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Neto do Nascimento C, Palmela C, Soares AS, Antunes ML, Fidalgo CA, Glória L. Groove Pancreatitis: Clinical Cases and Review of the Literature. GE Port J Gastroenterol 2023; 30:437-443. [PMID: 38476156 PMCID: PMC10928862 DOI: 10.1159/000526855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/06/2022] [Indexed: 03/14/2024]
Abstract
Introduction Groove pancreatitis (GP) is a type of chronic segmental pancreatitis that affects the pancreatoduodenal groove area, and it is often misdiagnosed. Outflow obstruction of the minor papilla associated with alcohol consumption seems to be the main pathophysiological mechanism, and it affects mainly middle-aged males. Symptoms include nausea and postprandial vomiting from gastric outlet obstruction, weight loss, and abdominal pain. Despite modern advances, such as radiological and endoscopic methods, distinction between GP and pancreatic cancer remains a challenge, and histological examination is sometimes necessary. When a diagnosis can be obtained without a surgical specimen, management can be conservative in the absence of acute or chronic complications. Case Presentation The authors present 2 clinical cases which portray the diagnostic workup and management decisions of this entity. Discussion/Conclusion GP is a clinical entity, offering diagnostic and therapeutic challenges. Imaging exams are crucial in the diagnosis and follow-up, but surgery may be necessary in a significant number of cases due to the incapacity to rule out malignancy.
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Affiliation(s)
| | - Carolina Palmela
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | | | | | | | - Luísa Glória
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
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Revés J, Mascarenhas A, José Temido M, Morão B, Neto Nascimento C, Rita Franco A, Mendes RR, Palmela C, Chagas C, Figueiredo PN, Glória L, Portela F, Torres J. Early intervention with biologic therapy in Crohn´s disease: how early is early? J Crohns Colitis 2023; 17:1752-1760. [PMID: 37220397 DOI: 10.1093/ecco-jcc/jjad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/25/2023] [Accepted: 05/19/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Early biologic therapy within the first 18-24 months after diagnosis is associated with improved clinical outcomes in Crohn's disease [CD]. However, the definition of the best time to initiate biologic therapy remains unclear. We aimed to assess if there is an optimal timing for early biologic therapy initiation. METHODS This was a multicentre retrospective cohort study including newly diagnosed CD patients who started anti-tumour necrosis factor [TNF] therapy within 24 months from diagnosis. The timing of initiation of biologic therapy was categorised as ≤6, 7-12, 13-18, and 19-24 months. The primary outcome was CD-related complications defined as a composite of progression of Montreal disease behaviour, CD-related hospitalisations, or CD-related intestinal surgeries. Secondary outcomes included clinical, laboratory, endoscopic, and transmural remission. RESULTS We included 141 patients where 54%, 26%, 11%, and 9% started biologic therapy at ≤6, 7-12, 13-18, and 19-24 months after diagnosis, respectively. A total of 34 patients [24%] reached the primary outcome: 8% had progression of disease behaviour, 15% were hospitalised, and 9% required surgery. There was no difference in the time to a CD-related complication according to the time of initiation of biologic therapy within the first 24 months. Clinical, endoscopic, and transmural remission was achieved in 85%, 50%, and 29%, respectively, but no differences were found according to the time of initiation of biologic therapy. CONCLUSION Starting anti-TNF therapy within the first 24 months after diagnosis was associated with a low rate of CD-related complications and high rates of clinical and endoscopic remission, although we found no differences with earlier initiation within this window of opportunity.
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Affiliation(s)
- Joana Revés
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - André Mascarenhas
- Gastroenterology Division, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Maria José Temido
- Gastroenterology Division, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Bárbara Morão
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Ana Rita Franco
- Gastroenterology Division, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Raquel R Mendes
- Gastroenterology Division, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Carolina Palmela
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Cristina Chagas
- Gastroenterology Division, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro Narra Figueiredo
- Gastroenterology Division, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Luísa Glória
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Francisco Portela
- Gastroenterology Division, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Joana Torres
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Ferreira AO, Reves JB, Nascimento C, Frias-Gomes C, Costa-Santos MP, Ramos LR, Palmela C, Gloria L, Cravo M, Dinis-Ribeiro M, Canena J. Narrow Band Imaging versus White Light for the Detection of Sessile Serrated Colorectal Lesions: A Randomized Clinical Trial. GE Port J Gastroenterol 2023; 30:368-374. [PMID: 37868631 PMCID: PMC10586213 DOI: 10.1159/000526606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/14/2022] [Indexed: 10/24/2023]
Abstract
Background Colorectal cancer (CRC) is a leading cause of cancer. The detection of pre-malignant lesions by colonoscopy is associated with reduced CRC incidence and mortality. Narrow band imaging has shown promising but conflicting results for the detection of serrated lesions. Methods We performed a randomized clinical trial to compare the mean detection of serrated lesions and hyperplastic polyps ≥10 mm with NBI or high-definition white light (HD-WL) withdrawal. We also compared all sessile serrated lesions (SSLs), adenoma, and polyp prevalence and rates. Results Overall, 782 patients were randomized (WL group 392 patients; NBI group 390 patients). The average number of serrated lesions and hyperplastic polyps ≥10 mm detected per colonoscopy (primary endpoint) was similar between the HD-WL and NBI group (0.118 vs. 0.156, p = 0.44). Likewise, the adenoma detection rate (55.2% vs. 53.2%, p = 0.58) and SSL detection rate (6.8% vs. 7.5%, p = 0.502) were not different between the two study groups. Withdrawal time was higher in the NBI group (10.88 vs. 9.47 min, p = 0.004), with a statistically nonsignificant higher total procedure time (20.97 vs. 19.30 min, p = 0.052). Conclusions The routine utilization of narrow band imaging does not improve the detection of serrated class lesions or any pre-malignant lesion and increases the withdrawal time.
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Affiliation(s)
- Alexandre Oliveira Ferreira
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Department of Gastroenterology, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Joana Branco Reves
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | | | | | - Maria Pia Costa-Santos
- Department of Gastroenterology, Hospital do Divino Espirito Santo, Ponta Delgada, Portugal
| | - Lídia Roque Ramos
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Department of Gastroenterology, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Carolina Palmela
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Department of Gastroenterology, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Luísa Gloria
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
- Department of Gastroenterology, Hospital da Luz Lisboa, Lisboa, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Instituto Português de Oncologia, Porto, Portugal
- Cintesis, Center for Health Technology and Services Research, Porto, Portugal
| | - Jorge Canena
- Cintesis, Center for Health Technology and Services Research, Porto, Portugal
- Department of Gastroenterology, Nova Medical School/Faculty of Medical Sciences, Lisboa, Portugal
- University Center of Gastroenterology, Hospital Cuf Tejo, Lisbon, Portugal
- Department of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
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Kucharzik T, Wilkens R, D'Agostino MA, Maconi G, Le Bars M, Lahaye M, Bravatà I, Nazar M, Ni L, Ercole E, Allocca M, Machková N, de Voogd FAE, Palmela C, Vaughan R, Maaser C. Early Ultrasound Response and Progressive Transmural Remission After Treatment With Ustekinumab in Crohn's Disease. Clin Gastroenterol Hepatol 2023; 21:153-163.e12. [PMID: 35842121 DOI: 10.1016/j.cgh.2022.05.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In this STARDUST substudy, the effect of ustekinumab on transmural bowel inflammation was assessed in adults with moderate-to-severe Crohn's disease (CD) by using intestinal ultrasound (IUS), a noninvasive imaging procedure. METHODS STARDUST was an international, multicenter, phase 3b, interventional, randomized controlled trial specifically designed to compare treat-to-target and standard-of-care treatment strategies in ustekinumab-treated CD patients. In this substudy, the most affected bowel segment at baseline by IUS was used for all analyses. Key IUS endpoints (centrally read, parameter-blinded) were IUS response, transmural remission, bowel wall thickness (BWT), blood flow, bowel wall stratification, and inflammatory fat. RESULTS Seventy-seven patients were evaluated. IUS response could be determined 4 weeks after treatment initiation, with progressive improvement through week 48. IUS response and transmural remission rates at week 48 were 46.3% and 24.1%, respectively. IUS response, transmural remission, BWT, and blood flow normalization rates were more pronounced in the colon and biologic-naive patients. Fair/moderate reliability (κ = 0.21-0.51) was observed between week 4 IUS response and week 48 overall endoscopic response and fecal calprotectin/complete biomarker outcomes. Endoscopy and IUS baseline agreement was >90% in determining the terminal ileum as the most affected bowel segment. IUS response absence at week 4 was associated with no endoscopic response (based on the simplified endoscopic score for Crohn's disease terminal ileum subscore) at week 48 (negative predictive value = 73%). CONCLUSIONS In this first international, multicenter, interventional study, IUS showed that ustekinumab-treated CD patients achieved progressive IUS response (46.3%) and transmural remission (24.1%) through week 48, with a more robust response in the colon and biologic-naive patients. CLINICALTRIALS gov number: NCT03107793.
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Affiliation(s)
- Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Germany.
| | - Rune Wilkens
- Digestive Disease Center, Bispebjerg Hospital Copenhagen, Denmark; Gastro Unit, Section of Medicine, Hvidovre Hospital Copenhagen, Denmark
| | - Maria-Antonietta D'Agostino
- Università Cattolica del Sacro Cuore, UOC Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences; "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | | | | | | | | | - Lioudmila Ni
- Janssen-Cilag Russia, Moscow, Russian Federation
| | - Elena Ercole
- Gastroenterology Unit, Mauriziano Hospital, Turin, Italy
| | | | - Naděžda Machková
- Clinical and Research Center for Inflammatory Bowel Diseases, Clinical Center ISCARE, Prague, Czech Republic
| | - Floris A E de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Carolina Palmela
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rose Vaughan
- The Royal Melbourne Hospital, Melbourne, Australia
| | - Christian Maaser
- Ambulanzzentrum Gastroenterologie am Klinikum Lüneburg, Lüneburg, Germany
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Palmela C, Maaser C. The Use of Intestinal Ultrasound in Ulcerative Colitis-More Than a Mucosal Disease? Gastroenterology 2022; 163:1485-1487. [PMID: 36223828 DOI: 10.1053/j.gastro.2022.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Carolina Palmela
- Gastroenterology Service, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal.
| | - Christian Maaser
- Outpatient Department of Gastroenterology and Department of Geriatrics, University Teaching Hospital, Lüneburg, Germany
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Madsen GR, Wilkens R, Boysen T, Burisch J, Bryant R, Carter D, Gecse K, Maaser C, Maconi G, Novak K, Palmela C, Nayahangan LJ, Tolsgaard M. The knowledge and skills needed to perform intestinal ultrasound for inflammatory bowel diseases-an international Delphi consensus survey. Aliment Pharmacol Ther 2022; 56:263-270. [PMID: 35488472 PMCID: PMC9325538 DOI: 10.1111/apt.16950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/08/2022] [Accepted: 04/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Intestinal ultrasound (IUS) is a non-invasive modality for monitoring disease activity in inflammatory bowel diseases (IBD). IUS training currently lacks well-defined standards and international consensus on competency criteria. AIM To achieve international consensus on what competencies should be expected from a newly certified IUS practitioner. METHODS A three-round, iterative Delphi process was conducted among 54 IUS experts from 17 countries. Round 1 was a brainstorming phase with an open-ended question to identify the knowledge and skills that experts believe a newly certified IUS practitioner should possess. The experts' suggestions were then organised into statements by a Steering Committee. In round 2, the experts commented upon and rated the statements, which were revised accordingly. In round 3, the experts rated the revised statements. Statements meeting the pre-defined consensus criterion of at least 70% agreement were included in the final list of statements. RESULTS In total, 858 items were suggested by the experts in the first round. Based on these suggestions, 55 statements were organised into three categories: knowledge, technical skills and interpretation skills. After the second round, 53 revised statements remained. After the final round, a total of 41 statements had achieved consensus. CONCLUSIONS We established international, expert consensus on the knowledge and skills that should be expected from newly certified IUS practitioners. These consensus statements are the first step towards mastery learning for IUS training. Educators can utilise these statements to design training programmes and evaluate the competencies of trainees before they engage in independent practice.
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Affiliation(s)
- Gorm Roager Madsen
- Gastrounit, Medical DivisionCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and AdultsCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark,Copenhagen Academy for Medical Education and Simulation, Centre for HR and EducationCopenhagenDenmark
| | - Rune Wilkens
- Gastrounit, Medical DivisionCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and AdultsCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark
| | - Trine Boysen
- Gastrounit, Medical DivisionCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and AdultsCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark
| | - Johan Burisch
- Gastrounit, Medical DivisionCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark,Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and AdultsCopenhagen University Hospital – Amager and HvidovreHvidovreDenmark
| | - Robert Bryant
- Inflammatory Bowel Disease Service, Department of GastroenterologyThe Queen Elizabeth HospitalAdelaideSouth AustraliaAustralia
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat Gan, Israel and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Krisztina Gecse
- Department of Gastroenterology and HepatologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Christian Maaser
- Outpatients Department of Gastroenterology, Department of GeriatricsHospital LüneburgLüneburgGermany
| | - Giovanni Maconi
- Gastrointestinal Unit, Department of Clinical Sciences"L.Sacco" University HospitalMilanItaly
| | - Kerri Novak
- Department of Medicine, Division of GastroenterologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Carolina Palmela
- Division of Gastroenterology, Surgical DepartmentHospital Beatriz ÂngeloLouresPortugal
| | - Leizl Joy Nayahangan
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and EducationCopenhagenDenmark
| | - Martin Grønnebæk Tolsgaard
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and EducationCopenhagenDenmark,Department of ObstetricsCopenhagen University HospitalCopenhagenDenmark
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Morão B, Revés JB, Nascimento C, Loureiro R, Glória L, Palmela C. Secondary Sclerosing Cholangitis in a Critically Ill Patient with Severe SARS-CoV-2 Infection: A Possibly Emergent Entity during the Current Global Pandemic. GE Port J Gastroenterol 2022; 27:1-6. [PMID: 35528723 PMCID: PMC9059009 DOI: 10.1159/000521758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/27/2021] [Indexed: 11/19/2022]
Abstract
A 46-year-old woman without previous history of hepatobiliary disease was admitted to the intensive care unit due to SARS-CoV-2 infection. Admission blood tests revealed impending hyperinflammation in the context of systemic inflammatory response syndrome. She required 12 days of mechanical ventilation and vasopressor support. After admission, liver function tests became deranged in a cholestatic pattern and continued to worsen despite overall clinical improvement. Magnetic resonance cholangiopancreatography revealed liver abscesses, intrahepatic bile duct dilation with multiple strictures and some linear repletion defects at the bifurcation of the common hepatic duct. During endoscopic retrograde cholangiopancreatography, biliary casts were retrieved confirming the diagnosis of secondary sclerosing cholangitis in the critically ill patient triggered by a severe SARS-CoV-2 infection. Other causes of cholestasis and secondary sclerosing cholangitis were properly excluded. We present an illustrative case and discuss the current literature, focusing on SARS-CoV-2 infection contribution to the development of this potentially underdiagnosed and severe condition.
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Affiliation(s)
- Bárbara Morão
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal
| | | | | | - Rui Loureiro
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal
- Serviço de Gastrenterologia, Hospital da Luz, Lisbon, Portugal
| | - Luísa Glória
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - Carolina Palmela
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal
- Serviço de Gastrenterologia, Hospital da Luz, Lisbon, Portugal
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Libânio D, Palmela C, Maia L, Areia M. Keeping the Path towards Even Brighter Times. GE Port J Gastroenterol 2021; 29:1-2. [DOI: 10.1159/000520702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/19/2022]
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Frias-Gomes C, Torres J, Palmela C. Intestinal Ultrasound in Inflammatory Bowel Disease: A Valuable and Increasingly Important Tool. GE Port J Gastroenterol 2021; 29:223-239. [PMID: 35979252 PMCID: PMC9275009 DOI: 10.1159/000520212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022]
Abstract
Background Intestinal ultrasound is emerging as a non-invasive tool for monitoring disease activity in inflammatory bowel disease patients due to its low cost, excellent safety profile, and availability. Herein, we comprehensively review the role of intestinal ultrasound in the management of these patients. Summary Intestinal ultrasound has a good accuracy in the diagnosis of Crohn's disease, as well as in the assessment of disease activity, extent, and evaluating disease-related complications, namely strictures, fistulae, and abscesses. Even though not fully validated, several scores have been developed to assess disease activity using ultrasound. Importantly, intestinal ultrasound can also be used to assess response to treatment. Changes in ultrasonographic parameters are observed as early as 4 weeks after treatment initiation and persist during short- and long-term follow-up. Additionally, Crohn's disease patients with no ultrasound improvement seem to be at a higher risk of therapy intensification, need for steroids, hospitalisation, or even surgery. Similarly to Crohn's disease, intestinal ultrasound has a good performance in the diagnosis, activity, and disease extent assessment in ulcerative colitis patients. In fact, in patients with severe acute colitis, higher bowel wall thickness at admission is associated with the need for salvage therapy and the absence of a significant decrease in this parameter may predict the need for colectomy. Short-term data also evidence the role of intestinal ultrasound in evaluating therapy response, with ultrasound changes observed after 2 weeks of treatment and significant improvement after 12 weeks of follow-up in ulcerative colitis. Key Messages Intestinal ultrasound is a valuable tool to assess disease activity and complications, and to monitor response to therapy. Even though longer prospective data are warranted, intestinal ultrasound may lead to a change in the paradigm of inflammatory bowel disease management as it can be used in a point-of-care setting, enabling earlier intervention if needed.
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Affiliation(s)
- Catarina Frias-Gomes
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Torres
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Carolina Palmela
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
- *Carolina Palmela,
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10
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Ilvemark JFKF, Hansen T, Goodsall TM, Seidelin JB, Al- Farhan H, Allocca M, Begun J, Bryant RV, Carter D, Christensen B, Dubinsky MC, Gecse KB, Kucharzik T, Lu C, Maaser C, Maconi G, Nylund K, Palmela C, Wilson SR, Novak K, Wilkens R. Defining Transabdominal Intestinal Ultrasound Treatment Response and Remission in Inflammatory Bowel Disease: Systematic Review and Expert Consensus Statement. J Crohns Colitis 2021; 16:554-580. [PMID: 34614172 PMCID: PMC9089416 DOI: 10.1093/ecco-jcc/jjab173] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS No consensus exists on defining intestinal ultrasound response, transmural healing, or transmural remission in inflammatory bowel disease, nor clear guidance for optimal timing of assessment during treatment. This systematic review and expert consensus study aimed to define such recommendations, along with key parameters included in response reporting. METHODS Electronic databases were searched from inception to July 26, 2021, using pre-defined terms. Studies were eligible if at least two intestinal ultrasound [IUS] assessments at different time points during treatment were reported, along with an appropriate reference standard. The QUADAS-2 tool was used to examine study-level risk of bias. An international panel of experts [n = 18] rated an initial 196 statements [RAND/UCLA process, scale 1-9]. Two videoconferences were conducted, resulting in additional ratings of 149 and 13 statements, respectively. RESULTS Out of 5826 records, 31 full-text articles, 16 abstracts, and one research letter were included; 83% [40/48] of included studies showed a low concern of applicability, and 96% [46/48] had a high risk of bias. A consensus was reached on 41 statements, with clear definitions of IUS treatment response, transmural healing, transmural remission, timing of assessment, and general considerations when using intestinal ultrasound in inflammatory bowel disease. CONCLUSIONS Response criteria and time points of response assessment varied between studies, complicating direct comparison of parameter changes and their relation to treatment outcomes. To ensure a unified approach in routine care and clinical trials, we provide recommendations and definitions for key parameters for intestinal ultrasound response, to incorporate into future prospective studies.
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Affiliation(s)
- Johan F K F Ilvemark
- Corresponding author: Johan Ilvemark, MD, Department of Gastroenterology, Herlev Hospital, Borgmester Ib Juuls Vej 1 2730, Herlev, Denmark.
| | - Tawnya Hansen
- Department of Medicine, Section Gastroenterology, University of Manitoba, Manitoba, MN, Canada
| | - Thomas M Goodsall
- Department of Gastroenterology, John Hunter Hospital, Newcastle, NSW, Australia,Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Jakob B Seidelin
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Heba Al- Farhan
- Department of Gastroenterology, Department of Internal Medicine, Al Amiri Hospital, Kuwait City, Kuwait
| | - Mariangela Allocca
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Jakob Begun
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Robert V Bryant
- Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Britt Christensen
- Department of Gastroenterology, TRoyal Melbourne Hospital, Melbourne, VIC, Australia
| | - Marla C Dubinsky
- Department of Pediatrics, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, New York, NY, USA
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lüneburg, Lüneburg, Germany
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine. University of Calgary, Calgary, AB, Canada
| | - Christian Maaser
- Outpatients Department of Gastroenterology, University Teaching Hospital Lüneburg, Lüneburg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Carolina Palmela
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Angelo, Loures, Portugal
| | - Stephanie R Wilson
- Department of Radiology and Medicine, University of Calgary, Calgary, AB, Canada
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Revés JB, Frias-Gomes C, Morão B, Nascimento C, Palmela C, Fidalgo C, Roque Ramos L, Sampaio A, Glória L, Cravo M, Torres J. Inflammatory Bowel Disease Patients' Perspectives during COVID-19 Pandemic: Results from a Portuguese Survey. GE Port J Gastroenterol 2021; 5:1-9. [PMID: 34934777 PMCID: PMC8678223 DOI: 10.1159/000518945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/03/2021] [Indexed: 11/19/2022]
Abstract
Introduction Patients with inflammatory bowel disease (IBD) do not seem to be at increased risk of infection by SARS-CoV-2, but there is a concern whether immunosuppressive therapy may be associated with more severe disease. Several clinical practice recommendations have been published to help guide IBD care during the COVID-19 pandemic. Nonetheless, few studies have addressed patients' perspectives and fears. We aimed to evaluate Portuguese IBD patients' perspectives on the clinical management of their disease during the SARS-CoV-2 pandemic as well as the impact on their professional life. Methods An anonymous electronic survey was created using REDCap and was distributed by the Portuguese Association of Inflammatory Bowel Disease (APDI) between May and August 2020. Patients' perspectives on immunosuppressive therapy, disease management, interaction with gastroenterology departments, and the impact of the pandemic in their professional life were assessed. Patients' proposals to improve medical care were also evaluated. Descriptive analysis and logistic regression were performed. Results A total of 137 participants answered the survey (79.6% females, mean age 41.7 ± 12.1 years). Although having IBD and receiving treatment with immunosuppressors (thiopurines, steroids, or biologics) were considered promotors of anxiety, most patients (85.4%) agreed that disease remission was a priority and only a minority of patients interrupted their treatment during the pandemic. In multivariate analysis, active disease, biologic treatment, and use of corticosteroids in the last 3 months were perceived by the patients as high-risk features for increased risk of SARS-Cov-2 infection and more severe disease. Fifty-nine patients (44%) believed that their follow-up was influenced by the pandemic and only 58.8% felt that they had the opportunity to discuss their therapeutic options with their doctor. Sixty-three patients (46.0%) were working from home during the pandemic, although this decision was related to IBD and immunosuppressive therapy in only 36.5 and 39.7% of the cases, respectively. Areas where care could have been improved during the pandemic were identified by patients, namely enhancement of the communication with IBD professionals, conciliation of telemedicine with face-to-face appointments, and facilitation of the interaction between patients and employers. Conclusion Most patients agreed that maintaining IBD remission is crucial, and only a minority of the patients stopped their treatment as per their own initiative. IBD status only had a small influence on patients' professional activity during the COVID-19 outbreak, with most changes being related to the pandemic itself.
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Affiliation(s)
- Joana Branco Revés
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Catarina Frias-Gomes
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Bárbara Morão
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Catarina Nascimento
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Carolina Palmela
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Catarina Fidalgo
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Lídia Roque Ramos
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Ana Sampaio
- Associação Portuguesa da Doença Inflamatória do Intestino (APDI), Matosinhos, Portugal
| | - Luísa Glória
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Joana Torres
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Novak KL, Nylund K, Maaser C, Petersen F, Kucharzik T, Lu C, Allocca M, Maconi G, de Voogd F, Christensen B, Vaughan R, Palmela C, Carter D, Wilkens R. Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease. J Crohns Colitis 2021; 15:609-616. [PMID: 33098642 PMCID: PMC8023841 DOI: 10.1093/ecco-jcc/jjaa216] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity. METHODS There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score. RESULTS Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]). CONCLUSIONS Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.
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Affiliation(s)
- Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Medicine, University in Bergen, Klinisk institutt 1, Bergen, Norway
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Mariangela Allocca
- Humanitas Clinical and Research Centre, Rozzano, Italy
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences. FBF- L.Sacco University Hospital, Milan. Italy
| | - Floris de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Rose Vaughan
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Carolina Palmela
- Division of Gastroenterology, Department of General Surgery, Hospital Beatriz Ângelo, Loures, Portugal
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Centre, Tel Hashomer, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
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13
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Moreira-Pinto J, Leão I, Palmela C, Branco F, Godinho J, Simões P, Leal-Costa L, Lopes F, Faria A, Casa-Nova M, Escária A, Costa F, Galvão I, Teixeira J, Passos-Coelho JL. Febrile Neutropenia in Patients with Solid Tumors Undergoing Intravenous Chemotherapy. Oncol Res Treat 2020; 43:605-612. [PMID: 32818937 DOI: 10.1159/000506109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/22/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Febrile neutropenia (FN) is a potentially life-threatening complication of systemic chemotherapy (CT) that often requires hospital admission. Delay in diagnosis and treatment are associated with higher morbidity and mortality. OBJECTIVE We aimed to determine the factors that influence FN episodes outcomes in the emergency room (ER). METHODS This was a retrospective study of all FN episodes (with a collected blood culture [BC]) that occurred between 2012 and 2016 at our institution. FN was defined as a temperature ≥38°C and an absolute neutrophil count (ANC) <1,000/μL, expected to decrease to <500/μL in the following week. RESULTS Between 2012 and 2016, there were 173 FN episodes in 153/1,947 patients treated with intravenous CT. Most of these episodes (n = 121, 70%) were diagnosed in the ER, 29 in the outpatient clinic, and 23 as inpatients. In the ER, the median time was 36 min from hospital nurse triage to medical observation, and 52 min from medical observation to complete blood count specimen collection. There was a positive BC in 33 FN episodes, 72% with Gram-negative bacteria. A total of 160 FN episodes led to hospital admission and 13 were treated as outpatients. Mortality associated with the FN episode was 15% and an ANC <100/μL was predictive of increased mortality. CONCLUSION This study confirms that FN is a serious and common complication of IV CT which must be diagnosed and treated promptly. Profound neutropenia was the only predictive factor of mortality.
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Affiliation(s)
| | - Inês Leão
- Medical Oncology, Centro Hospital Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | | | | | - João Godinho
- Medical Oncology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Pedro Simões
- Medical Oncology, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Fabio Lopes
- Medical Oncology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Ana Faria
- Medical Oncology, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Ana Escária
- Systems Management, Hospital Beatriz Ângelo, Loures, Portugal
| | - Filipa Costa
- Pharmacy, Hospital Beatriz Ângelo, Loures, Portugal
| | - Isabel Galvão
- Clinical Pathology, Hospital Beatriz Ângelo, Loures, Portugal
| | - José Teixeira
- Medical Oncology, Hospital Beatriz Ângelo, Loures, Portugal
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14
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Costa-Santos MP, Palmela C, Torres J, Ferreira A, Velho S, Ourô S, Glória L, Gordo I, Maio R, Cravo M. Preoperative enteral nutrition in adults with complicated Crohn's disease: Effect on disease outcomes and gut microbiota. Nutrition 2020; 70S:100009. [PMID: 34301372 DOI: 10.1016/j.nutx.2020.100009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 02/02/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The use of exclusive enteral nutrition (EEN) in patients with Crohn's disease (CD) before surgical resection can reduce disease activity and improve nutritional status. The mechanism of EEN action is unclear, but it might involve modulation of the intestinal microbiota. The aim of this study was to evaluate the effects (namely changes in gut microbiota) of preoperative EEN in adults with complicated CD referred to surgery. METHODS This was a prospective study of adult patients with CD referred to surgery. Patients with body mass index <18.5 kg/m2, weight loss >10 %, serum albumin <3 g/dL, or a combination of some or all three, received EEN for ≥2 wk. The effects of EEN on clinical (Harvey-Bradshaw Index [HBI]) and laboratory markers (C-reactive protein [CRP], serum albumin, and fecal calprotectin) and fecal microbiota were analyzed after EEN (before surgery) and 6 mo later. We used 16 S rRNA gene sequencing to determine changes in the fecal microbiota. RESULTS Fifteen patients were included, of whom 60% were men with a mean age of 45.4 ± 19.1 y. Of those, 10 received EEN. The median duration of preoperative EEN was 41.5 d (15-70 d). During EEN, there was a significant reduction in mean HBI (8.7 ± 1.9 versus 4.1 ± 2.4; P = 0.001) and CRP (11.7 ± 10.3 versus 0.8 ± 0.8 mg/dL; P = 0.008) and an increase in serum albumin (3.1 ± 0.6 versus 4 ± 0.6 g/dL; P = 0.022). Two patients did not require surgery after EEN. The overall microbial composition changed after EEN (Permutational analysis of variance test, P = 0.046) and there was a significant reduction in α diversity (8 ± 2.3 versus 5.2 ± 1.5; P = 0.023). EEN significantly changed the relative abundance of 11 taxonomic operational units (OTUs). At the family level, we found this was mainly due to the decrease in the Enterobacteriaceae family (7 OTUs). Six months after surgery, α diversity was not different from that before or after EEN; at this time point 6 OTUs were significantly different, mainly due to the decrease of Clostridiales order (3 OTUs). The incidence of postoperative complications and hospital length of stay were similar in EEN and immediate surgery groups, as well as clinical and endoscopic recurrence rates 6 mo after surgery. CONCLUSIONS Preoperative EEN improved disease activity and nutritional status in patients with CD referred to surgery. Despite being malnourished, patients given EEN did not have increased postoperative complications compared with well-nourished patients. During EEN, overall microbiota composition changed and α diversity decreased. EEN did not influence postoperative recurrence and gut microbiota 6 mo after surgery.
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Affiliation(s)
| | - Carolina Palmela
- Gastroenterology Service, Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Torres
- Gastroenterology Service, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Sónia Velho
- Nutrition Service, Hospital Beatriz Ângelo, Loures, Portugal
| | - Susana Ourô
- Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Luísa Glória
- Gastroenterology Service, Hospital Beatriz Ângelo, Loures, Portugal
| | - Isabel Gordo
- Evolutionary Biology Group, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Rui Maio
- Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Service, Hospital Beatriz Ângelo, Loures, Portugal
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15
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Torres J, Ellul P, Langhorst J, Mikocka-Walus A, Barreiro-de Acosta M, Basnayake C, Ding NJS, Gilardi D, Katsanos K, Moser G, Opheim R, Palmela C, Pellino G, Van der Marel S, Vavricka SR. European Crohn's and Colitis Organisation Topical Review on Complementary Medicine and Psychotherapy in Inflammatory Bowel Disease. J Crohns Colitis 2019; 13:673-685e. [PMID: 30820529 DOI: 10.1093/ecco-jcc/jjz051] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/26/2019] [Indexed: 12/11/2022]
Abstract
Patients with inflammatory bowel disease [IBD] increasingly use alternative and complementary therapies, for which appropriate evidence is often lacking. It is estimated that up to half of all patients with IBD use various forms of complementary and alternative medicine during some point in their disease course. Considering the frequent use of such therapies, it is crucial that physicians and patients are informed about their efficacy and safety in order to provide guidance and evidence-based advice. Additionally, increasing evidence suggests that some psychotherapies and mind-body interventions may be beneficial in the management of IBD, but their best use remains a matter of research. Herein, we provide a comprehensive review of some of the most commonly used complementary, alternative and psychotherapy interventions in IBD.
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Affiliation(s)
- Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Jost Langhorst
- Department of Internal Medicine and Integrative Gastroenterology, Kliniken Essen-Mitte and Chair for Integrative Medicine and Translational Gastroenterology, Klinikum Bamberg, University Duisburg-Essen, Germany
| | | | - Manuel Barreiro-de Acosta
- Department of Gastroenterology, IBD Unit, University Hospital Santiago De Compostela (CHUS), Santiago De Compostela, Spain
| | - Chamara Basnayake
- Department of Gastroenterology, St. Vincent's Hospital Melbourne, Fitzroy, Melbourne, Australia
| | - Nik John Sheng Ding
- Department of Gastroenterology, St. Vincent's Hospital Melbourne, Fitzroy, Melbourne, Australia
| | - Daniela Gilardi
- IBD Centre, Department of Gastroenterology, Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Gabriele Moser
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Randi Opheim
- Department of Gastroenterology, Oslo University Hospital, and Department of Nursing Science, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Carolina Palmela
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Sander Van der Marel
- Department of Gastroenterology and Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
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16
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Palmela C, Gouveia C, Fidalgo C, Ferreira AO. Rare case of a giant duodenal ulcer penetrating the pancreas during antiangiogenic treatment. BMJ Case Rep 2019; 12:12/5/e228612. [PMID: 31061194 DOI: 10.1136/bcr-2018-228612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a patient with renal cell carcinoma on pazopanib, who presented with severe upper gastrointestinal bleeding. Endoscopy showed a giant bulbar ulcer with a visible vessel of 4 mm. Due to unavailability of surgical rescue backup, large calibre vessel treatment was delayed. Endoscopy was repeated after 48 hours and showed a reduction in the vessel diameter. Endoscopic adrenalin injection and electrocoagulation were performed. However, the vessel increased in size and became pulsatile. The patient was operated, confirming a giant bulbar ulcer penetrating the pancreas with active bleeding from the gastroduodenal artery. Pazopanib therapy was suspended, and the patient is asymptomatic. Antiangiogenic treatment has been associated with gastrointestinal bleeding, perforation and fistulisation. Although we cannot confirm the causal association between the penetrating ulcer and pazopanib, the absence of Helicobacter pylori infection or non-steroidal anti-inflammatory drugs, and the reported cases of gastrointestinal bleeding during these therapies favour a possible association.
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Affiliation(s)
- Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Angelo, Loures, Portugal
| | - Catarina Gouveia
- Gastroenterology Department, Hospital Beatriz Angelo, Loures, Portugal
| | - Catarina Fidalgo
- Gastroenterology Department, Hospital Beatriz Angelo, Loures, Portugal
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17
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Ten Hove JR, Shah SC, Shaffer SR, Bernstein CN, Castaneda D, Palmela C, Mooiweer E, Elman J, Kumar A, Glass J, Axelrad J, Ullman TA, Colombel JF, Torres J, van Bodegraven AA, Hoentjen F, Jansen JM, de Jong ME, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Itzkowitz SH, Oldenburg B. Consecutive negative findings on colonoscopy during surveillance predict a low risk of advanced neoplasia in patients with inflammatory bowel disease with long-standing colitis: results of a 15-year multicentre, multinational cohort study. Gut 2019; 68:615-622. [PMID: 29720408 DOI: 10.1136/gutjnl-2017-315440] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/31/2018] [Accepted: 03/01/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surveillance colonoscopy is thought to prevent colorectal cancer (CRC) in patients with long-standing colonic IBD, but data regarding the frequency of surveillance and the findings thereof are lacking. Our aim was to determine whether consecutive negative surveillance colonoscopies adequately predict low neoplastic risk. DESIGN A multicentre, multinational database of patients with long-standing IBD colitis without high-risk features and undergoing regular CRC surveillance was constructed. A 'negative' surveillance colonoscopy was predefined as a technically adequate procedure having no postinflammatory polyps, no strictures, no endoscopic disease activity and no evidence of neoplasia; a 'positive' colonoscopy was a technically adequate procedure that included at least one of these criteria. The primary endpoint was advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia or CRC. RESULTS Of 775 patients with long-standing IBD colitis, 44% (n=340) had >1 negative colonoscopy. Patients with consecutive negative surveillance colonoscopies were compared with those who had at least one positive colonoscopy. Both groups had similar demographics, disease-related characteristics, number of surveillance colonoscopies and time intervals between colonoscopies. No aCRN occurred in those with consecutive negative surveillance, compared with an incidence rate of 0.29 to 0.76/100 patient-years (P=0.02) in those having >1 positive colonoscopy on follow-up of 6.1 (P25-P75: 4.6-8.2) years after the index procedure. CONCLUSION Within this large surveillance cohort of patients with colonic IBD and no additional high-risk features, having two consecutive negative colonoscopies predicted a very low risk of aCRN occurrence on follow-up. Our findings suggest that longer surveillance intervals in this selected population may be safe.
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Affiliation(s)
- Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shailja C Shah
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth R Shaffer
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel Castaneda
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Carolina Palmela
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jordan Elman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Akash Kumar
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jason Glass
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Columbia University, New York, USA
| | - Thomas A Ullman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Surgical Department, Gastroenterology Division, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
| | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
| | - Frank Hoentjen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Michiel E de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nofel Mahmmod
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Andrea E van der Meulen-de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Cyriel Y Ponsioen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Christine J van der Woude
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Steven H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
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18
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Palmela C, Peerani F, Castaneda D, Torres J, Itzkowitz SH. Inflammatory Bowel Disease and Primary Sclerosing Cholangitis: A Review of the Phenotype and Associated Specific Features. Gut Liver 2018; 12:17-29. [PMID: 28376583 PMCID: PMC5753680 DOI: 10.5009/gnl16510] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/19/2016] [Accepted: 01/05/2017] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic disease that is associated with inflammatory bowel disease (IBD) in approximately 70% of cases. Although the pathogenesis is still unknown for both diseases, there is increasing evidence to indicate that they share a common underlying predisposition. Herein, we review the epidemiology, diagnosis, disease pathogenesis, and specific clinical features of the PSC-IBD phenotype. Patients with PSC-IBD have a distinct IBD phenotype with an increased incidence of pancolitis, backwash ileitis, and rectal sparing. Despite often having extensive colonic involvement, these patients present with mild intestinal symptoms or are even asymptomatic, which can delay the diagnosis of IBD. Although the IBD phenotype has been well characterized in PSC patients, the natural history and disease behavior of PSC in PSC-IBD patients is less well defined. There is conflicting evidence regarding the course of IBD in PSC-IBD patients who receive liver transplantation and their risk of recurrent PSC. IBD may also be associated with an increased risk of cholangiocarcinoma in PSC patients. Overall, the PSC-IBD population has an increased risk of developing colorectal neoplasia compared to the conventional IBD population. Lifelong annual surveillance colonoscopy is currently recommended.
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Affiliation(s)
- Carolina Palmela
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Farhad Peerani
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Daniel Castaneda
- Division of Internal Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, NY, USA
| | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Goncalves J, Santos M, Acurcio R, Iria I, Gouveia L, Matos Brito P, Catarina Cunha-Santos A, Barbas A, Galvão J, Barbosa I, Aires da Silva F, Alcobia A, Cavaco M, Cardoso M, Delgado Alves J, Carey JJ, Dörner T, Eurico Fonseca J, Palmela C, Torres J, Lima Vieira C, Trabuco D, Fiorino G, Strik A, Yavzori M, Rosa I, Correia L, Magro F, D'Haens G, Ben-Horin S, Lakatos PL, Danese S. Antigenic response to CT-P13 and infliximab originator in inflammatory bowel disease patients shows similar epitope recognition. Aliment Pharmacol Ther 2018; 48:507-522. [PMID: 29873091 DOI: 10.1111/apt.14808] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/18/2018] [Accepted: 04/25/2018] [Indexed: 12/14/2022]
Abstract
AIM To test the cross-immunogenicity of anti-CT-P13 IBD patients' sera to CT-P13/infliximab originator and the comparative antigenicity evoked by CT-P13/infliximab originator sera. METHODS Sera of patients with IBD with measurable anti-CT-P13 antibodies were tested for their cross-reactivity to 5 batches of infliximab originator and CT-P13. Anti-drug antibody positive sera from treated patients were used to compare antigenic epitopes. RESULTS All 42 anti-CT-P13 and 37 anti-infliximab originator IBD sera were cross-reactive with infliximab originator and CT-P13 respectively. Concentration of anti-drug antibodies against infliximab originator or CT-P13 were strongly correlated both for IgG1 and IgG4 (P < 0.001). Anti-CT-P13 sera of patients with IBD (n = 32) exerted similar functional inhibition on CT-P13 or infliximab originator TNF binding capacity and showed reduced binding to CT-P13 in the presence of five different batches of CT-P13 and infliximab originator. Anti-CT-P13 and anti-infliximab originator IBD sera selectively enriched phage-peptides from the VH (CDR1 and CDR3) and VL domains (CDR2 and CDR3) of infliximab. Sera reactivity detected major infliximab epitopes in these regions of infliximab in 60%-79% of patients, and no significant differences were identified between CT-P13 and infliximab originator immunogenic sera. Minor epitopes were localised in framework regions of infliximab with reduced antibody reactivity shown, in 30%-50% of patients. Monoclonal antibodies derived from naïve individuals and ADA-positive IBD patients treated with CT-P13 provided comparable epitope specificity to five different batches of CT-P13 and infliximab originator. CONCLUSIONS These results strongly support a similar antigenic profile for infliximab originator and CT-P13, and point toward a safe switching between the two drugs in anti-drug antibody negative patients.
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Affiliation(s)
| | | | | | | | | | | | | | - A Barbas
- Oeiras, Portugal.,Carnaxide, Portugal
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Shah SC, Ten Hove JR, Castaneda D, Palmela C, Mooiweer E, Colombel JF, Harpaz N, Ullman TA, van Bodegraven AA, Jansen JM, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Oldenburg B, Itzkowitz SH, Torres J. High Risk of Advanced Colorectal Neoplasia in Patients With Primary Sclerosing Cholangitis Associated With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2018; 16:1106-1113.e3. [PMID: 29378311 DOI: 10.1016/j.cgh.2018.01.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC, termed PSC-IBD) are at increased risk for colorectal cancer, but their risk following a diagnosis of low-grade dysplasia (LGD) is not well described. We aimed to determine the rate of advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia and/or colorectal cancer, following a diagnosis of indefinite dysplasia or LGD in this population. METHODS We performed a retrospective, longitudinal study of 1911 patients with colonic IBD (293 with PSC and 1618 without PSC) who underwent more than 2 surveillance colonoscopies from 2000 through 2015 in The Netherlands or the United States (9265 patient-years of follow-up evaluation). We collected data on clinical and demographic features of patients, as well as data from each surveillance colonoscopy and histologic report. For each surveillance colonoscopy, the severity of active inflammation was documented. The primary outcome was a diagnosis of aCRN during follow-up evaluation. We also investigated factors associated with aCRN in patients with or without a prior diagnosis of indefinite dysplasia or LGD. RESULTS Patients with PSC-IBD had a 2-fold higher risk of developing aCRN than patients with non-PSC IBD. Mean inflammation scores did not differ significantly between patients with PSC-IBD (0.55) vs patients with non-PSC IBD (0.56) (P = .89), nor did proportions of patients with LGD (21% of patients with PSC-IBD vs 18% of patients with non-PSC IBD) differ significantly (P = .37). However, the rate of aCRN following a diagnosis of LGD was significantly higher in patients with PSC-IBD (8.4 per 100 patient-years) than patients with non-PSC IBD (3.0 per 100 patient-years; P = .01). PSC (adjusted hazard ratio [aHR], 2.01; 95% CI, 1.09-3.71), increasing age (aHR 1.03; 95% CI, 1.01-1.05), and active inflammation (aHR, 2.39; 95% CI, 1.63-3.49) were independent risk factors for aCRN. Dysplasia was more often endoscopically invisible in patients with PSC-IBD than in patients with non-PSC IBD. CONCLUSIONS In a longitudinal study of almost 2000 patients with colonic IBD, PSC remained a strong independent risk factor for aCRN. Once LGD is detected, aCRN develops at a higher rate in patients with PSC and is more often endoscopically invisible than in patients with only IBD. Our findings support recommendations for careful annual colonoscopic surveillance for patients with IBD and PSC, and consideration of colectomy once LGD is detected.
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Affiliation(s)
- Shailja C Shah
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carolina Palmela
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas A Ullman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Nofel Mahmmod
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Christine J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H Itzkowitz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joana Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Surgical Department, Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal.
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Boyapati RK, Torres J, Palmela C, Parker CE, Silverberg OM, Upadhyaya SD, Nguyen TM, Colombel J. Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn's disease. Cochrane Database Syst Rev 2018; 5:CD012540. [PMID: 29756637 PMCID: PMC6494506 DOI: 10.1002/14651858.cd012540.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Crohn's disease (CD) is a chronic, relapsing and remitting disease of the gastrointestinal tract that can cause significant morbidity and disability. Current treatment guidelines recommend early intervention with immunosuppressant or biological therapy in high-risk patients with a severe disease phenotype at presentation. The feasibility of therapeutic de-escalation once remission is achieved is a commonly encountered question in clinical practice, driven by patient and clinician concerns regarding safety, adverse events, cost and national regulations. Withdrawal of immunosuppressant and biologic drugs in patients with quiescent CD may limit adverse events and reduce healthcare costs. Alternatively, stopping these drug therapies may result in negative outcomes such as disease relapse, drug desensitization, bowel damage and need for surgery. OBJECTIVES To assess the feasibility and safety of discontinuing immunosuppressant or biologic drugs, administered alone or in combination, in patients with quiescent CD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and the Cochrane IBD Group Specialized Register from inception to 19 December 2017. We also searched the reference lists of potentially relevant manuscripts and conference proceedings to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs) and prospective cohort studies that followed patients for a minimum duration of six months after drug discontinuation were considered for inclusion. The patient population of interest was adults (> 18 years) with CD (as defined by conventional clinical, endoscopic or histologic criteria) who had achieved remission while receiving immunosuppressant or biologic drugs administered alone or in combination. Patients then discontinued the drug regimen following a period of maintenance therapy of at least six months. The comparison was usual care (i.e. continuation of the drug regimen). DATA COLLECTION AND ANALYSIS The primary outcome measure was the proportion of patients who relapsed following discontinuation of immunosuppressant or biologic drugs, administered alone or in combination. Secondary outcomes included: the proportion of patients who responded to the reintroduction of immunosuppressant or biologic drugs, given as monotherapy or combination therapy; the proportion of patients who required surgery following relapse; the proportion of patients who required hospitalization for CD following relapse; the proportion of patients who developed new CD-related complications (e.g. fistula, abscesses, strictures) following relapse; the proportion of patients with elevated biomarkers of inflammation (CRP, fecal calprotectin) in those who stop and those who continue therapy; the proportion of patients with anti-drug antibodies and low serum trough drug levels; time to relapse; and the proportion of patients with adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (95% CI). Data were analyzed on an intention-to-treat basis where patients with missing outcome data were assumed to have relapsed. The overall quality of the evidence supporting the primary and secondary outcomes was assessed using the GRADE criteria. MAIN RESULTS A total of six RCTs (326 patients) evaluating therapeutic discontinuation in patients with quiescent CD were eligible for inclusion. In four RCTs azathioprine monotherapy was discontinued, and in two RCTs azathioprine was discontinued from a combination therapy regimen consisting of azathioprine with infliximab. No studies of biologic monotherapy withdrawal were eligible for inclusion. The majority of studies received unclear or low risk of bias ratings, with the exception of three open-label RCTs, which were rated as high risk of bias for blinding. Four RCTs (215 participants) compared discontinuation to continuation of azathioprine monotherapy, while two studies (125 participants) compared discontinuation of azathioprine from a combination regimen to continuation of combination therapy. Continuation of azathioprine monotherapy was shown to be superior to withdrawal for risk of clinical relapse. Thirty-two per cent (36/111) of azathioprine withdrawal participants relapsed compared to 14% (14/104) of participants who continued with azathioprine therapy (RR 0.42, 95% CI 0.24 to 0.72, GRADE low quality evidence). However, it is uncertain if there are any between-group differences in new CD-related complications (RR 0.34, 95% CI 0.06 to 2.08, GRADE low quality evidence), adverse events (RR 0.88, 95% CI 0.67 to 1.17, GRADE low quality evidence), serious adverse events (RR 3.29, 95% CI 0.35 to 30.80, GRADE low quality evidence) or withdrawal due to adverse events (RR 2.59, 95% CI 0.35 to 19.04, GRADE low quality evidence). Common adverse events included infections, mild leukopenia, abdominal symptoms, arthralgias, headache and elevated liver enzymes. No differences between azathioprine withdrawal from combination therapy versus continuation of combination therapy were observed for clinical relapse. Among patients who continued combination therapy with azathioprine and infliximab, 48% (27/56) had a clinical relapse compared to 49% (27/55) of patients discontinued azathioprine but remained on infliximab (RR 1.02, 95% CI 0.68 to 1.52, P = 0.32; GRADE low quality evidence). The effects on adverse events (RR 1.11, 95% CI 0.44 to 2.81, GRADE low quality of evidence) or serious adverse events are uncertain (RR 1.00, 95% CI 0.21 to 4.66; GRADE very low quality of evidence). Common adverse events in the combination therapy studies included infections, liver test elevations, arthralgias and infusion reactions. AUTHORS' CONCLUSIONS The effects of withdrawal of immunosuppressant therapy in people with quiescent Crohn's disease are uncertain. Low quality evidence suggests that continuing azathioprine monotherapy may be superior to withdrawal for avoiding clinical relapse, while very low quality evidence suggests that there may be no difference in clinical relapse rates between discontinuing azathioprine from a combination therapy regimen, compared to continuing combination therapy. It is unclear whether withdrawal of azathioprine, initially administered alone or in combination, impacts on the development of CD-related complications, adverse events, serious adverse events or withdrawal due to adverse events. Further high-quality research is needed in this area, particularly double-blind RCTs in which biologic therapy or an immunosuppressant other than azathioprine is withdrawn.
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Affiliation(s)
- Ray K Boyapati
- Monash HealthDepartment of GastroenterologyClaytonVictoriaAustralia
| | - Joana Torres
- Icahn Medical School of Medicine at Mount SinaiDepartment of Medicine, Division of GastroenterologyNew YorkPortugal
| | - Carolina Palmela
- Hospital Beatriz ÂngeloDivision of Gastroenterology, Surgical DepartmentLouresPortugal
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - Orli M Silverberg
- University of Western OntarioDepartment of Health SciencesLondonONCanada
| | - Sonam D Upadhyaya
- University of Western OntarioDepartment of Health SciencesLondonONCanada
| | - Tran M Nguyen
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanada
| | - Jean‐Frédéric Colombel
- Icahn Medical School of Medicine at Mount SinaiDepartment of Medicine, Division of GastroenterologyNew YorkUSA
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Palmela C, Chevarin C, Xu Z, Torres J, Sevrin G, Hirten R, Barnich N, Ng SC, Colombel JF. Adherent-invasive Escherichia coli in inflammatory bowel disease. Gut 2018; 67:574-587. [PMID: 29141957 DOI: 10.1136/gutjnl-2017-314903] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/20/2017] [Accepted: 10/28/2017] [Indexed: 02/06/2023]
Abstract
Intestinal microbiome dysbiosis has been consistently described in patients with IBD. In the last decades, Escherichia coli, and the adherent-invasive E coli (AIEC) pathotype in particular, has been implicated in the pathogenesis of IBD. Since the discovery of AIEC, two decades ago, progress has been made in unravelling these bacteria characteristics and its interaction with the gut immune system. The mechanisms of adhesion of AIEC to intestinal epithelial cells (via FimH and cell adhesion molecule 6) and its ability to escape autophagy when inside macrophages are reviewed here. We also explore the existing data on the prevalence of AIEC in patients with Crohn's disease and UC, and the association between the presence of AIEC and disease location, activity and postoperative recurrence. Finally, we highlight potential therapeutic strategies targeting AIEC colonisation of gut mucosa, including the use of phage therapy, bacteriocins and antiadhesive molecules. These strategies may open new avenues for the prevention and treatment of IBD in the future.
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Affiliation(s)
- Carolina Palmela
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.,Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Caroline Chevarin
- Université Clermont Auvergne, Inserm U1071, USC-INRA 2018, M2iSH, CRNH Auvergne, F-63000 Clermont-Ferrand, France
| | - Zhilu Xu
- Department of Medicine and Therapeutics, Institute of Digestive Diseases, LKS Institute of Health Science, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.,Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gwladys Sevrin
- Université Clermont Auvergne, Inserm U1071, USC-INRA 2018, M2iSH, CRNH Auvergne, F-63000 Clermont-Ferrand, France
| | - Robert Hirten
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Nicolas Barnich
- Université Clermont Auvergne, Inserm U1071, USC-INRA 2018, M2iSH, CRNH Auvergne, F-63000 Clermont-Ferrand, France
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Diseases, LKS Institute of Health Science, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Torres J, Palmela C, Gomes de Sena P, Santos MPC, Gouveia C, Oliveira MH, Henriques AR, Rodrigues C, Cravo M, Borralho P. Farnesoid X Receptor Expression in Microscopic Colitis: A Potential Role in Disease Etiopathogenesis. GE Port J Gastroenterol 2017; 25:30-37. [PMID: 29457048 DOI: 10.1159/000481197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/04/2017] [Indexed: 12/20/2022]
Abstract
Introduction Microscopic colitis (MC) is a chronic inflammatory bowel disease with unclear etiology. Bile acid (BA) malabsorption has been described in MC patients. Farnesoid X receptor (FXR) is the main BA receptor; FXR-mediated mechanisms prevent the noxious effects of BA accumulation, preserving the integrity of the intestinal epithelial barrier and preventing intestinal inflammation. Aim Our aim was to describe the expression of FXR in patients with MC. Methods Archival formalin-fixed paraffin-embedded samples from the terminal ileum, right and left colon were obtained from patients with MC and matched controls. Immunohistochemistry was performed and nuclear FXR expression scored in a semi-quantitative way. Results 169 formalin-fixed paraffin-embedded samples from 35 patients with MC and 31 controls were retrieved. There was a significant reduction of FXR expression in patients with MC versus controls both in the right colon (moderate-strong FXR expression: 21.1 vs. 64.3%; p = 0.003) and left colon (moderate-strong FXR expression: 8.3 vs. 38.7%; p = 0.027). No significant differences in FXR expression were observed in the ileum of patients with MC (moderate-strong FXR expression: 76.9 vs. 90.9%; p = 0.5). We found no difference in FXR expression between the two types of MC. No association between the degree of lymphocyte infiltration or the thickness of collagen band and FXR expression was found. Conclusions Patients with MC present a significantly lower expression of FXR in the colon. This could render colonic epithelial cells more susceptible to the deleterious effects of BA, contributing to disease pathogenesis and symptoms in MC.
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Affiliation(s)
- Joana Torres
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Pedro Gomes de Sena
- Pathology Department, Hospital Beatriz Ângelo, Loures, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Maria Pia Costa Santos
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Catarina Gouveia
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Maria Helena Oliveira
- Pathology Department, Hospital Beatriz Ângelo, Loures, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Raquel Henriques
- Faculty of Medicine, Universidade de Lisboa, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Cecília Rodrigues
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Marília Cravo
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Paula Borralho
- Gastroenterology Department, Hospital Beatriz Ângelo, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal.,Pathology Department, Hospital Cuf Descobertas, Lisbon, Portugal
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Gouveia C, Loureiro R, Ferreira R, Oliveira Ferreira A, Santos AA, Santos MPC, Palmela C, Cravo M. Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis. GE Port J Gastroenterol 2017; 25:24-29. [PMID: 29457047 DOI: 10.1159/000479973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 07/04/2017] [Indexed: 01/27/2023]
Abstract
Introduction The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients. Aim The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis. Material/Methods A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography. Results Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%. Discussion and Conclusions Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.
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Affiliation(s)
- Catarina Gouveia
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Rui Loureiro
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Rosa Ferreira
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | | | | | | | - Carolina Palmela
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
| | - Marília Cravo
- Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Lisbon, Portugal
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Ferreira A, Costa M, Palmela C, Velho S, Torres J, Ouro S, Luisa G, Cravo M. SUN-P264: The Impact of Preoperative Exclusive Enteral Nutrition in Malnourished Patients With Crohn’s Disease. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)30365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cravo ML, Velho S, Torres J, Costa Santos MP, Palmela C, Cruz R, Strecht J, Maio R, Baracos V. Lower skeletal muscle attenuation and high visceral fat index are associated with complicated disease in patients with Crohn's disease: An exploratory study. Clin Nutr ESPEN 2017; 21:79-85. [PMID: 30014873 DOI: 10.1016/j.clnesp.2017.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 04/01/2017] [Accepted: 04/09/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS The prognostic value of body composition analysis in patients with Crohn's disease (CD) is poorly explored. The aims of the present study were to assess fat and skeletal muscle compartments including muscle radiation attenuation (MA) in patients with CD, and to analyze its predictive value to identify complicated phenotypes. METHODS Seventy one patients with CD who have had an abdominal CT within one month of clinical, laboratory, and endoscopic evaluation were included. Skeletal muscle area (SMA) and index (SMI), visceral fat area (VFA) and index (VFI), subcutaneous fat area (SFA), and mean MA were measured using appropriate software. Sarcopenia, as defined by Martin's criteria was assessed. Montreal classification was used to characterize disease phenotype. RESULTS Mean MA was lower in patients >40 years (p = 0.001), L2 (p = 0.09) and stricturing/penetrating disease (p = 0.03) whereas SMA and SMI were significantly lower in patients with positive C-reactive protein and previous hospital admissions (p < 0.01). On multivariate analysis, higher MA was protective against the complicated disease phenotype (stricturing/penetrating disease and/or previous surgeries) (OR 0.81; p = 0.002) whereas a high visceral fat index increased such risk (OR 26.1; p = 0.02). A ROC curve showed a 82.4% sensibility, 90.3% specificity, 17.6% positive predictive value, 9.7% negative predictive value and an area under the curve (AUC) of 0.91 for body composition analysis to predict complicated disease. CONCLUSIONS A lower muscle attenuation and a high visceral fat index seem to be associated with more severe phenotypes in patients with CD.
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Affiliation(s)
- Marília L Cravo
- Department of Gastroenterology, Hospital Beatriz Ângelo, Portugal
| | - Sónia Velho
- Department of Nutrition and Dietetics, Hospital Beatriz Ângelo, Portugal
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Portugal
| | | | - Carolina Palmela
- Department of Gastroenterology, Hospital Beatriz Ângelo, Portugal
| | - Rita Cruz
- Department of Radiology, Hospital Beatriz Ângelo, Portugal
| | - João Strecht
- Department of Radiology, Hospital Beatriz Ângelo, Portugal
| | - Rui Maio
- Department of Surgery, Hospital Beatriz Ângelo, Portugal
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Torres J, Palmela C, Brito H, Bao X, Ruiqi H, Moura-Santos P, Pereira da Silva J, Oliveira A, Vieira C, Perez K, Itzkowitz SH, Colombel JF, Humbert L, Rainteau D, Cravo M, Rodrigues CM, Hu J. The gut microbiota, bile acids and their correlation in primary sclerosing cholangitis associated with inflammatory bowel disease. United European Gastroenterol J 2017; 6:112-122. [PMID: 29435321 DOI: 10.1177/2050640617708953] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 04/12/2017] [Indexed: 12/16/2022] Open
Abstract
Background Patients with primary sclerosing cholangitis associated with inflammatory bowel disease (PSC-IBD) have a very high risk of developing colorectal neoplasia. Alterations in the gut microbiota and/or gut bile acids could account for the increase in this risk. However, no studies have yet investigated the net result of cholestasis and a potentially altered bile acid pool interacting with a dysbiotic gut flora in the inflamed colon of PSC-IBD. Aim The aim of this study was to compare the gut microbiota and stool bile acid profiles, as well as and their correlation in patients with PSC-IBD and inflammatory bowel disease alone. Methods Thirty patients with extensive colitis (15 with concomitant primary sclerosing cholangitis) were prospectively recruited and fresh stool samples were collected. The microbiota composition in stool was profiled using bacterial 16S rRNA sequencing. Stool bile acids were assessed by high-performance liquid chromatography tandem mass spectrometry. Results The total stool bile acid pool was significantly reduced in PSC-IBD. Although no major differences were observed in the individual bile acid species in stool, their overall combination allowed a good separation between PSC-IBD and inflammatory bowel disease. Compared with inflammatory bowel disease alone, PSC-IBD patients demonstrated a different gut microbiota composition with enrichment in Ruminococcus and Fusobacterium genus compared with inflammatory bowel disease. At the operational taxonomic unit level major shifts were observed within the Firmicutes (73%) and Bacteroidetes phyla (17%). Specific microbiota-bile acid correlations were observed in PSC-IBD, where 12% of the operational taxonomic units strongly correlated with stool bile acids, compared with only 0.4% in non-PSC-IBD. Conclusions Patients with PSC-IBD had distinct microbiota and microbiota-stool bile acid correlations as compared with inflammatory bowel disease. Whether these changes are associated with, or may predispose to, an increased risk of colorectal neoplasia needs to be further clarified.
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Affiliation(s)
- J Torres
- Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal.,Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - C Palmela
- Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - H Brito
- Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal
| | - X Bao
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - H Ruiqi
- Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - P Moura-Santos
- Gastroenterology and Hepatology Division, Hospital de Santa Maria, Lisboa, Portugal
| | - J Pereira da Silva
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa, Portugal
| | - A Oliveira
- Department of Gastroenterology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - C Vieira
- Department of Gastroenterology, Centro Hospitalar Barreiro Montijo, Portugal
| | - K Perez
- INSERM ERL1157, Sorbonne Université - UPMC Univ Paris 06, Paris, France
| | - S H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - J F Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - L Humbert
- INSERM ERL1157, Sorbonne Université - UPMC Univ Paris 06, Paris, France
| | - D Rainteau
- INSERM ERL1157, Sorbonne Université - UPMC Univ Paris 06, Paris, France
| | - M Cravo
- Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - C M Rodrigues
- Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal
| | - J Hu
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
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Palmela C, Velho S, Agostinho L, Branco F, Santos M, Santos MPC, Oliveira MH, Strecht J, Maio R, Cravo M, Baracos VE. Body Composition as a Prognostic Factor of Neoadjuvant Chemotherapy Toxicity and Outcome in Patients with Locally Advanced Gastric Cancer. J Gastric Cancer 2017; 17:74-87. [PMID: 28337365 PMCID: PMC5362836 DOI: 10.5230/jgc.2017.17.e8] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 03/03/2017] [Accepted: 03/03/2017] [Indexed: 12/29/2022] Open
Abstract
Purpose Neoadjuvant chemotherapy has been shown to improve survival in locally advanced gastric cancer, but it is associated with significant toxicity. Sarcopenia and sarcopenic obesity have been studied in several types of cancers and have been reported to be associated with higher chemotherapy toxicity and morbi-mortality. The aim of this study was to assess the prevalence of sarcopenia/sarcopenic obesity in patients with gastric cancer, as well as its association with chemotherapy toxicity and long-term outcomes. Materials and Methods A retrospective analysis was performed using an academic cancer center patient cohort diagnosed with locally advanced gastric cancer between January 2012 and December 2014 and treated with neoadjuvant chemotherapy. We analyzed body composition (skeletal muscle and visceral fat index) in axial computed tomography images. Results A total of 48 patients met the inclusion criteria. The mean age was 68±10 years, and 33 patients (69%) were men. Dose-limiting toxicity was observed in 22 patients (46%), and treatment was terminated early owing to toxicity in 17 patients (35%). Median follow-up was 17 months. Sarcopenia and sarcopenic obesity were found at diagnosis in 23% and 10% of patients, respectively. We observed an association between termination of chemotherapy and both sarcopenia (P=0.069) and sarcopenic obesity (P=0.004). On multivariate analysis, the odds of treatment termination were higher in patients with sarcopenia (odds ratio=4.23; P=0.050). Patients with sarcopenic obesity showed lower overall survival (median survival of 6 months [95% confidence interval {CI}=3.9–8.5] vs. 25 months [95% CI=20.2–38.2]; log-rank test P=0.000). Conclusions Sarcopenia and sarcopenic obesity were associated with early termination of neoadjuvant chemotherapy in patients with gastric cancer; additionally, sarcopenic obesity was associated with poor survival.
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Affiliation(s)
- Carolina Palmela
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Sónia Velho
- Nutrition Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Lisa Agostinho
- Radiology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Marta Santos
- General Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Maria Pia Costa Santos
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - João Strecht
- Radiology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rui Maio
- General Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Vickie E Baracos
- Division of Palliative Care Medicine, Department of Oncology, Cross Cancer Institute, University of Alberta, Alberta, Canada
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Oliveira Ferreira A, Fidalgo C, Palmela C, Costa Santos MP, Torres J, Nunes J, Loureiro R, Ferreira R, Barjas E, Glória L, Santos AA, Cravo M. Adenoma Detection Rate: I Will Show You Mine if You Show Me Yours. GE Port J Gastroenterol 2016; 24:61-67. [PMID: 28848785 DOI: 10.1159/000450901] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/13/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the first cause of cancer-related mortality in Portugal. CRC screening reduces disease-specific mortality. Colonoscopy is currently the preferred method for screening as it may contribute to the reduction of CRC incidence. This beneficial effect is strongly associated with the adenoma detection rate (ADR). AIM Our aim was to evaluate the quality of colonoscopy at our unit by measuring the currently accepted quality parameters and publish them as benchmarking indicators. METHODS From 5,860 colonoscopies, 654 screening procedures (with and without previous fecal occult blood testing) were analyzed. RESULTS The mean age of the patients was 66.4 ± 7.8 years, and the gender distribution was 1:1. The overall ADR was 36% (95% confidence interval [CI] 32-39), the mean number of adenomas per colonoscopy was 0.66 (95% CI 0.56-0.77), and the sessile serrate lesion detection rate was 1% (95% CI 0-2). The bowel preparation was rated as adequate in 496 (76%) patients. The adjusted cecal intubation rate (CIR) was 93.7% (95% CI 91.7-95.8). Most colonoscopies were performed under monitored anesthesia care (53%), and 35% were unsedated. The use of sedation (propofol or midazolam based) was associated with a higher CIR with an odds ratio of 3.60 (95% CI 2.02-6.40, p < 0.001). CONCLUSION Our data show an above-standard ADR. The frequency of poor bowel preparation and the low sessile serrated lesion detection rate were acknowledged, and actions were implemented to improve both indicators. Quality auditing in colonoscopy should be compulsory, and while many units may do so internally, this is the first national report from a high-throughput endoscopy unit.
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Affiliation(s)
| | - Catarina Fidalgo
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Joana Torres
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Nunes
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rui Loureiro
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rosa Ferreira
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Elídio Barjas
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Luísa Glória
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Marília Cravo
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
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Costa Santos MP, Palmela C, Ferreira R, Barjas E, Santos AA, Maio R, Cravo M. Self-Expandable Metal Stents for Colorectal Cancer: From Guidelines to Clinical Practice. GE Port J Gastroenterol 2016; 23:293-299. [PMID: 28868482 PMCID: PMC5580185 DOI: 10.1016/j.jpge.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Colonic self-expandable metal stent placement is widely used for palliation of obstructive colorectal cancer. The European recommendations for stent placement as a bridge to elective surgery in obstructive colorectal cancer were recently reviewed. The aim of this study was to evaluate the efficacy and safety of stent placement in obstructive colorectal cancer and to discuss these recent guidelines. MATERIALS AND METHODS Demographic characteristics, procedure indications, complications and final outcome in patients with obstructive colorectal cancer who underwent endoscopic stent placement between January 2012 and June 2015 were retrospectively analyzed. Statistical analysis was performed with SPSS V22. RESULTS Thirty-six patients were included, 20 (56%) women, mean age 70.6 ± 10.9 years. Stent placement as a bridge to elective surgery was performed in 75% (n = 27) of patients and with palliation intent in 25% (n = 9). In 94% (n = 34) of procedures, technical and clinical success was achieved. A total of eleven (11%) complications were observed: 2 migrations and 9 perforations. No procedure related death was recorded. When stents were placed as a bridge to surgery, average time between endoscopic procedure and surgery was 11.7 ± 9.4 days (excluding three patients who underwent neoadjuvant chemotherapy). Six perforations were recorded in this group: one overt and five silent (three during surgery and two after histopathological examination of the resected specimen). Twenty-one patients underwent adjuvant chemotherapy. During the follow-up period of 14.7 ± 10.9 months recurrence was observed in five patients. None of the recurrence occurred in the group of patients with perforation. CONCLUSIONS In this study, stent placement was an effective procedure in obstructive colorectal cancer. It was mainly used as a bridge to elective surgery. However, a significant rate of silent perforation was observed, which may compromise the oncological outcome of these potentially curable patients. Prospective real life studies are warranted for a better definition of actual recommendations.
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Affiliation(s)
| | - Carolina Palmela
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Rosa Ferreira
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Elídio Barjas
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Rui Maio
- General Surgery Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal
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Palmela C, Fonseca C, Faria R, Baptista RB, Ribeiro S, Ferreira AO. Increased risk for metachronous gastric adenocarcinoma following gastric MALT lymphoma-A US population-based study. United European Gastroenterol J 2016; 5:473-478. [PMID: 28588876 DOI: 10.1177/2050640616671643] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Gastric mucosa-associated lymphoid tissue lymphoma (gMALT) and gastric adenocarcinoma (GC) are long-term complications of chronic Helicobacter pylori (HP) gastritis. Treatment of HP infection induces remission in most patients with gMALT. Endoscopic follow-up is not currently endorsed after complete remission. However, the risk of GC in these patients is unclear. OBJECTIVE The objective of this study is to estimate GC risk in gMALT patients. METHODS The National Cancer Institute Surveillance, Epidemiology and End Results 13 (SEER) database-Nov 2014 Sub (1992-2012) was used to identify adult patients diagnosed with gMALT between 1992 and 2012. The standardized incidence ratio of second primary GC after a latency period of 12 months was calculated and compared to a reference SEER cohort of identical age, sex and time period. The risk of GC in these patients was also stratified by latency period (five years) and age. RESULTS We identified 2195 cases of gMALT lymphoma, and 20 (0.91%) of them subsequently developed GC with a relative risk (RR) of 4.32 (95% CI 2.64-6.67) compared to the American population. The median latency time was five years and the risk was maintained afterward (RR 4.92, 95% CI 2.45-8.79). When stratified by age group the risk was highest for the 45-64 group (RR 14.04, 95% CI 5.64-28.93). CONCLUSION gMALT lymphoma is associated with an increased risk of metachronous gastric adenocarcinoma. The risk is still present after more than five years of follow-up. Further studies may clarify the most adequate follow-up strategy.
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Affiliation(s)
- Carolina Palmela
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Cristina Fonseca
- Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, EPE, Coimbra, Portugal
| | - Rita Faria
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
| | - Rute Baeta Baptista
- Department of Pediatrics, Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
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Cravo M, Velho S, Santos M, Palmela C, Cruz R, Strecht J, Torres J, Baracos V. MON-P047: Lower Skeletal Muscle Radiation Attenuation is Associated with Stricturing or Penetrating Phenotype in Patients with Crohn's Disease (CD): An Exploratory Study. Clin Nutr 2016. [DOI: 10.1016/s0261-5614(16)30681-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cravo M, Fidalgo C, Garrido R, Rodrigues T, Luz G, Palmela C, Santos M, Lopes F, Maio R. Towards curative therapy in gastric cancer: Faraway, so close! World J Gastroenterol 2015; 21:11609-11620. [PMID: 26556990 PMCID: PMC4631964 DOI: 10.3748/wjg.v21.i41.11609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/14/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023] Open
Abstract
Although recent diagnostic and therapeutic advances have substantially improved the survival of patients with gastric cancer (GC), the overall prognosis is still poor. Surgery is the only curative treatment and should be performed in experienced centers. Due to high relapse following surgery, complementary and systemic treatment aimed at eradicating micrometastasis should be performed in most cases. Cytotoxic treatments are effective in downstaging locally advanced cancer, but different sensitivities and toxicities probably exist in different GC subtypes. Current treatment protocols are based primarily on clinical data and histological features, but molecular biomarkers that would allow for the prediction of treatment responses are urgently needed. Understanding how host factors are responsible for inter-individual variability of drug response or toxicity will also contribute to the development of more effective and less toxic treatments.
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Abstract
Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory disease of the gastrointestinal (GI) tract. In the past decade a shift in the treatment paradigm of IBD has ensued. The availability of drugs capable of inducing mucosal healing, combined with the recognition that IBD is not an intermittent disease, but rather a progressive one causing bowel damage and disability, led us to a more stringent strategy. Tailored therapy with more aggressive treatment in high-risk patients, treating beyond symptoms, intervening early before damage occurs, optimizing therapeutic regimens, and actively pursuing sustained remission and sustained control of inflammation are strategies that are slowly being incorporated in our clinical practice. Furthermore, new drugs targeting different immunological pathways, such as vedolizumab, have recently been approved and therefore more therapeutic resources for patients failing anti-tumour necrosis factor alpha (anti-TNFα) agents will be available. The future years look promising for IBD. Hopefully the new trends in IBD management, combined with new drugs, will make possible to change the course of disease and provide better therapy and quality of life for patients suffering from this disabling disease.
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Affiliation(s)
| | | | - Marilia Cravo
- Gastroenterology Department, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
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Martins MJ, Laíns I, Brochado B, Oliveira-Santos M, Pinto Teixeira P, Brandão M, Cerqueira RJ, Castro-Ferreira R, Bernardes C, Nobre Menezes M, Soares Baptista B, Ladeiras-Lopes R, Cruz Rei M, Pires da Rosa G, Martins JL, Mendonça Sanches M, Ferreira-Pinto MJ, Rato M, Costa e Silva M, Policiano C, Beato J, Barbosa-Breda J, Pimentel Torres J, Leal I, Aguiar Rosa S, Carvalho Ribeiro B, Rego Costa F, Palmela C, Cúrdia Gonçalves T, Morais L, Marques TR. Satisfação com a Especialidade entre os Internos da Formação Específica em Portugal. ACTA MEDICA PORT 2015. [DOI: 10.20344/amp.5899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<strong>Introduction:</strong> The satisfaction with the medical profession has been identified as an essential factor for the quality of care, the wellbeing of patients and the healthcare systems’ stability. Recent studies have emphasized a growing discontent of physicians, mainly as a result of changes in labor relations.<br /><strong>Objectives: </strong>To assess the perception of Portuguese medical residents about: correspondence of residency with previous expectations; degree of satisfaction with the specialty, profession and place of training; reasons for dissatisfaction; opinion regarding clinical practice in Portugal and emigration intents.<br /><strong>Material and Methods:</strong> Cross-sectional study. Data collection was conducted through the “Satisfaction with Specialization Survey”, created in an online platform, designed for this purpose, between May and August 2014.<br /><strong>Results: </strong>From a total population of 5788 medical residents, 804 (12.25 %) responses were obtained. From this sample, 77% of the responses were from residents in the first three years. Results showed that 90% of the residents are satisfied with their specialty, 85% with the medical profession and 86% with their place of training. Nevertheless, results showed a decrease in satisfaction over the final years of residency. The overall assessment of the clinical practice scenario in Portugal was negative and 65% of residents have plans to emigrate after completing their residency.<br /><strong>Conclusion:</strong> Portuguese residents revealed high satisfaction levels regarding their profession. However, their views on Portuguese clinical practice and the results concerning the intent to emigrate highlight the need to take steps to reverse this scenario.
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Martins MJ, Laíns I, Brochado B, Oliveira-Santos M, Teixeira PP, Brandão M, Cerqueira RJ, Castro-Ferreira R, Bernardes C, Menezes MN, Baptista BS, Ladeiras-Lopes R, Rei MC, Rosa GPD, Martins JL, Mendonça Sanches M, Ferreira-Pinto MJ, Rato M, Costa e Silva M, Policiano C, Beato J, Barbosa-Breda J, Torres JP, Leal I, Rosa SA, Ribeiro BC, Costa FR, Palmela C, Gonçalves TC, Morais L, Marques TR. [Career Satisfaction of Medical Residents in Portugal]. ACTA MEDICA PORT 2015; 28:209-221. [PMID: 26061512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/16/2015] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The satisfaction with the medical profession has been identified as an essential factor for the quality of care, the wellbeing of patients and the healthcare systems' stability. Recent studies have emphasized a growing discontent of physicians, mainly as a result of changes in labor relations. OBJECTIVES To assess the perception of Portuguese medical residents about: correspondence of residency with previous expectations; degree of satisfaction with the specialty, profession and place of training; reasons for dissatisfaction; opinion regarding clinical practice in Portugal and emigration intents. MATERIAL AND METHODS Cross-sectional study. Data collection was conducted through the "Satisfaction with Specialization Survey", created in an online platform, designed for this purpose, between May and August 2014. RESULTS From a total population of 5788 medical residents, 804 (12.25 %) responses were obtained. From this sample, 77% of the responses were from residents in the first three years. Results showed that 90% of the residents are satisfied with their specialty, 85% with the medical profession and 86% with their place of training. Nevertheless, results showed a decrease in satisfaction over the final years of residency. The overall assessment of the clinical practice scenario in Portugal was negative and 65% of residents have plans to emigrate after completing their residency. CONCLUSION Portuguese residents revealed high satisfaction levels regarding their profession. However, their views on Portuguese clinical practice and the results concerning the intent to emigrate highlight the need to take steps to reverse this scenario.
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Affiliation(s)
- Maria João Martins
- Faculdade de Psicologia e Ciências da Educação. Universidade de Coimbra. Coimbra. Portugal
| | - Inês Laíns
- Serviço de Oftalmologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal. Faculdade de Medicina da Universidade de Coimbra. Coimbra. Portugal
| | - Bruno Brochado
- Serviço de Cardiologia. Centro Hospitalar do Porto. Porto. Portugal
| | - Manuel Oliveira-Santos
- Serviço de Cardiologia A. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | | | - Mariana Brandão
- Serviço de Oncologia Médica. Instituto Português de Oncologia Francisco Gentil. Porto. Portugal
| | - Rui João Cerqueira
- Serviço de Cirurgia Cardiotorácica. Centro Hospitalar São João. Porto. Portugal. Departamento de Fisiologia e Cirurgia Cardiotorácica. Faculdade de Medicina da Universidade do Porto. Porto. Portugal
| | | | - Carlos Bernardes
- Serviço de Gastroenterologia. Hospital de Santo António dos Capuchos. Centro Hospitalar de Lisboa Central. Lisboa. Portugal
| | - Miguel Nobre Menezes
- Serviço de Cardiologia. Hospital de Santa Maria. Centro Hospitalar de Lisboa Norte. Lisboa. Portugal
| | | | - Ricardo Ladeiras-Lopes
- Serviço de Cardiologia. Centro Hospitalar de Vila Nova de Gaia/Espinho. Vila Nova de Gaia. Portugal. Unidade de Investigação Cardiovascular. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Mariana Cruz Rei
- Serviço de Neurologia. Centro Hospitalar Entre o Douro e Vouga. Santa Maria da Feira. Portugal
| | | | - José Luís Martins
- Serviço de Cardiologia. Centro Hospitalar do Baixo Vouga. Aveiro. Portugal
| | - Maria Mendonça Sanches
- Serviço de Dermatologia. Hospital de Santa Maria. Centro Hospitalar de Lisboa Norte. Lisboa. Portugal
| | - Manuel J Ferreira-Pinto
- Serviço de Cirurgia Cardiotorácica. Centro Hospitalar São João. Porto. Portugal. Serviço de Oncologia Cirúrgica. Instituto Português de Oncologia Francisco Gentil. Porto. Portugal
| | - Margarida Rato
- Serviço de Dermatovenerologia. Hospital Distrital de Santarém. Santarém. Portugal
| | | | - Catarina Policiano
- Departamento de Ginecologia e Obstetrícia. Hospital de Santa Maria. Centro Hospitalar Lisboa Norte. Lisboa. Portugal
| | - João Beato
- Departamento de Oftalmologia. Centro Hospitalar de São João. Porto. Portugal
| | - João Barbosa-Breda
- Departamento de Oftalmologia. Centro Hospitalar de São João. Porto. Portugal
| | - João Pimentel Torres
- Serviço de Urologia. Hospital de Braga. Braga. Portugal. Instituto de Ciências da Vida e da Saúde. Universidade do Minho. Braga. Portugal
| | - Inês Leal
- Departamento de Ãâtica e Deontologia Médica. Faculdade de Medicina de Lisboa. Lisboa. Portugal. Serviço de Oftalmologia. Hospital de Santa Maria. Centro Hospitalar Lisboa Norte. Lisboa. Portugal
| | - Sílvia Aguiar Rosa
- Serviço de Gastroenterologia. Hospital de Santo António dos Capuchos. Centro Hospitalar de Lisboa Central. Lisboa. Portugal
| | | | | | - Carolina Palmela
- Serviço de Gastroenterologia. Hospital Beatriz ÃÇngelo. Loures. Portugal
| | | | - Luis Morais
- Serviço de Cardiologia. Centro Hospitalar do Porto. Porto. Portugal
| | - Tiago Reis Marques
- Department of Psychosis Studies. Institute of Psychiatry, Psychology and Neuroscience. King´s College. London. United Kingdom
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Palmela C, Badura R, Valadas E. Acute Q fever in Portugal. Epidemiological and clinical features of 32 hospitalized patients. Germs 2012; 2:43-59. [PMID: 24432263 DOI: 10.11599/germs.2012.1013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 05/22/2012] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Q fever is a worldwide zoonosis caused by Coxiella burnetii. The main characteristic of acute Q fever is its clinical polymorphism, usually presenting as a febrile illness with varying degrees of hepatitis and/or pneumonia. Q fever is endemic in Portugal, and it is an obligatory notifiable disease since 1999. However, its epidemiological and clinical characteristics are still incompletely described. METHODS We performed a retrospective study of 32 cases admitted in the Infectious Diseases Department, Santa Maria's University Hospital, from January 2001 to December 2010, in whom acute Q fever was diagnosed by the presence of antibodies to phase II Coxiella burnetii antigens associated with a compatible clinical syndrome. RESULTS Out of the 32 cases recorded, 29 (91%) were male, with a male:female ratio of 9.7:1. Individuals at productive age were mainly affected (88%, n=28, with ages between 25 and 64 years). Clinically, the most common manifestation of acute Q fever was hepatic involvement (84%, n=27), which occurred isolated in 53% (n=17) of the cases. Hepatitis was more severe, presenting with higher values of liver function tests, in patients presenting both pulmonary and hepatic involvement. Additionally, we report one case of myocarditis and another one with neurological involvement. Empiric but appropriate antibiotic therapy was given in 66% (n=21) of the cases. There was a complete recovery in 94% (n=30) of the patients, and one death. We confirmed the sub-notification of this disease in Portugal, with only 47% (n=15) of the cases notified. CONCLUSION In Portugal further studies are needed to confirm our results. From the 32 cases studied, acute Q fever presented more frequently as a febrile disease with hepatic involvement affecting mainly young male individuals. Furthermore, acute Q fever is clearly underdiagnosed and underreported in Portugal, which suggests that an increased awareness of the disease is needed, together with a broader use of serological testing.
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Affiliation(s)
| | - Robert Badura
- MD, Infectious and Parasitic Diseases University Clinic, Faculty of Medicine, Santa Maria's University Hospital, Lisbon, Portugal
| | - Emília Valadas
- PhD, Infectious and Parasitic Diseases University Clinic, Faculty of Medicine, Santa Maria's University Hospital, Lisbon, Portugal
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