestive (RR = 0.10, 95% CI [0.05 to 0.22]; I2 = 0%) but more pain-related adverse events (RR = 7.79, 95% CI [1.78 to 34.07]; I2 = 0%). Hospital stay durations and mortality rates were similar between the two groups.

INTERPRETATION

IVIS offers a superior improvement in hematological parameters for elective surgery patients but not reducing transfusion needs compared to OIS. While IVIS has fewer digestive adverse events, it increases pain-related complications. These findings highlight the importance of personalized approaches in selecting iron supplementation methods, carefully balancing time, efficacy, and adverse event profiles.

REGISTRATION

PROSPERO CRD42023483284.

Clinical effectiveness and safety of ustekinumab in youth with refractory inflammatory bowel disease: A retrospective cohort study

BACKGROUND

Inflammatory bowel disease (IBD) incidence and prevalence has been increasing worldwide. Limited data exists on the effectiveness of ustekinumab (UST) in children. We aimed to describe the effectiveness and safety of UST in pediatric patients with IBD.

METHODS

A single-center retrospective study was conducted between January 2017 and February 2022. The study included patients ≤16 years of age who were treated with UST and followed up for ≥1 year. Clinical remission was defined as a score of the Pediatric Crohn's Disease (CD) and Pediatric Ulcerative Colitis (UC) Activity Indices ≤10 at week 52.

RESULTS

Thirteen patients who had failed anti-tumor necrosis factor-α (anti-TNFα) therapy were included, eight (61.5%) with CD and five (38.5%) with UC. The median age was 13 years (interquartile range [IQR]: 11.5 to 14). UST treatment was initiated at a median age of 3 years (IQR: 2.3 to 7) after diagnosis. Ten patients (76.9%) achieved clinical remission. There were no statistically significant differences in characteristics between patients who achieved and did not achieve clinical remission. Biochemical remission (BioR) was achieved in six patients (46.2%). Body mass index (BMI) significantly improved, C-reactive protein (CRP) significantly decreased, and the need for corticosteroids significantly decreased in the remission group. Endoscopy conducted post-treatment in seven patients confirmed remission in six patients. Adverse events included two cases of infection and one of headache.

CONCLUSIONS

UST was effective as a secondary biologic therapy for the induction and maintenance of remission in patients with anti-TNFα refractory IBD. At one year, 84% of patients remained on UST with no severe adverse reactions reported.

[Position paper of the Society for Paediatric Gastroenterology and Nutrition (GPGE) on the off-label use of biologics and signal inhibitors in children and adolescents with IBD that have already been approved for adults]

Therapy for children and adolescents with chronic inflammatory bowel disease (IBD) is basically no different from that for adult patients. However, of the steadily increasing number of biologics and signalling inhibitors for adults, only two TNFα antibodies are currently approved in Germany for the treatment of IBD from the age of 6. This means that a large proportion of the drugs authorised for adults with IBD are not available for children and adolescents with moderate to severe disease. The small number of approved drugs also makes it difficult to achieve the prognostically important goal of achieving a sustained remission of IBD soon after diagnosis, which is characterised by the patient being free of symptoms and also the objectifiable goal of mucosa healing. This position paper is intended to present the current study situation on the drug treatment of children and adolescents with IBD outside the age limit and to serve as a basis for information and decision-making for the Medical Service in the assessment of individual case applications as well as for the treating physicians, the cost bearers, health policy and social court decision-makers.

Forty-eight months outcomes of teduglutide treatment in adult stable patients with short bowel syndrome and home parenteral nutrition dependence: A real-world Italian single-center observational cohort study

AIM OF THE STUDY

This real-life study is designed to investigate the short and long-term efficacy and safety of teduglutide (TED) and its effects on the quality of life (QoL) in a cohort of adult, stable patients with short bowel syndrome and chronic intestinal failure receiving long-term parenteral support (PS).

PATIENT AND METHODS

A prospective, single-center study was conducted for individuals who began to take TED between March 2017 and August 2023.

RESULTS

Ten patients were included in the analysis, among whom the median duration of TED administration was 48 (range, 12-71) months. Data relative to short-term clinical outcomes demonstrate that 4 of 10 (40%) patients were early responders to TED therapy, defined as a >20% reduction in PS requirement at 3 months. Six of the 10 (60%) were non-responders. Data relative to 48 months long-term clinical outcomes demonstrated the absence of late responder patients and underline that all 4 early TED responder patients continued to maintain a sustained reduction in PS. Indeed, two of the 4 patients (50%) responding to TED discontinued PS while the other 2 patients (50%) reduced the number of weekly PS infusions by approximately 50%. The physical and mental components of the QoL improved significantly (P < 0.05) in responsive patients but did not change in non-responsive ones. Predictability of response to TED therapy in this study seemed to be linked to 1) SBS type 3, which was completely absent in the non-responder patients (P < 0.0001), 2) the residual small bowel length was significantly (P < 0.02) higher in responder (102 ± 18 cm) compared to non-responder patients (67 ± 27 cm), and 3) SBS type 1 and 2, enterostomy, surgical complications are significantly predictive of no response. Crohn's disease is equally present in both responder and non-responder patients. The number of side effects observed in our experience was extremely small both at the 3rd (0.01 n°/d/patients) and at the 48th month (0.001 n°/d/patients). No endoscopic neoplastic lesions were observed up to the 48th month of TED therapy.

CONCLUSIONS

This real-world experience allows us to state that, after 48 months of treatment, TED: 1) is a safe therapy with minimal, rare side effects; 2) produces a rapid reduction in PS volumes in 40% of treated patients; 3) consents 20% of enrolled patients to be weaned off PS; 4) maintains a stable nutritional state and, finally, 5) significantly improves the QoL.

Assessment and management for latent tuberculosis before advanced therapies for immune-mediated inflammatory diseases: A comprehensive review

Tuberculosis (TB), caused by Mycobacterium tuberculosis , is the most significant infectious cause of mortality across the globe. While TB disease can prey on immunocompetent individuals, it is more likely to occur in immunocompromised individuals. Immune-mediated inflammatory diseases (IMIDs) are a group of diseases (rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis, psoriasis, hidradenitis suppurativa, autoimmune blistering diseases, and others) where there may be a need for systemic immunosuppression to control the disease manifestations, treat symptoms and improve long term outcomes. Immunosuppression may predispose them to active TB either from recent infection or reactivation of Latent TB (LTB). The major determinants of reactivation include the type of therapy (highest risk with TNF inhibitors and JAK inhibitors) and the underlying TB endemicity. The strategy to avoid TB reactivation includes the detection of LTB using tests that detect immunoreactivity to TB antigens (interferon-gamma release assays or tuberculin skin test) and treating LTB before or with initiation of IMID therapies. Available diagnostic tests have deficiencies in diagnostic sensitivity to detect LTB and even worse capability in predicting reactivation of TB. In addition to immunological tests, more stringent testing strategy utilizing one or many LTB equivalents may point towards subclinical TB. LTB equivalents include clinical (past history of TB, recent exposure to TB) and radiological criteria (use of chest roentgenogram, computed tomography, or, sometimes positron emission tomography - computed tomography). The present review summarizes the risk factors for TB reactivation in patients initiated on advanced therapies, geographically appropriate strategies for LTB testing, and treatment of LTB.

Proximal small intestinal bypass outperforms Roux-en-Y and jejunoileal bypass in glucose regulation in streptozotocin induced diabetic rats

BACKGROUND

The efficacy of various bariatric surgeries varies in reducing blood glucose levels. Given the distinct mechanisms and anatomical alterations associated with each procedure, it is crucial to compare their glycemic control outcomes. We hypothesize that proximal small intestinal bypass (PSIB) is superior in blood glucose reduction over Roux-en-Y gastric bypass (RYGB) and jejunoileal bypass (JIB).

AIM

To compare the effectiveness of PSIB, RYGB, and JIB in lowering blood glucose.

METHODS

Rats with streptozotocin-induced diabetes were randomly divided into PSIB, RYGB, JIB, and sham-operated groups. Body weight, food intake, fasting blood glucose level, oral glucose tolerance test, insulin tolerance test, liver enzymes, and blood lipids were measured.

RESULTS

Postoperatively, only the JIB group had a lower body weight compared to the sham group. The food intake of the rats in all three surgical groups was significantly less than that in the sham group. Fasting blood glucose was reduced in all surgical groups and was lower in the PSIB group than in the RYGB and JIB groups. Glucose tolerance and insulin sensitivity improved in all three surgical groups compared to the sham group, but the improvement appeared earliest in the PSIB group. At six weeks post-surgery, the PSIB group showed a reduction in alanine transaminase levels and maintained a normal lipid profile.

CONCLUSION

PSIB demonstrated excellent hypoglycemic effects in the early postoperative period, and had better efficacy than RYGB and JIB.

Azathioprine and 6-mercaptopurine for maintenance of remission in ulcerative colitis

BACKGROUND

Maintenance of remission is essential in inflammatory bowel disease (IBD) in terms of disease course and long-term prognosis. The thiopurines azathioprine and 6-mercaptopurine have longstanding merit in ulcerative colitis, but more therapeutic options have been developed. This review is an update and extension of a review last published in 2016.

OBJECTIVES

To assess the effectiveness and safety of azathioprine and 6-mercaptopurine in monotherapy or combined therapy regimens compared to placebo or active controls for the maintenance of remission in ulcerative colitis.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (until May 2023), ClinicalTrials.gov (until May 2023), Embase (until August 2022), MEDLINE (until May 2023), and WHO ICTRP (until May 2023). We checked reference lists of the included studies and, if needed, contacted the authors to request more data or information.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of at least 24 weeks' duration comparing azathioprine or 6-mercaptopurine with placebo or any other medication, or comparing different treatment modalities of azathioprine or 6-mercaptopurine, in persons of any age with quiescent ulcerative colitis were eligible. We only considered studies with mixed IBD populations or with a preceding induction period if separate results on participants with ulcerative colitis in remission were available or could be calculated. The primary outcome was failure to maintain clinical or endoscopic remission (relapse). Secondary outcomes included change in disease activity, quality of life, hospitalization, need for surgery, days off work, adverse events, and withdrawal due to adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data using standard forms, resolved any disagreements by consensus, and assessed study quality using the Cochrane risk of bias tool (RoB 2). We conducted separate analyses by type of control, calculated pooled risk ratios (RRs) or risk differences (RDs) using the fixed-effect model unless heterogeneity was likely, and assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies in the review, including 468 adult participants with ulcerative colitis. The risk of bias across these was low for most outcomes, but we considered some outcomes to have some concerns or high risk of bias due to insufficient information on concealment of allocation and outcome measurement. Based on five placebo-controlled studies, azathioprine or 6-mercaptopurine may reduce the risk of failing to maintain remission. In the thiopurine group, 45% (64/143) of participants failed to maintain remission compared to 67% (96/143) of participants receiving placebo (RR 0.66, 95% confidence interval (CI) 0.54 to 0.82; 5 studies, 286 participants; low-certainty evidence). Three studies reported withdrawals due to adverse events. Among participants on azathioprine, 4% (3/80) withdrew due to adverse events compared to 0% (0/82) of placebo participants (RD 0.04, 95% CI -0.02 to 0.09; 3 studies, 162 participants; low-certainty evidence). The evidence is of low certainty when comparing 6-mercaptopurine to 5-aminosalicylate. Based on one three-armed trial, 27% (3/11) of 6-mercaptopurine participants failed to maintain remission compared to 100% (2/2) of 5-aminosalicylate participants (RR 0.35, 95% CI 0.13 to 0.97; 1 study, 13 participants; low-certainty evidence). This trial also involved an induction phase; we only included the results for participants in remission. The single trial comparing 6-mercaptopurine to 5-aminosalicylate did not report separate data on adverse events and withdrawals due to adverse events for the subgroup with successful induction of remission, so we could not analyze these outcomes for this comparison.

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that azathioprine or 6-mercaptopurine therapy may be more effective than placebo for the maintenance of remission in ulcerative colitis. More research is needed to evaluate the value of therapeutic drug monitoring and the effects of various treatment modalities on long-term safety.

Preparation technologies, structural characteristics and biological activities of polysaccharides from bee pollen: A review

Bee pollen, a natural honeybee product, is hailed as a treasure trove of human nutrition. Among the nourishing substances of bee pollen, the constituents with a low molecular weight (such as phenolic acids and flavonoid glycosides) have been extensively studied in the past decades, whereas the polysaccharides with a relatively high molecular weight have received much less attention. To deepen our understanding of bee pollen polysaccharides, this review summarizes the published findings related to their preparation technologies, structural characteristics and biological activities. Among the preparation technologies, ultrasonic-assisted extraction is currently the most effective technology for the recovery of polysaccharides from bee pollen, because ultrasound can crack the pollen exine into fragments and facilitate the release of polysaccharides present in the pollen intine. The preliminary structures, including the molecular weight and monosaccharide composition, of bee pollen polysaccharides have been widely reported, but their fine structures have not fully elucidated. Moreover, bee pollen polysaccharides have antioxidant, immunomodulatory, and antitumor activities, exhibiting potential application in functional foods. Furthermore, bee pollen polysaccharides can modulate the composition of gut microbiota and promote the production of short-chain fatty acids. It is expected that this review can provide inspiration for the development and utilization of bee pollen polysaccharides.

Nutrition Support Therapy for Hospitalized Children with Malnutrition: A Narrative Review

Nutrition support is essential to improve clinical outcomes and prevent malnutrition-related complications in hospitalized children. This review aims to explore the latest international guidelines and recommendations for nutrition support therapy over the last decade. Many organizations and pediatric societies emphasize the importance of nutrition support therapy and the critical role of nutrition support teams in assessing and managing malnutrition, particularly after screening patients who are at high risk. Although current recommendations address gaps in clinical practice related to nutrition support, minor differences remain across guidelines due to geographical variations among these societies. A unified approach to implementing nutrition support therapy from admission to discharge, with a clear pathway and the involvement of competent healthcare providers, is needed in all healthcare settings. Furthermore, more in-depth systematic reviews, meta-analyses, and consensus statements that integrate guidelines from all societies are required. Such efforts would better support healthcare providers in aligning clinical practices with the highest standards of care.

The role of immunogenicity in optimizing biological therapies for inflammatory bowel disease

INTRODUCTION

Immunogenicity of biologic agents for inflammatory bowel disease (IBD) is a critical issue, especially for tumor necrosis factor (TNF) inhibitors, where anti-drug antibodies (ADAs) significantly impact drug clearance, efficacy, and safety. Studies have demonstrated that non-TNF biologics tend to have lower susceptibility to immunogenicity, potentially offering advantages, especially in long-term management. Understanding these differences is important for optimizing IBD treatment outcomes.

AREAS COVERED

This review examines immunogenicity associated with different classes and individual biologic agents used in IBD; including TNF inhibitors and biologics targeting integrins and interleukins. We discuss key factors influencing ADAs formation, including drug structure, route of administration, and patient-specific factors. The literature reviewed includes recent clinical studies and long-term trials focusing on strategies to reduce immunogenicity such as therapeutic drug monitoring (TDM) and advanced combination.

EXPERT OPINION

While newer biologics demonstrate lower immunogenicity compared to anti-TNF agents, challenges remain in management to overcome existing ADAs responses while advances in genetic profiling, point-of-care TDM, and combination therapies offer promising pathways to reduce immunogenicity and enhance treatment durability. Continued research and innovation in biologic delivery methods, such as oral and subcutaneous formulations, will be critical in the next decade to further mitigate immunogenic risks and improve patient outcomes.

Analytical evaluation of eight qualitative FIT for haemoglobin products, for professional use in the UK

OBJECTIVES

Qualitative faecal immunochemical tests for haemoglobin (FIT), for triaging for colorectal cancer investigations, are available for professional use. The aim was to evaluate these lateral flow tests. No previous analytical evaluations have been published.

METHODS

Analytical sensitivity (AS) was assessed using samples spanning manufacturers' quoted AS, concurrently with the quantitative OC-SENSOR PLEDIA, using Hb-spiked samples in manufacturers' buffer (n≥5; ≤9-99 ng Hb/mL buffer), Hb-spiked feces (n=6; <2-34 µg Hb/g feces) and natural feces (n=17; <2-82 μg/g); concentrations for 50 %/100 % Hb-detected were compared with quoted AS. Compatibility with two external quality assessment schemes (EQAS) (n=9; 3-96 μg/g) and prozone compared with manufacturers limits (n=9; 2,500-10,000,000 ng/mL) were tested. Ease-of-use by five healthcare personnel was assessed.

RESULTS

Seven products showed lower AS (ng/mL) than manufacturers quoted using Hb-spiked aqueous samples compared with OC-SENSOR, one was equivocal; six manufacturers quoted AS in µg/g, five showed lower AS using Hb-spiked feces. Results were similar but less consistent for natural feces. Result lines for low concentrations can be faint and open to interpretation. Results were consistent with manufacturers quoted prozone limits. Results were consistent for seven products for two EQAS. The ease-of-use was 68.5-85.6 %; products with lower scores could be improved with better instructions and sample bottles.

CONCLUSIONS

AS was lower for seven products (aqueous samples) and five products (aqueous/faecal samples) and prozone consistent with manufacturers expected concentrations, compared with OC-SENSOR. EQAS results were mostly consistent with expected results; products can be used by healthcare professionals, though some manufacturer improvements could be made.

Progressing advanced therapies for inflammatory bowel disease: Current status including dual biologic therapy and discontinuation of biologics

INTRODUCTION

Advanced therapies (ADT) that encompass biological agents and small molecules have been approved for the treatment of inflammatory bowel disease (IBD), broadening the spectrum of available treatment options. Nevertheless, a substantial proportion of patients fail to achieve satisfactory responses, necessitating surgical intervention. Treatment objectives have evolved beyond clinical remission, reduction of inflammation, and mucosal healing, shifting focus toward enhancing the quality of life, acknowledging the profound impact of IBD on physical and mental well-being.

AREA COVERED

This comprehensive review describes the current landscape of ADT for IBD, including dual biologic therapy (DBT), which involves the combination of two biologics or a single biologic with a small-molecule compound, as well as considerations surrounding the discontinuation of biologics.

EXPERT OPINION

ADT is the standard treatment for moderate to severe IBD, while DBT appears promising for specific subsets of patients, including those with refractory disease or extraintestinal manifestations. However, these approaches may increase the risk of adverse effects, including malignancy. To optimize individualized treatment strategies in patients with refractory IBD, further trials are needed to refine ADT's predictive value, establish DBT's safety and indications, define biologic discontinuation criteria, and evaluate emerging biomarkers, artificial intelligence, and bowel ultrasound in patient management.

Comparison of intestinal microbes and metabolites in active VKH versus acute anterior uveitis associated with ankylosing spondylitis

BACKGROUND

It has been reported that the gut microbiome is involved in the pathogenesis of uveitis, but the specific pathogenic microbes and metabolites in different types of uveitis are still unclear.

METHODS

Microbiome and metabolites were detected using 16S ribosomal DNA and LC‒MS/MS (liquid chromatography tandem mass spectrometry) in 45 individuals, including 16 patients with Vogt Koyanagi Harada (VKH), 11 patients with acute anterior uveitis (AAU) and 18 healthy controls.

RESULT

The diversity of intestinal microbes among the VKH, AAU and control groups was not significantly different. Thirteen specific microbes and 38 metabolites were detected in the VKH group, and 7 metabolites (vanillin, erythro-isoleucine, pyrimidine, 1-aminocyclopropanecarboxylic acid, beta-tocopherol, (-)-gallocatechin and N1-methyl-4-pyridone-3-carboxamide) significantly changed only in patients with VKH, which mainly acted on nicotinamide and nicotinamide metabolism and biotin metabolism (p<0.05). Compared with the VKH group, the AAU group had milder intestinal changes. Only 11 specific microbes and 29 metabolites changed in the AAU group, while these metabolites were not specific (p<0.05). These metabolites mainly acted on arachidonic acid metabolism. In addition, three microbes and two metabolites had the same changes in the VKH and AAU groups (p<0.05). Multiple correlations were found between gut microbes and metabolites in the VKH and AAU groups. Six microbes (Pediococcus, Pseudomonas, Rhodococcus, Photobacterium, Gardnerella and Lawsonia) and two metabolites (pyrimidine and gallocatechin) as biomarkers could effectively distinguish patients with VKH from patients with AAU and healthy individuals, with AUC (area under the curve) values greater than 82%. Four microbes (Lentilactobacillus, Lachnospiraceae_UCG-010, Cetobacterium, Liquorilactobacillus) could distinguish patients with AAU from patients with VKH and healthy controls with AUC>76%.

CONCLUSION

Significant differences in intestinal microbes and metabolites suggest their different roles in the pathogenesis of uveitis entities. Changes in the metabolism of certain B vitamins may be involved in the pathogenesis of VKH.

Investigating intestinal epithelium metabolic dysfunction in celiac disease using personalized genome-scale models

BACKGROUND

Celiac disease (CeD) is an autoimmune condition characterized by an aberrant immune response triggered by the ingestion of gluten, which damages epithelial cells lining the small intestine. Small intestinal epithelial cells (sIECs) play key roles in the enzymatic digestion and absorption of nutrients, maintaining gut barrier integrity, and regulating immune response. Chronic inflammation and tissue damage associated with CeD disrupt the intricate network of metabolic processes in sIECs that support these functions, impairing their ability to perform their essential roles. However, the specific disrupted metabolic processes underlying sIECs dysfunction in CeD remain largely undefined.

METHODS

To address this knowledge gap, personalized, sex-specific genome-scale models of sIECs metabolism were constructed using transcriptional data from intestinal biopsies of 42 subjects with active CeD, CeD in remission (on a gluten-free diet), and non-CeD controls. These models were computationally simulated under relevant dietary conditions for each group of subjects to assess the activity of several metabolic tasks essential for sIECs function and to profile metabolite secretion into the bloodstream and intestinal lumen.

RESULTS

Significant alterations in the activity of 28 essential metabolic tasks were observed in active CeD and remission CeD, impacting critical processes integral to sIECs function such as oxidative stress regulation, nucleotide synthesis and DNA repair, energy production, and polyamine and amino acid metabolism. Additionally, altered secretion profiles of several metabolites, encompassing amino acids, vitamins, polyamines, lipids, and fatty acids, into the bloodstream were detected in active CeD and remission CeD patients. These findings were partially supported by comparisons with independent external datasets and further corroborated through extensive review of existing literature. Furthermore, a drug target analysis was performed, identifying 22 FDA-approved drugs that target genes encoding impaired sIECs metabolic functions in CeD, potentially helping to restore their normal activity.

CONCLUSIONS

This study unveils new insights into the metabolic reprogramming of sIECs in CeD, highlighting specific dysregulated metabolic processes that compromise cellular functions essential for gut health. These findings offer a foundation for developing therapeutic interventions targeting impaired metabolic processes in CeD.

Incidence of dysphagia-related safety incidents in older adults across feeding methods: A systematic review and meta-analysis

OBJECTIVE

Dysphagia-related safety incidents encompass near-miss events, no-harm occurrences, or harmful incidents associated with oral or enteral feeding methods. This systematic review and meta-analysis aimed to assess the incidence rates of dysphagia-related safety incidents in older adults across various feeding methods.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and CINAHL databases to identify studies reporting dysphagia-related safety incidents in older adults. The feeding methods analyzed included oral feeding, nasogastric (NG) tube feeding, and percutaneous endoscopic gastrostomy (PEG) tube feeding. Randomized controlled trials (RCTs), non-randomized studies, and cohort studies were included. The analysis adhered to the PRISMA guidelines, and meta-analytic outcomes were presented with 95% confidence intervals (CIs).

RESULTS

A total of 30 studies satisfied the inclusion criteria. The overall incidence rates of safety incidents were 13.8% for oral feeding, 23.9% for NG tube feeding, and 26.5% for PEG tube feeding. Aspiration pneumonia emerged as the most prevalent safety incident across all feeding methods, with incidence rates of 12.0% for oral feeding, 20.6% for NG tube feeding, and 12.4% for PEG tube feeding. Tube feeding methods were associated with diarrhea and wound infection. Additionally, specialized safety incidents were observed for each feeding method: suffocation in oral feeding; gastroesophageal reflux in NG tube feeding; and tube blockage, tube dislodgment, tube leakage, vomiting, nausea, site pain, gastrointestinal hemorrhage, and peritonitis in PEG tube feeding.

CONCLUSIONS

Dysphagia-related safety incidents in older adults demonstrated considerable variability in type and frequency across different feeding methods. Understanding these differences could provide healthcare professionals with valuable insights for targeted risk prediction and proactive management strategies to mitigate such incidents.

Genomics-Informed Drug Repurposing Strategy Identifies Novel Therapeutic Targets for Metabolic Dysfunction-Associated Steatotic Liver Disease

Identification of drug-repurposing targets with genetic and biological support is an economically and temporally efficient strategy for improving treatment of diseases. We employed a cross-disciplinary approach to identify potential treatments for metabolic dysfunction associated steatotic liver disease (MASLD) using humans as a model organism. We identified 212 putative causal genes associated with MASLD using data from a large multi-ancestry genetic association study, of which 158 (74.5%) are novel. From this set we identified 57 genes that encode for druggable protein targets, and where the effects of increasing genetically predicted gene expression on MASLD risk align with the function of that drug on the protein target. These potential targets were then evaluated for evidence of efficacy using Mendelian randomization, pathway analysis, and protein structural modeling. Using these approaches, we present compelling evidence to suggest activation of FADS1 by icosopent ethyl as well as S1PR2 by fingolimod could be promising therapeutic strategies for MASLD.

Effectiveness of biologics for endoscopic healing in patients with isolated proximal small bowel Crohn's disease

BACKGROUND

Endoscopic healing (EH) is a key therapeutic target in Crohn's disease (CD). Proximal small bowel (SB) lesions in patients with CD are associated with a significant risk of strictures and bowel resection. Assessing SB in patients with CD is necessary because of its significant therapeutic implications. The advent of biologic therapies, including infliximab, ustekinumab, and vedolizumab, has significantly altered CD treatment. However, data on the efficacy of biologics in achieving EH, specifically in the proximal SB of patients with CD, remain limited.

AIM

To assess the effectiveness of biologics for EH in patients with jejunal and/or proximal ileal CD.

METHODS

Between 2017 and 2023, we retrospectively included 110 consecutive patients with isolated proximal SB CD, identified through baseline balloon-assisted enteroscopy. These patients completed 1-year of treatment with infliximab, ustekinumab, or vedolizumab, and underwent a second balloon-assisted enteroscopy at 1 year. Complete EH was defined as a modified Simple Endoscopic Score for CD (SES-CD) of < 3, while EH of the jejunum and proximal ileum was defined as a segmental modified SES-CD of 0.

RESULTS

In total, 64 patients were treated with infliximab, 28 with ustekinumab, and 18 with vedolizumab. The complete EH rate at 1 year was 20.9% (23/110), with 29.6% (19/64) for infliximab, 10.7% (3/28) for ustekinumab, and 5.5% (1/18) for vedolizumab. The median modified SES-CD significantly decreased compared to baseline [5 (2-8) vs 8 (6-9), P < 0.001]. The jejunal and proximal ileal EH rates at 1 year were 30.8% (12/39) and 15.5% (16/103), respectively. Multiple logistic regression analysis showed that stricturing or penetrating disease [odds ratio (OR) = 0.261, 95%CI: 0.087-0.778, P = 0.016], prior exposure to biologics (OR = 0.080, 95%CI: 0.010-0.674, P = 0.020), and moderate-to-severe endoscopic disease (OR = 0.277, 95%CI: 0.093-0.829, P = 0.022) were associated with a lower likelihood of achieving EH at 1 year.

CONCLUSION

Only 20.9% of patients with isolated proximal SB CD achieved complete EH after 1 year of biologic therapy.

Natural Polyamine Spermidine Inhibits the In Vitro Oxidation of LDL

Spermidine is a natural autophagy-inducer and anti-aging compound. Herein, we investigated a potential autophagy-independent mechanism of spermidine, namely its capability to directly impede LDL oxidation, an early step in atherogenesis. In our in vitro-model, LDL oxidation was induced by the addition of CuCl2 in the presence of increasing concentrations of spermidine, and the degree of oxidation of the lipid, as well as of the protein part of LDL, was measured. We found that spermidine concentration-dependently inhibited the production of lipid hydroperoxides, malondialdehyde, and oxidation-specific immune epitopes in the LDL particle, associated with decreased relative electrophoretic mobilities, respectively. For example, the LPO content was significantly lower when LDL was oxidized in the presence of 500 µg/mL spermidine (26.9 ± 1.6 nmol/mg LDL) than in the absence of spermidine (180.6 ± 7.7 nmol/mg LDL, p < 0.0001). When oxLDL was obtained under increasing spermidine concentrations, its cytotoxicity in EA.hy926 cells concentration-dependently decreased. Quantum chemical calculations show that the reaction between spermidine and hydroxyl radicals is exergonic. We conclude that spermidine is a direct inhibitor of LDL oxidation due to its capability to scavenge hydroxyl radicals. Thus, spermidine supplementation might be a suitable tool to impede atherogenesis and associated (cardio)vascular diseases. Further prospective clinical studies are needed to evaluate the potential atheroprotective/health-promoting effects of spermidine-rich diets.

Vitamin D Supplementation and Allergic Rhinitis: A Systematic Review and Meta-Analysis

Background and Objectives: Vitamin D supplementation is effective for allergic rhinitis; however, its usefulness is unclear. We conducted a systematic review and meta-analysis to examine the conditions in which vitamin D supplementation was effective in allergic rhinitis management. Materials and Methods: Randomized controlled trials of vitamin D supplementation used for patients with allergic rhinitis were searched for across different databases. We extracted scores on patients' symptoms and the medication types used as the baseline treatments and performed a meta-analysis to evaluate the effect of vitamin D supplementation on allergic rhinitis symptoms. Meta-regression and subgroup analyses were performed for the average age, proportion of female participants, concomitant medications, vitamin D administration durations, and baseline serum 25-hydroxyvitamin D levels. Results: In total, 2389 articles were screened, and 5 randomized controlled trials (RCTs) were included in the meta-analysis. Compared with placebos, vitamin D supplementation alleviated allergic rhinitis symptoms, although the difference was not significant; there was significant heterogeneity among studies (standardized mean difference [SMD] = -2.69, 95% confidence interval [CI]: -6.20 to 0.82, I2 = 98%, p < 0.01). The proportion of female participants in the RCTs (slope: 0.21, p = 0.026) and concomitant corticosteroid use (slope: -9.16, p = 0.005) influenced the vitamin D response. Compared with the placebos, vitamin D supplementation without corticosteroids alleviated the allergic rhinitis symptoms (SMD = -0.56, 95% CI: -0.90 to -0.23). Combination treatment with corticosteroids also non-significantly alleviated symptoms. Additionally, the heterogeneity between studies was significant (SMD = -5.97, 95% CI: -13.55 to 1.16, I2 = 99%, p < 0.01). Conclusions: The study results suggest that vitamin D supplementation alleviates allergic rhinitis symptoms, although the effects differ according to the patient's sex and concomitant medications.

Reparative immunological consequences of stem cell transplantation as a cellular therapy for refractory Crohn's disease

BACKGROUND

Treatment strategies for Crohn's disease (CD) suppress diverse inflammatory pathways but many patients remain refractory to treatment. Autologous haematopoietic stem cell transplantation (SCT) is an emerging therapy for medically refractory CD though the mechanisms through which it circumvents refractory pathophysiology are unknown.

OBJECTIVE

The objective of this study is to understand how the immune system reconstitutes post-SCT and whether SCT may function as a cellular therapy restoring appropriately responsive immune cell populations from haematopoietic stem cells (HSCs).

DESIGN

Adults with CD with active clinical and endoscopic disease who failed available medical therapies were enrolled in a phase II study of SCT for refractory CD (n=19). Blood and intestinal samples were collected longitudinally and analysed using CyTOF and scRNA-seq. Stem cell autografts were functionally assayed in mouse xenograft models.

RESULTS

scRNA-seq and CyTOF analyses reveal that SCT predominantly affected the intestinal myeloid lineage with loss of inflammatory populations and return of macrophages capable of supporting mucosal healing. Xenograft models using patient HSCs suggested that HSCs support the early reconstitution of the myeloid lineage and reveal an impairment of short and long-term HSC engraftment that may determine SCT outcomes.

CONCLUSIONS

This study suggests SCT functions as a myeloid-directed cellular therapy reinforcing the critical role of macrophages in refractory CD pathophysiology and as a target for cellular therapies. Furthermore, we report an unrecognised functional heterogeneity among HSC subpopulations in CD that may be relevant to our understanding of CD treatment and pathophysiology.

Impacts of long-term nasogastric tube feeding and tracheostomy on pharyngeal and laryngeal structure in ABI patients: an FEES study

OBJECTIVES

To investigate the characteristics of pharyngeal and laryngeal structure in patients with acquired brain injury (ABI), who were long time wearing nasogastric tube (NGT) with or without tracheostomy.

METHODS

103 ABI patients with NGT indwelled for more than 1 month were retrospectively studied and divided into two groups by whether or not undergoing tracheostomy. Age, gender, types of brain injury, course of the disease, disorders of consciousness, activities of daily living (ADL) and fiberoptic endoscopic examination of swallowing (FEES) were evaluated. The structure and function of pharyngeal and laryngeal were assessed by FEES, focusing on the morphology of the arytenoid cartilage, epiglottis, vocal folds, tongue base, and pharyngeal cavity.

RESULTS

Prolonged indwelling nasogastric tubes and tracheostomy tubes might lead to abnormal alterations of the structure and function in the arytenoid cartilage, epiglottis, tongue base, and pharyngeal cavity. Epiglottis shape abnormality, glossoptosis and pharyngeal stenosis were present in a larger proportion of the NGT-TRACH (nasogastric tube with tracheostomy) group than the NGT group (p < 0.05).

CONCLUSIONS

This study highlights potential physiological changes associated with prolonged placement of nasogastric tubes and tracheostomy tubes, which could impede the recovery of swallowing function and decannulation. We hope to provide valuable evidence to develop effective management strategies for ABI patients with NGT or tracheostomy.

A novel gemcitabine analog as a potential anticancer agent: synthesis and in-vitro evaluation against pancreatic cancer

Gemcitabine (Gem) is approved for use in pancreatic cancer chemotherapy. However, Gem undergoes rapid metabolism in the blood, producing an inactive metabolite. Due to this rapid metabolism, the effective dose of Gem is high, thereby predisposing patients to severe adverse effects. This study aimed to improve Gem's metabolic and therapeutic stability by modifying the amine group (4-NH2) with hydroxylamine to form 4-N-hydroxylGem hydrochloride (GemAGY). Micro-elemental analysis and Nuclear Magnetic Resonance (NMR) were used to characterize GemAGY, and its anticancer activity was investigated against MiaPaCa-2, BxPC-3, and PANC-1 pancreatic cancer cell lines. The GemAGY metabolic stability was evaluated in human liver microsomal solution. In the 2D cytotoxicity assay, the IC50 values of GemAGY-treated MiaPaCa-2, PANC-1, and BxPC-3 cells were significantly lower when compared to GemHCl-treated cultures. More so, in 3D spheroid assay results, GemAGY IC50 values were found to be 9.5 ± 1.1 µM and 12.6 ± 1.0 µM when compared to GemHCl IC50 values of 24.1 ± 1.6 µM and 30.2 ± 1.8 µM in MiaPaCa-2 and PANC-1 cells, respectively. GemAGY was stable, with 60% remaining intact after 2 hours of digestion in microsomal enzymes, compared to GemHCl, which had less than 45% remaining intact after 30 minutes. GemAGY-treated MiaPaCa-2 and PANC-1 cells at 3.12 and 6.25 μM concentrations demonstrated a significantly reduced cell migration towards the wound area compared to the GemHCl-treated cultures at the same concentrations. Further, GemAGY-treated MiaPaCa-2 cells significantly increased the expression of p53 and BAX compared to GemHCl-treated cells. GemAGY demonstrated significant anticancer activity and improved metabolic stability compared to GemHCl and is most likely to have potential anticancer activity against pancreatic cancer.

Anemia in inflammatory bowel disease-A comprehensive review

Anemia is a frequent complication in inflammatory bowel disease (IBD) patients. The etiology is multifactorial, with iron deficiency and anemia of chronic disease being the main reasons. Other causes include vitamin B12 and folate deficiency, hemolytic anemia and medications such as azathioprine and sulfasalazine. Apart from physical symptoms, it is associated with several negative outcomes, including poor quality of life, increased risk of hospital admission, increased risk of surgery and higher treatment costs. Diagnostic evaluation aims to identify the underlying cause and severity to determine the appropriate therapeutic strategy. Investigations include a complete blood count, iron indices, inflammatory markers and vitamin B12 and folate levels. Patients with iron deficiency need adequate replacement therapy to improve hemoglobin and replenish iron stores. Those with moderate to severe anemia and/or active disease need intravenous iron, while mild anemia can be treated with oral iron. Multiple parenteral iron formulations are available which differ in dose and frequency of administration. Traditional oral iron supplements are available in ferrous forms, which, although effective, are associated with gastrointestinal side effects. Newer oral iron formulations have helped reduce these adverse effects but are expensive. Anemia of chronic disease is mainly driven by the effects of inflammatory mediators on iron metabolism and erythropoiesis and treatment requires control of disease activity. Relapse of anemia after therapy is frequent; hence, patients need to be closely followed up for early detection and appropriate management. Significant advances have been made in understanding the pathophysiology of anemia in IBD and better and safer iron formulations are available. However, a significant proportion of IBD patients with anemia go undetected or untreated and there is a need for improved recognition and better management practices. This review discusses various aspects of anemia in IBD and the current approach to diagnosis and management.

Synergistic role of gut-microbial L-ornithine in enhancing ustekinumab efficacy for Crohn's disease

The role of the intestinal microbiome in Crohn's disease (CD) treatment remains poorly understood. This study investigates microbe-host interactions in CD patients undergoing ustekinumab (UST) therapy. Fecal metagenome, metabolome, and host transcriptome data from 85 CD patients were analyzed using multi-omics integration and mediation analysis. Our findings reveal significant microbiome-metabolite-host interactions. Specifically, Faecalibacterium prausnitzii was linked to altered L-ornithine biosynthesis, resulting in higher L-ornithine levels in patients before UST therapy. In vivo and in vitro studies demonstrated that microbiome-derived L-ornithine enhances UST treatment sensitivity in CD by disrupting the host IL-23 receptor signaling and inhibiting Th17 cell stabilization through the IL-12RB1/TYK2/STAT3 axis. L-ornithine significantly enhances the therapeutic efficacy of UST in CD patients, as demonstrated in a prospective clinical trial. These findings suggest that targeting specific microbe-host metabolic pathways may improve the efficacy of inflammatory bowel disease (IBD) treatments.

The holistic management of peripheral spondyloarthritis: focus on articular involvement in patients with inflammatory bowel disease

OBJECTIVE

To provide a comprehensive overview of peripheral spondyloarthritis (pSpA), focusing specifically on its occurrence and management in patients with inflammatory bowel disease (IBD).

METHODS

An exhaustive literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, and Google Scholar to identify relevant studies on pSpA in IBD patients. Titles, abstracts, and full-text articles were screened for relevance. Data on study design, patient characteristics, diagnostic criteria, main findings, and conclusions were extracted from selected articles. Study quality was assessed using appropriate checklists. Information was synthesized narratively to summarize current understanding.

RESULTS

pSpA is the most common extraintestinal manifestation of IBD, with a median prevalence of 16%. It worsens quality of life and requires collaboration between gastroenterologists and rheumatologists for optimal diagnosis and treatment. Several "red flags" guide appropriate specialist referral of IBD patients with suspected pSpA. Once the diagnosis is confirmed, the choice of therapy depends on IBD phenotype and patterns of articular/axial involvement. Anti-tumor necrosis factor (TNF) drugs are first-line biologics, with interleukin (IL)-12/23 and IL-23 inhibitors as alternatives for anti-TNF failure. Small molecules like apremilast and Janus kinase inhibitors also have utility. Recommended treatment algorithms exist, but more randomized controlled trials are needed.

CONCLUSIONS

Early identification of pSpA is crucial in IBD patients to enable timely intervention, prevent structural damage, and minimize disability. A multidisciplinary, holistic approach addressing musculoskeletal and extra-musculoskeletal manifestations is key to optimal patient outcomes.

Prevalence of Malnutrition in People Hospitalized for Surgery: Prospective Cross-Sectional Study

Background/Objectives: Malnutrition poses a significant challenge to public health, affecting millions worldwide, particularly among people in hospital, notably among surgical cases that require adequate nutritional support for effective recovery. Factors contributing to malnutrition include chronic illnesses that hinder nutritional intake and socioeconomic barriers limiting food access. This study aimed to assess malnutrition in surgical patients at admission to enhance recovery, minimize complications, and improve clinical outcomes. Methods: This prospective observational cross-sectional study involved 282 adults hospitalized for over 48 h for surgery. This study utilized the MUST and MNA-SF assessments to evaluate malnutrition risk, confirming diagnoses via the GLIM criteria. Statistical analysis, including the Pearson chi-square test and univariate and multivariate logistic regression, identified significant malnutrition risk factors. Results: This study found an 18.1% malnutrition prevalence among these patients, with Stage 1 malnutrition being the most common at 9.6%. Additionally, a notable proportion of patients were classified as obese (46.5%) or overweight (27.7%). Men had higher malnutrition rates (12.8%) than women (5.3%). Age disparities were also significant, with higher rates among older (7.4%) and younger adults (7.1%) compared to middle-aged individuals (2.5%). Patients undergoing elective surgeries (9.9%) and emergency surgeries (6.7%) had higher malnutrition rates than those admitted for surgical complications. Furthermore, malnutrition was observed in 12% of patients undergoing orthopedic or general surgeries. Conclusions: Among adult patients admitted to surgical wards, malnutrition prevalence during admission was 18%, underscoring the need for comprehensive preoperative nutritional assessments and targeted interventions for patients undergoing surgery.

Dietary manipulation of intestinal microbes prolongs survival in a mouse model of Hirschsprung disease

Enterocolitis is a common and potentially deadly manifestation of Hirschsprung disease (HSCR) but disease mechanisms remain poorly defined. Unexpectedly, we discovered that diet can dramatically affect the lifespan of a HSCR mouse model ( Piebald lethal , sl/sl ) where affected animals die from HAEC complications. In the sl/sl model, diet alters gut microbes and metabolites, leading to changes in colon epithelial gene expression and epithelial oxygen levels known to influence colitis severity. Our findings demonstrate unrecognized similarity between HAEC and other types of colitis and suggest dietary manipulation could be a valuable therapeutic strategy for people with HSCR.

Abstract

Hirschsprung disease (HSCR) is a birth defect where enteric nervous system (ENS) is absent from distal bowel. Bowel lacking ENS fails to relax, causing partial obstruction. Affected children often have "Hirschsprung disease associated enterocolitis" (HAEC), which predisposes to sepsis. We discovered survival of Piebald lethal ( sl/sl ) mice, a well-established HSCR model with HAEC, is markedly altered by two distinct standard chow diets. A "Protective" diet increased fecal butyrate/isobutyrate and enhanced production of gut epithelial antimicrobial peptides in proximal colon. In contrast, "Detrimental" diet-fed sl/sl had abnormal appearing distal colon epithelium mitochondria, reduced epithelial mRNA involved in oxidative phosphorylation, and elevated epithelial oxygen that fostered growth of inflammation-associated Enterobacteriaceae . Accordingly, selective depletion of Enterobacteriaceae with sodium tungstate prolonged sl/sl survival. Our results provide the first strong evidence that diet modifies survival in a HSCR mouse model, without altering length of distal colon lacking ENS.

Highlights

Two different standard mouse diets alter survival in the Piebald lethal ( sl/sl ) mouse model of Hirschsprung disease, without impacting extent of distal colon aganglionosis (the region lacking ENS). Piebald lethal mice fed the "Detrimental" diet had many changes in colon epithelial transcriptome including decreased mRNA for antimicrobial peptides and genes involved in oxidative phosphorylation. Detrimental diet fed sl/sl also had aberrant-appearing mitochondria in distal colon epithelium, with elevated epithelial oxygen that drives lethal Enterobacteriaceae overgrowth via aerobic respiration. Elimination of Enterobacteriaceae with antibiotics or sodium tungstate improves survival of Piebald lethal fed the "Detrimental diet".

Graphical abstract

Intravenous Sodium Ferric Gluconate Complex for Hospitalized Pediatric Patients with Iron Deficiency Anemia

Background/Objectives: Iron deficiency anemia is common in the pediatric population. Red blood cell transfusions, a common acute treatment, pose well-recognized risks including lung injury, circulatory overload, and immune dysfunction. Intravenous iron, specifically sodium ferric gluconate complex (SFGC), is a potential alternative, however investigation on its use in hospitalized children is lacking. This study aims to describe the physiologic response via change in hematologic values to cumulative dose of SFGC, investigate the effect of cumulative dosing on the amount of RBC transfusions received, and comment on its safety. Methods: This is a retrospective investigation of pediatric patients with iron deficiency who received SFGC during their admission to the Helen DeVos Children's Hospital between 2016 and 2018 (N = 85). Results: A total of 258 doses of intravenous SFGC were provided to 85 patients. The average pre-treatment serum hemoglobin was 8.73 ± 1.33, and 7 days post-treatment this increased to 10.41 ± 1.43. Mean corpuscular volume, ferritin, serum ion, total iron binding capacity, reticulocyte percentage, and reticulocyte hemoglobin all increased 7 days post-treatment, as would be suspected, but without any statistically significant difference between hematologic outcomes and cumulative dose of SFGC. Our study did not reveal any correlation between the cumulative dose of SFGC administered and the amount of RBC transfusions received. Only one adverse event was recorded. Conclusions: Our results complement the trend of increased use and emerging evidence of favorable safety profiles of IV iron in the pediatric population. This descriptive investigation revealed that administering higher cumulative doses of SFGC provided no further benefits in terms of hematologic response or RBC transfusion administration.

Role of Mirikizumab in the Treatment of Inflammatory Bowel Disease-From Bench to Bedside

Mirikizumab is a monoclonal antibody directed against the p19 subunit of interleukin (IL)-23 to inhibit its interaction with the IL-23 receptor. IL-23 is a key cytokine involved in initiating and perpetuating the inflammatory cascade in inflammatory bowel disease (IBD). Mirikizumab is the first agent from the novel anti-IL-23p19 drug class to be licensed for ulcerative colitis and the first to present long-term endoscopic, histologic, symptomatic, and quality-of-life outcomes. More recently, the VIVID trial programme has led to the approval of mirikizumab in moderate to severe Crohn's disease. This review explores the history of its development, discusses key immunopharmacological properties unique to the drug, and details the available clinical trials and real-world evidence supporting its use in IBD.

Use of Feeding Tubes Among Hospitalized Older Adults With Dementia

Importance

Although dementia is a contraindication for feeding tube placement, guidelines recommending against its use are inconsistently followed, and factors associated with its use are unclear.

Objective

To describe the incidence of feeding tube placement among hospitalized older adults (aged ≥65 years) with dementia and their health outcomes during and after hospitalization and to identify factors associated with placement of feeding tubes (ie, gastrostomy, gastrostomy-jejunostomy, and jejunostomy tubes).

Design, Setting, and Participants

This population-based retrospective cohort study was conducted using a linked database in Ontario, Canada. Older adults who were diagnosed with dementia prior to a hospitalization between April 1, 2014, and March 31, 2018, were included. Data analyses were completed between October 2021 and November 2024.

Exposures

Sociodemographic characteristics, health profiles, functional status, and advanced directives.

Main Outcomes and Measures

Whether individuals received a feeding tube insertion (ie, gastrostomy, gastrostomy-jejunostomy, or jejunostomy tube), as identified by Ontario Health Insurance Plan billing codes.

Results

Among 143 331 older adults with dementia (83 536 [58.3%] female; mean [SD] age, 83.8 [7.5] years), 1312 (0.9%) received a feeding tube in hospital and 142 019 (99.1%) did not. During hospitalization, feeding tube recipients stayed longer in hospital (mean [SD] stay, 65.6 [120.8] vs 14.8 [35.2] days for nonrecipients) and were more likely to be admitted to the intensive care unit (557 [42.5%] vs 14 423 [10.2%] of nonrecipients) or to die in hospital (294 [22.4%] vs 14 698 [10.3%] of nonrecipients). Within 1 year of discharge, 509 of 1018 feeding tube recipients (50.0%) died compared with 36 162 of 127 321 nonrecipients (28.4%). Among recipients of home care and long-term care residents, regression modeling showed that having swallowing problems (odds ratio [OR], 2.22; 95% CI, 1.99-2.49) and greater functional impairments (OR, 2.75; 95% CI, 1.80-4.20) were associated with increased odds of receiving a feeding tube, while being female (OR, 0.66; 95% CI, 0.52-0.84), older (OR for every 5-year increase in age, 0.75; 95% CI, 0.70-0.81), having a do-not-resuscitate directive (OR, 0.38; 95% CI, 0.31-0.47), and living in rural settings (OR, 0.38; 95% CI, 0.22-0.66) were associated with reduced odds.

Conclusions and Relevance

In this cohort study of hospitalized individuals with dementia, feeding tube insertion was not associated with improved survival or postdischarge outcomes. Factors that were (or were not) associated with feeding tube placement were sometimes misaligned with best practice guidelines. Goals of care conversations, alternative intervention options, and improved clinical protocols are recommended.

Pancreatic exocrine insufficiency after pancreatic resection: a systematic review

INTRODUCTION

Pancreatic exocrine insufficiency (PEI) is a condition defined by a reduction in pancreatic exocrine activity that impairs normal digestion. Despite established guidelines recommendations, precise diagnosis of PEI after pancreatic resection are infrequently achieved. This review aims to provide a comprehensive overview of the methodology and accuracy of diagnostic tools available for evaluating PEI after pancreatic resection.

METHODS

A review of PEI diagnostic tests was conducted using a combined text and MeSH search strategy to identify relevant articles focused on post-pancreatectomy PEI diagnosis.

RESULTS

The literature search yielded 4,874 records, and 30 studies were included in the analysis, with a total of 2,305 patients. The reported frequency of PEI across the included studies varied widely, though more than two-thirds of included papers reported an incidence of PEI above 65% in patients who underwent pancreatoduodenectomy or distal pancreatectomy. The faecal elastase-1 (FE-1) test was the most frequently used test for diagnosing post-pancreatectomy PEI. Six studies compared the diagnostic accuracy of FE-1 with faecal fat tests or 13 C breath tests, finding no significant differences. Five studies reported on micronutrient deficiencies.

CONCLUSION

The FE-1 test is the most commonly used diagnostic tool for post-pancreatectomy PEI; however, well-designed studies comparing the diagnostic accuracy of various tests for PEI are lacking. Additionally, few studies report on micronutrient deficiencies, variations in anthropometric data or PEI-related patient-reported outcomes. Future studies should aim to establish a gold standard for diagnosis and severity assessment of post-pancreatectomy PEI and provide guidance for tailored pancreatic enzyme replacement therapy.

UNEXPECTED FINDINGS DURING LAPAROTOMY SURGERY AND URGENT SURGICAL INDICATIONS ARE ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE

BACKGROUND

Patients undergoing Crohn's disease (CD) surgery may develop a higher rate of postoperative complications (POC) than other patients.

AIMS

The aim of this study was to investigate factors determining POC in patients with CD undergoing urgent laparotomy.

METHODS

This is a retrospective cohort study conducted on adult patients undergoing urgent laparotomy for CD. Clinical and surgical variables, medication history, American Society of Anesthesiologists classification, and POC were investigated. Data collection and management were carried out using the REDCap software (REDCap electronic data capture tools) hosted at the hospital institution. For statistical analysis, the χ2 (or Fisher's exact) test, Student's t-test, Mann-Whitney test, and simple and multiple multilevel logistic regression analyses were used.

RESULTS

There was an association regarding the history of adalimumab use (p=0.04, OR 2.8, 95%CI 1.03-7.65), previous use of prednisone (p<0.01, OR 2.03, 95%CI 2.00-2.05), urgent surgery indications (p<0.01, OR=4.32, 95% CI=1.58-11.82), mechanical anastomosis (p=0.02, OR=0.22, 95%CI 0.06-0.80), unexpected intraoperative findings (p=0.02, OR 10.46, 95%CI 1.50-72.99), length of hospital stay greater than 10 days (p<0.01, OR 16.86, 95%CI 2.99-94.96), unplanned intensive care unit (ICU) admission (p=0.01, OR 15.06, 95%CI 1.96-115.70), and planned ICU admission (p<0.01, OR 18.46, 95%CI 3.60-94.51). On multivariate analysis, there was an association between the indication of urgent surgery (or emergency) (p=0.01, OR 4.38, 95%CI 1.43-13.37) and unexpected intraoperative findings (p=0.03, OR 8.11, 95%CI 1.21-54.50).

CONCLUSIONS

Unexpected changes and urgent surgical indications are considered risk factors for POC in patients with CD.

Extended Risankizumab Treatment in Patients With Crohn's Disease Who Did Not Achieve Clinical Response to Induction Treatment

BACKGROUND & AIMS

The efficacy and safety of extended treatment with risankizumab (RZB), an anti-interleukin-23 p19 monoclonal antibody, were evaluated in patients with moderate to severe Crohn's disease (CD) who did not achieve clinical response to 12 weeks (W) RZB induction treatment ('initial nonresponders').

METHODS

Initial nonresponders to intravenous (IV) RZB induction (600 mg or 1200 mg at W0, W4, and W8) were rerandomized 1:1:1 to receive extended blinded RZB treatment (1200 mg IV at W12, W16, and W20, or subcutaneous [SC] 180 mg or 360 mg at W12 and W20). Patients with clinical response to SC RZB at W24 ('delayed responders') continued their dose in FORTIFY. Clinical, endoscopic, and safety outcomes were evaluated.

RESULTS

Most initial nonresponders achieved stool frequency (SF)/ abdominal pain score (APS) clinical response by W24 (76.2% [180 mg SC], 63.7% [360 mg SC], 62.3% [1200 mg IV]), whereas a subset also achieved W24 SF/APS clinical remission (43.0%, 45.1%, and 22.1%), endoscopic response (32.4%, 32.5%, and 40.5%), and endoscopic remission (25.1%, 18.0%, and 23.5%). Most delayed responders to SC RZB continued to demonstrate clinical response at FORTIFY W52 (56.7% [180 mg SC], 69.7% [360 mg SC]), along with SF/APS clinical remission (43.3% and 54.5%), endoscopic response (36.7% and 45.5%), and endoscopic remission (40.0% and 42.4%). Numerically greater efficacy was generally observed with 360 mg SC vs 180 mg SC. The safety profile of extended treatment was consistent with previously reported trials.

CONCLUSION

Most initial nonresponders to IV RZB induction who received 12W of extended RZB treatment demonstrated improved clinical and endoscopic outcomes at W24. Improvements in patients who received SC RZB extended treatment were maintained during FORTIFY. Extended treatment was well tolerated with no new safety risks identified.

CLINICALTRIALS

gov: MOTIVATE (Number: NCT03104413), ADVANCE (Number: NCT03105128), and FORTIFY (Number: NCT03105102).

Bovine lactopontin promotes bone development in growing rats by altering the composition of intestinal flora and bile acid metabolism

Lactopontin (LPN) is an important milk protein with the potential to improve bone health; however, its specific effects have not been determined. This study aims to investigate the effects of LPN on early bone growth and development. 3 week-old SD rats (n = 32) were assigned to the control group, whey protein concentration (WPC) group, LPN-L (low-dose LPN) group, and LPN-H (high-dose LPN) group, with intragastric administration of deionized water, 65.8 mg kg-1 WPC, and 5 and 45 mg kg-1 LPN for 30 days, respectively. LPN-H supplementation increased body length and femur length, improved femoral bone volume and microarchitecture, and upregulated osteoblast activity-related mRNA (Bmp2, Smad8, and Runx-2) expression in the femur. The content of secondary bile acid glycolithocholic acid (GLCA) in stool and serum was significantly increased after LPN-H intervention and positively correlated with the increased abundance of Parabacteroides in feces. In addition, the bile acid receptor FXR in femur was also activated in the LPN-H group, suggesting that LPN may regulate bone health through the microbiota-metabolite-bone axis. The results of this study suggest that LPN has potential application value in regulating bone metabolism during growth.

Comparative analysis of tongue cancer organoids among patients identifies the heritable nature of minimal residual disease

The relapse of tongue cancer (TC) after chemotherapy is caused by minimal residual disease (MRD), which is a few remaining cancer cells after chemotherapy. To understand the mechanism of MRD in TC, we created a library of TC organoids (TCOs) from 28 untreated TC patients at diverse ages and cancer stages. These TCOs reproduced the primary TC tissues both in vitro and in a xenograft model, and several TCO lines survived after cisplatin treatment (chemo-resistant TCOs). Of note, the chemo-resistant TCOs showed "heritable" embryonic diapause-like features before treatment and activation of the autophagy and cholesterol biosynthetic pathways. Importantly, inhibiting these pathways with specific inhibitors converted the chemo-resistant TCOs into chemo-sensitive TCOs. Conversely, autophagy activation with mTOR inhibitors conferred chemo-resistance on the chemo-sensitive TCOs. This unique model provides insights into the mechanism of MRD formation in TCs, leading to effective therapeutic approaches to reduce the recurrence of TC.

Ustekinumab Drug Clearance Is Better Associated with Disease Control than Serum Trough Concentrations in a Prospective Cohort of Inflammatory Bowel Disease

Background/Objectives: This study aimed to compare the association of ustekinumab (UST) drug clearance (CL) and trough drug concentrations with disease activity in patients with inflammatory bowel diseases (IBDs). Methods: A prospective cohort of 83 patients with IBD receiving maintenance therapy with 90 mg subcutaneous UST was analyzed using Bayesian PK modeling. UST concentrations and antibodies to UST (ATU) were collected at the trough and measured using a drug-tolerant homogenous mobility shift assay (HMSA). CL was estimated using Bayesian estimation methods with priors from a previous population pharmacokinetic study specifically reparametrized using HMSA. Outcomes were combined clinical and biochemical remission and endoscopic healing index (EHI) score, a validated marker of endoscopic active disease in IBD. Statistical analysis consisted of linear and nonlinear mixed effect models for repeated time-to-event analysis. Results: A total of 83 patients with IBD were enrolled (median age 42 years, 52% female) and evaluated across 312 dose cycles (median follow-up: 279 days, median of 3 cycles/patient). Median concentrations and CL were 5.0 µg/mL and 0.157 L/day, respectively. Most patients (89%) were exposed to other biologics before starting UST, which was associated with lower rates of clinical and biochemical remission (p = 0.01). Longitudinal changes in concentrations were not associated with remission (p = 0.53). Conversely, higher CL was associated with a lower likelihood of remission (p < 0.01). EHI > 50 points (endoscopic active disease, n = 303 cycles) was associated with higher UST CL (p < 0.01). Conclusions: UST CL was more strongly associated with clinical and biochemical outcomes than trough concentrations, highlighting its potential role in therapy optimization.

Retrospective Cohort Study on the Predictive Value of Primary Non-response to Initial Biologic for Future Biologic Use in Patients with Inflammatory Bowel Disease

BACKGROUND

The armamentarium of medical therapies to treat inflammatory bowel disease (IBD) continues to grow, which has expanded treatment options, particularly after first biologic failure. Currently, there are limited studies investigating the predictive value of first biologic primary non-response (PNR) on subsequent biologic success. Our objective was to determine if PNR to the first biologic for IBD is predictive of response to subsequent biologic therapy.

METHODS

A multicenter retrospective chart review study was performed with patients with IBD that received two or more biologics. PNR was defined as no clinical or symptomatic improvement after at least six weeks of treatment leading to cessation of drug. Patients who stopped their first biologic due to adverse side effects were classified in the intolerance group. Patients with initial significant response to biologic followed by a loss of response were classified as secondary loss of response (SLOR). Data analysis was performed with Python and Excel.

RESULTS

Of the 249 patients that met inclusion criteria, there were 87 patients with PNR, 96 patients with SLOR, and 66 patients with intolerance to their first biologic exposure. Patients with ulcerative colitis (UC: 41.3%, p = 0.0083) and IBD-unclassified (IC: 56.3%, p = 0.0099) were found to have a significantly higher rate of primary non-response compared to patients with Crohn's disease (CD: 25.0%). Patients on adalimumab for their first biologic had a significantly (p = 0.0014) higher rate of PNR (42.7%, UC: 50.0%, CD: 32.7%) compared to those on infliximab (23.0%, UC: 31.0%, CD: 12.1%). Patients with PNR did not have a higher rate of second biologic nonresponse when compared to patients who had SLOR or intolerance to their first biologic. Univariate analyses demonstrated no difference in rates of response to second biologic when switching intra-class or out-of-class.

CONCLUSION

Ulcerative colitis and IBDU have higher rates of PNR compared to Crohn's disease, but still have high response rates to second biologic agents. Adalimumab may be a suboptimal initial biologic given its higher PNR rate compared to infliximab. Our results support that there is an equally likely chance of response to second biologic after first biologic PNR. Subanalyses evaluating intraclass and out-of-class medication switching showed similar success.

Dietary assessments in individuals living with coeliac disease: key considerations

BACKGROUND

Coeliac disease (CeD) is a type of enteropathy characterised by an immune-mediated reaction to ingested gluten, resulting in impaired absorption of nutrients and symptoms such as bloating, abdominal cramping and diarrhoea. Currently, the only treatment for CeD is adherence to a gluten-free diet (GFD). The latest draft guidance from the US Food and Drug Administration recommends that dietitians experienced in CeD management evaluate patients during the screening and treatment period of CeD clinical trials to assess adherence to a GFD. However, there are currently no standardised guidelines on dietary assessment of patients with CeD on a GFD and there is a lack of widespread availability of expertise in this field.

METHODS

Based on the findings of a literature review conducted between April and September 2023, this article provides an overview of key points to consider in the nutritional and dietary assessment of patients with CeD who are following a GFD, with particular focus on the clinical trial setting.

RESULTS

Based on a consensus from dietitians and gastroenterologists experienced in treating patients with CeD, we present specific recommendations for registered dietitians who manage patients with CeD. We also describe the development of a simplified tool for assessment of adherence to a GFD, the Gluten-Free Adherence Survey, based on these recommendations.

CONCLUSIONS

These guidelines cover nutritional and dietary assessment of patients with CeD, physical assessments, intake of oats, environmental considerations and the disease burden.

No longer to be ignored: Hypophosphatemia following intravenous iron administration

Intravenous iron supplementation is increasingly used to safely and effectively correct iron deficiency anemia, but some formulations are linked to a renal phosphate wasting syndrome which is mediated by fibroblast growth factor 23. Unawareness among prescribers and the nonspecific clinical symptoms of hypophosphatemia result in underreporting of this complication. Even though it is often an asymptomatic and self-limiting condition, accumulating evidence from case reports and dedicated randomized controlled trials show that IV iron induced hypophosphatemia may be associated with clinical symptoms. If hypophosphatemia is not recognized and treated, a metabolic bone disease phenotype may develop, pathophysiologically reminiscent of hypophosphatemic rickets as seen in X-linked hypophosphatemic rickets or oncogenic osteomalacia. This syndrome is particularly, but not uniquely, associated with formulations containing ferric carboxymaltose, probably due to specific chemical characteristics of its carbohydrate moiety. Risk factors include repeated infusion, severity of iron deficiency, as well as normal kidney function. Coexisting vitamin D deficiency or hyperparathyroidism increase the risk of metabolic bone disease. Complications can be easily prevented by an early diagnosis and switching to another IV iron formulation. In this review, we describe the epidemiology and pathophysiology of this condition, to raise awareness among prescribing clinicians.

American Society for Metabolic and Bariatric Surgery literature review on risk factors, screening recommendations, and prophylaxis for marginal ulcers after metabolic and bariatric surgery

BACKGROUND

Marginal ulcers (MU) are a significant postoperative complication following anastomotic metabolic and bariatric surgeries including Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), and biliopancreatic diversion with duodenal switch (BPD/DS). This review summarizes current knowledge on MU risk factors, screening, and prophylactic strategies.

OBJECTIVES

The goal of this review is to examine technical and patient-related risk factors for MU, assess screening strategies, and recommend prophylactic approaches to reduce MU incidence after anastomotic metabolic and bariatric surgery (MBS).

SETTING

A comprehensive review was conducted by members of the American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, based on available literature from 2000 to the present.

METHODS

A systematic search was performed using Ovid MEDLINE and PubMed databases. Relevant studies were screened for inclusion. Technical and patient-related factors were evaluated, and recommendations for MU prevention were formulated.

RESULTS

Several risk factors for MU were identified, including large gastric pouch size, circular stapled anastomoses, use of nonabsorbable sutures, smoking, nonsteroidal anti-inflammatory drugs use, and immunosuppression. While prophylactic proton pump inhibitor (PPI) therapy is widely recommended, its optimal duration remains debated. The role of Helicobacter pylori in MU development is not clearly defined.

CONCLUSIONS

Prophylactic PPI therapy for at least 3 months postsurgery significantly reduces the risk of MU. Risk stratification and individualized treatment plans are essential to minimize postoperative complications. Further research is needed to clarify the role of H. pylori and optimize prophylactic strategies.

Propionate-functionalized chitosan hydrogel nanoparticles for effective oral delivery of insulin

Oral delivery of macromolecular drugs is often hampered by the harsh gastrointestinal environment, which makes the drugs have poor bioavailability. Insulin, the most used drug for diabetes, also faces the same challenge for oral administration. Hence, we decorated microbial metabolite propionate on chitosan (CS) to fabricate insulin-loaded propionate-modified CS hydrogel nanoparticles (IN-CS/PA HNPs). The prepared IN-CS/PA HNPs exhibited high encapsulation efficiency (> 95 %) and loading capacity (∼10 %) for insulin. The system provided better protection for insulin in gastrointestinal environment compared to unmodified IN-CS HNPs. Moreover, the active functional group of propionate can be recognized and transported by mono-carboxylate transporter protein 1 (MCT1) targeting. Thus, in both Caco-2 cells and the ligated intestinal loops of rats, IN-CS/PA HNPs significantly improved permeability and uptake of insulin on intestinal epithelium, which was attributed to MCT1-mediated endocytosis. In type 1 diabetic (T1D) rats, oral delivery of IN-CS/PA HNPs with 60 IU/kg insulin led to more stable and long-lasting hypoglycemic effect than a 5IU/kg dose of subcutaneously injected insulin. It also generated 2.29-fold and 11.88-fold higher relative oral bioavailability compared with empty IN-CS HNPs and free insulin, respectively. This study demonstrated that propanoic acid-functionalized chitosan hydrogel nanoparticles could improve the oral absorption of insulin by overcoming multiple barriers in gastrointestinal tract, providing a promising active targeting strategy for the oral delivery of macromolecules drugs.

Treatment patterns for advanced therapies in Canadians with moderate-to-severe inflammatory bowel disease: a retrospective cohort analysis

Many patients with inflammatory bowel disease (IBD) show an inadequate response or experience a loss of response to advanced therapies. Guidelines recommend dose optimization and switching among therapies until an optimal treatment response is attained. With several advanced treatments available, we aimed to evaluate the persistence of different therapeutic sequences in IBD. The RECORDED study was a retrospective cohort study of Canadians with moderate-to-severely active ulcerative colitis (UC) or Crohn's disease (CD) who had been exposed to more than 1 advanced therapy between May 2015 and April 2021 for UC, and May 2016 and April 2021 for CD. The primary endpoint was time to permanent discontinuation of the first advanced treatment. Overall, 330 patients had CD and 344 had UC. The most common first-line treatments for CD and UC were adalimumab and infliximab, respectively. The median (95% CI) time to permanent discontinuation of first-line treatment was 12.3 (10.9, 13.6) months in patients with CD and 9.2 (8.2, 10.8) months for those with UC. The most common reason for treatment change across both diseases was lack of efficacy. First-line advanced treatments were optimized in 191 (58.1%) CD patients and 202 (59.1%) UC patients prior to permanent discontinuation. Second-line therapy was typically from a different class compared with the first-line treatment choice. The RECORDED study provides insights into the real-world sequencing and optimization patterns of advanced treatments in patients with moderate-to-severe IBD in Canada. Lack of efficacy was the most cited reason for switching to a different therapy.

Targeted Therapies: The Role of Monoclonal Antibodies in Disease Management

Monoclonal antibodies (mAbs) are a key class of biotherapeutic medicines used to treat a wide range of diseases, such as cancer, infectious diseases, autoimmune disorders, cardiovascular diseases, and hemophilia. They can be engineered for greater effectiveness and specific applications while maintaining their structural elements for immune targeting. Traditional immunoglobulin treatments have limited therapeutic uses and various adverse effects. That makes mAbs show rapid growth in the pharmaceutical market, with over 250 mAbs in clinical studies. Although mAbs offer higher specificity, they are less effective against complex antigens. They have become essential in treating diseases with limited medical options, providing innovative solutions that improve patients' quality of life through increasing survival rates, shortening the length of stay in hospitals with an improved treatment outcome, and reducing side effects. This review outlines the mechanisms, applications, and advancements of mAbs, highlighting their transformative role in modern medicine and their potential to shape future therapeutic interventions.