Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis

BACKGROUND

Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort.

METHOD

We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality.

RESULTS

Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2). Table 1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age  Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5  < 0.001 Gender  < 0.001  Male 59.1% 52.3%  Female 40.9% 47.7% *Missing-475 Age groups  < 0.001  18-44 3.7% 14.3%  45-64 48% 52.9%  65-84 32.2% 28.7%  ≥ 85 16.1% 4.1% Race  < 0.001  Caucasians 67.4% 61.9%  African Americans 9.6% 16.8%  Others 23% 21.3% *Missing-10 Insurance type  < 0.001  Medicare 40.9% 36.3%  Medicaid 17.2% 24.3%  Private 31.8% 27.9%  Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7%  < 0.001 Admission Type  < 0.001  Emergent 93.7% 94.3%  Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control  < 0.001  Rural 7.8% 10%  Urban nonteaching 26.3% 26.6%  Urban teaching 65.9% 63.4% Table 2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5%  < .0001 1.72(1.65-1.80)  < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6)  < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842)  < .0001 In-Hospital Complications  ARDS 0.4% 0.3% 0.08  Ventilator dependence respiratory failure 0.23% 0.29% 0.25  Septicemia 15.2% 9.6%  < .0001  Septic Shock 6.1% 2.9%  < .0001  AKI 24.8% 14.9%  < .0001 Disposition  < .0001  Discharge to home 58.9% 74.9%  Transfer other: includes  Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6%  Home health care 11.5% 8.1%  Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.

CSF1R-mediated myeloid cell depletion shifts the ratio of motor cortical excitatory to inhibitory neurons in a multiple system atrophy model

Motor cortical circuit functions depend on the coordinated fine-tuning of two functionally diverse neuronal populations: glutamatergic pyramidal neurons providing synaptic excitation and GABAergic interneurons adjusting the response of pyramidal neurons through synaptic inhibition. Microglia are brain resident macrophages which dynamically refine cortical circuits by monitoring perineuronal extracellular matrix and remodelling synapses. Previously, we showed that colony-stimulating factor 1 receptor (CSF1R)-mediated myeloid cell depletion extended the lifespan, but impaired motor functions of MBP29 mice, a mouse model for multiple system atrophy. In order to better understand the mechanisms underlying these motor deficits we characterized the microglial involvement in the cortical balance of GABAergic interneurons and glutamatergic pyramidal neurons in 4-months-old MBP29 mice following CSF1R inhibition for 12 weeks. Lack of myeloid cells resulted in a decreased number of COUP TF1 interacting protein 2-positive (CTIP2+) layer V pyramidal neurons, however in a proportional increase of calretinin-positive GABAergic interneurons in MBP29 mice. While myeloid cell depletion did not alter the expression of important presynaptic and postsynaptic proteins, the loss of cortical perineuronal net area was attenuated by CSF1R inhibition in MBP29 mice. These cortical changes may restrict synaptic plasticity and potentially modify parvalbumin-positive perisomatic input. Collectively, this study suggests, that the lack of myeloid cells shifts the neuronal balance toward an increased inhibitory connectivity in the motor cortex of MBP29 mice thereby potentially deteriorating motor functions.

Distinct forebrain regions define a dichotomous astrocytic profile in multiple system atrophy

The growing recognition of a dichotomous role of astrocytes in neurodegenerative processes has heightened the need for unraveling distinct astrocytic subtypes in neurological disorders. In multiple system atrophy (MSA), a rare, rapidly progressing atypical Parkinsonian disease characterized by increased astrocyte reactivity. However the specific contribution of astrocyte subtypes to neuropathology remains elusive. Hence, we first set out to profile glial fibrillary acidic protein levels in astrocytes across the human post mortem motor cortex, putamen, and substantia nigra of MSA patients and observed an overall profound astrocytic response. Matching the post mortem human findings, a similar astrocytic phenotype was present in a transgenic MSA mouse model. Notably, MSA mice exhibited a decreased expression of the glutamate transporter 1 and glutamate aspartate transporter in the basal ganglia, but not the motor cortex. We developed an optimized astrocyte isolation protocol based on magnetic-activated cell sorting via ATPase Na+/K+ transporting subunit beta 2 and profiled the transcriptomic landscape of striatal and cortical astrocytes in transgenic MSA mice. The gene expression profile of astrocytes in the motor cortex displayed an anti-inflammatory signature with increased oligodendroglial and pro-myelinogenic expression pattern. In contrast, striatal astrocytes were defined by elevated pro-inflammatory transcripts accompanied by dysregulated genes involved in homeostatic functions for lipid and calcium metabolism. These findings provide new insights into a region-dependent, dichotomous astrocytic response-potentially beneficial in the cortex and harmful in the striatum-in MSA suggesting a differential role of astrocytes in MSA-related neurodegenerative processes.

Cost-effectiveness of endoscopic, surgical and pharmacological obesity therapies: a microsimulation and threshold analyses

OBJECTIVE

Weight loss interventions to treat obesity include sleeve gastrectomy (SG), lifestyle intervention (LI), endoscopic sleeve gastroplasty (ESG) and semaglutide. We aimed to identify which treatments are cost-effective and identify requirements for semaglutide to be cost-effective.

DESIGN

We developed a semi-Markov microsimulation model to compare the effectiveness of SG, ESG, semaglutide and LI for weight loss in 40 years old with class I/II/III obesity. Extensive one-way sensitivity and threshold analysis were performed to vary cost of treatment strategies and semaglutide adherence rate. Outcome measures were incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay threshold of US$100 000/quality-adjusted life-year (QALY).

RESULTS

When strategies were compared with each other, ESG was cost-effective in class I obesity (US$4105/QALY). SG was cost-effective in class II obesity (US$5883/QALY) and class III obesity (US$7821/QALY). In class I/II/III, obesity, SG and ESG were cost-effective compared with LI. However, semaglutide was not cost-effective compared with LI for class I/II/III obesity (ICER US$508 414/QALY, US$420 483/QALY and US$350 637/QALY). For semaglutide to be cost-effective compared with LI, it would have to cost less than US$7462 (class III), US$5847 (class II) or US$5149 (class I) annually. For semaglutide to be cost-effective when compared with ESG, it would have to cost less than US$1879 (class III), US$1204 (class II) or US$297 (class I) annually.

CONCLUSIONS

Cost-effective strategies were: ESG for class I obesity and SG for class II/III obesity. Semaglutide may be cost-effective with substantial cost reduction. Given potentially higher utilisation rates with pharmacotherapy, semaglutide may provide the largest reduction in obesity-related mortality.

Esophageal Neuroendocrine Carcinoma Presenting After Definitive Chemoradiation of Squamous Cell Carcinoma in the Same Location

Esophageal neuroendocrine carcinoma is very rare and highly aggressive. An 85-year-old man with a history of esophageal squamous cell carcinoma in remission presented 4 years after definitive chemoradiation with new-onset dysphagia. Endoscopy with biopsy revealed high-grade malignancy consistent with neuroendocrine carcinoma. Treatment options were limited to chemotherapy because of his metastatic disease, and he unfortunately died 14 months after diagnosis. The occurrence of esophageal neuroendocrine carcinoma in a site of prior squamous cell carcinoma is very uncommon, and this likely represents a case of radiation-induced malignancy. Therefore, when undergoing radiotherapy, patients and providers should discuss the possibility of this life-threatening complication.

An Evaluation of Critical Factors for the Cost-Effectiveness of Real-Time Computer-Aided Detection: Sensitivity and Threshold Analyses Using a Microsimulation Model

BACKGROUND

The use of computer-aided detection (CAD) increases the adenoma detection rates (ADRs) during colorectal cancer (CRC) screening/surveillance. This study aimed to evaluate the requirements for CAD to be cost-effective and the impact of CAD on adenoma detection by endoscopists with different ADRs.

METHODS

We developed a semi-Markov microsimulation model to compare the effectiveness of traditional colonoscopy (mean ADR, 26%) to colonoscopy with CAD (mean ADR, 37%). CAD was modeled as having a $75 per-procedure cost. Extensive 1-way sensitivity and threshold analysis were performed to vary cost and ADR of CAD. Multiple scenarios evaluated the potential effect of CAD on endoscopists' ADRs. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/quality-adjusted life year.

RESULTS

When modeling CAD improved ADR for all endoscopists, the CAD cohort had 79 and 34 fewer lifetime CRC cases and deaths, respectively, per 10,000 persons. This scenario was dominant with a cost savings of $143 and incremental effectiveness of 0.01 quality-adjusted life years. Threshold analysis demonstrated that CAD would be cost-effective up to an additional cost of $579 per colonoscopy, or if it increases ADR from 26% to at least 30%. CAD reduced CRC incidence and mortality when limited to improving ADRs for low-ADR endoscopists (ADR <25%), with 67 fewer CRC cases and 28 CRC deaths per 10,000 persons compared with traditional colonoscopy.

CONCLUSIONS

As CAD is implemented clinically, it needs to improve mean ADR from 26% to at least 30% or cost less than $579 per colonoscopy to be cost-effective when compared with traditional colonoscopy. Further studies are needed to understand the impact of CAD on community practice.

Fully Covered Self-expanding Stents are Cost-effective at Remediating Biliary Strictures in Patients With Chronic Pancreatitis

Benign biliary strictures (BBS) develop in up to 10% to 30% of patients with chronic pancreatitis (CP).¹ Endoscopic endoprosthetics via endoscopic retrograde cholangiopancreatography (ERCP) has become the standard of care for remediating these strictures. Seventy percent to eighty percent of these strictures resolve with sequential or concurrent placement of multiple plastic stents (MPS).^1,2 More recently, placement of fully covered self-expanding metal stents (FCSEMS) have been shown to have similar outcomes as MPS.^3-6 FCSEMS provide a larger radial diameter and require fewer procedures, but may have drawbacks, including a higher risk of migration, cholecystitis, delamination, and tissue ingrowth. A recent study demonstrated that FCSEMS with a 12-month indwell had similar outcomes to MPS with fewer ERCP needed.⁷ However, the cost-effectiveness of either strategy for managing BBS has not been assessed previously nor has the impact of additional reimbursement to cover the cost of FCSEMS on the cost-effectiveness of FCSEMS utilization.

Cost-effectiveness of polatuzumab vedotin combined with chemoimmunotherapy in untreated diffuse large B-cell lymphoma

In patients with treatment-naive diffuse large B-cell lymphoma (DLBCL), the POLARIX study (A Study Comparing the Efficacy and Safety of Polatuzumab Vedotin With Rituximab-Cyclophosphamide, Doxorubicin, and Prednisone [R-CHP] Versus Rituximab-Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone [R-CHOP] in Participants With Diffuse Large B-Cell Lymphoma) reported a 6.5% improvement in the 2-year progression-free survival (PFS), with no difference in overall survival (OS) or safety using polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin, and prednisone (pola-R-CHP) compared with standard rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). We evaluated the cost-effectiveness of pola-R-CHP for DLBCL. We modeled a hypothetical cohort of US adults (mean age, 65 years) with treatment-naive DLBCL by developing a Markov model (lifetime horizon) to model the cost-effectiveness of pola-R-CHP and R-CHOP using a range of plausible long-term outcomes. Progression rates and OS were estimated from POLARIX. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $150 000 per quality-adjusted life-year (QALY). Assuming a 5-year PFS of 69.6% with pola-R-CHP and 62.7% with R-CHOP, pola-R-CHP was cost-effective at a WTP of $150 000 (incremental cost-effectiveness ratio, $84 308/QALY). pola-R-CHP was no longer cost-effective if its 5-year PFS was 66.1% or lower. One-way sensitivity analysis revealed that pola-R-CHP is cost-effective up to a cost of $276 312 at a WTP of $150 000. pola-R-CHP was the cost-effective strategy in 56.6% of the 10 000 Monte Carlo iterations at a WTP of $150 000. If the absolute benefit in PFS is maintained over time, pola-R-CHP is cost-effective compared with R-CHOP at a WTP of $150 000/QALY. However, its cost-effectiveness is highly dependent on its long-term outcomes and costs of chimeric antigen receptor T-cell therapy. Routine usage of pola-R-CHP would add significantly to health care expenditures. Price reductions or identification of subgroups that have maximal benefit would improve cost-effectiveness.

Cost-effectiveness of second-line axicabtagene ciloleucel in relapsed refractory diffuse large B-cell lymphoma

The ZUMA-7 (Efficacy of Axicabtagene Ciloleucel Compared to Standard of Care Therapy in Subjects With Relapsed/Refractory Diffuse Large B Cell Lymphoma) study showed that axicabtagene ciloleucel (axi-cel) improved event-free survival (EFS) compared with standard of care (SOC) salvage chemoimmunotherapy followed by autologous stem cell transplant in primary refractory/early relapsed diffuse large B-cell lymphoma (DLBCL); this led to its recent US Food and Drug Administration approval in this setting. We modeled a hypothetical cohort of US adults (mean age, 65 years) with primary refractory/early relapsed DLBCL by developing a Markov model (lifetime horizon) to model the cost-effectiveness of second-line axi-cel compared with SOC using a range of plausible long-term outcomes. EFS and OS were estimated from ZUMA-7. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $150 000 per quality-adjusted life-year (QALY). Assuming a 5-year EFS of 35% with second-line axi-cel and 10% with SOC, axi-cel was cost-effective at a WTP of $150 000 per QALY ($93 547 per QALY). axi-cel was no longer cost-effective if its 5-year EFS was ≤26.4% or if it cost more than $972 061 at a WTP of $150 000. Second-line axi-cel was the cost-effective strategy in 73% of the 10 000 Monte Carlo iterations at a WTP of $150 000. If the absolute benefit in EFS is maintained over time, second-line axi-cel for aggressive relapsed/refractory DLBCL is cost-effective compared with SOC at a WTP of $150 000 per QALY. However, its cost-effectiveness is highly dependent on long-term outcomes. Routine use of second-line chimeric antigen receptor T-cell therapy would add significantly to health care expenditures in the United States (more than $1 billion each year), even when used in a high-risk subpopulation. Further reductions in the cost of chimeric antigen receptor T-cell therapy are needed to be affordable in many regions of the world.

Abstract A22: Cost effectiveness of second line Axicabtagene ciloleucel in relapsed refractory diffuse large B-cell lymphoma

Background In patients with relapsed/refractory diffuse large B-cell lymphoma (RR-DLBCL), CAR T has been shown to be effective in patients with at least 2 prior lines of therapy. ZUMA-7 study demonstrated that axi-cel improved event free survival (EFS) compared to standard of care (SOC) salvage chemoimmunotherapy in primary refractory/early relapse DLBCL leading to its recent FDA approval in this setting. We evaluated the cost effectiveness of second line axi-cel. Methods We modeled a hypothetical cohort of US adults (mean age, 65 years) with primary refractory/early relapse DLBCL by developing a Markov model (20-year horizon) to model the cost-effectiveness of axi-cel in the second-line setting compared to SOC using a range of plausible long-term outcomes. EFS and OS were estimated from ZUMA-7. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $150,000/quality-adjusted life-year (QALY). Results Assuming a 5-year EFS of 35% with second line axi-cel and 10% with SOC, axi-cel was cost-effective at a WTP of 100,000 and 150,000 ($93,547/QALY). Axi-cel was no longer cost effective if its 5-year EFS was 26.4% or lower. One-way sensitivity analysis demonstrated that second-line CAR T is cost effective up to a cost of $972,061 at a WTP of $150,000. Second-line axi-cel was the cost-effective strategy in 73% of the 10,000 Monte-Carlo iterations at a WTP of $150,000. Conclusions If the absolute benefit in EFS is maintained over time, second line axi-cel for aggressive RR-DLBCL is cost effective when compared to SOC at WTPs of $100,000 and $150,000/QALY. However, its cost effectiveness is highly dependent on long-term outcomes. Routine usage of second-line CAR T would add significantly to healthcare expenditures even when used in a high-risk subpopulation. Further reductions in cost of CAR T are needed.

Citation Format: Swetha Kambhampati, Monica Saumoy, Yecheskel Schneider, Lihua E. Budde, Alexey Danilov, Matthew Mei, Leslie Popplewell, Tanya Siddiqi, Jasmine Zain, Stephen Forman, Larry Kwak, Steven Rosen, Alex Herrera, Nikhil Thiruvengadam. Cost effectiveness of second line Axicabtagene ciloleucel in relapsed refractory diffuse large B-cell lymphoma [abstract]. In: Proceedings of the Third AACR International Meeting: Advances in Malignant Lymphoma: Maximizing the Basic-Translational Interface for Clinical Application; 2022 Jun 23-26; Boston, MA. Philadelphia (PA): AACR; Blood Cancer Discov 2022;3(5_Suppl):Abstract nr A22.

Proton pump inhibitor therapy usage and associated hospitalization rates and critical care outcomes of COVID-19 patients

Proton Pump Inhibitors (PPI) are one of the most prescribed medications in the United States. However, PPIs have been shown to increase the risk of enteric infections. Our study aims to evaluate the correlation between PPI and COVID-19 severity. We performed a retrospective cohort study on patients who tested positive for SARS-CoV-2 from March to August 2020. Patients were categorized based on PPI user status. Primary outcomes included need for hospital or ICU admission and 30-day mortality. Secondary outcomes looked to determine the severity of COVID-19 infection and effect of comorbid conditions. 2,594 patients were reviewed. The primary outcomes of our study found that neither active nor past PPI use was associated with increased hospital admission or 30-day mortality following completion of multivariate analysis. Additionally, there was no association between COVID-19 infection and the strength of PPI dosing (low, standard, high). However, the following covariates were independently and significantly associated with increased admission: age, male gender, diabetes, COPD, composite cardiovascular disease, kidney disease, and obesity. The following covariates were associated with increased mortality: age, male gender, COPD, and kidney disease. In conclusion, the high risk features and comorbidities of PPI users were found to have a stronger correlation to severe COVID-19 infection and poor outcomes as opposed to the use of PPI therapy.

A Cost-Effectiveness Analysis for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis in the United States

BACKGROUND & AIMS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer's hydration. Our objective was to determine which PEP prophylactic strategies are cost effective.

METHODS

We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer's, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs).

RESULTS

Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs).

CONCLUSIONS

Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer's were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.

Threshold Analysis of the Cost-effectiveness of Endoscopic Ultrasound in Patients at High Risk for Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Data from the International Cancer of the Pancreas Screening Consortium studies have demonstrated that screening for pancreatic ductal adenocarcinoma can be effective and that surveillance improves survival in high-risk individuals. Endoscopic ultrasound (EUS) and cross-sectional imaging are both used, although there is some suggestion that EUS is superior. Demonstration of the cost-effectiveness of screening is important to implement screening in high-risk groups.

METHODS

Results from centers with EUS-predominant screening were pooled to evaluate efficacy of index EUS in screening. A decision analysis model simulated the outcome of high-risk patients who undergo screening and evaluated the parameters that would make screening cost-effective at a US $100,000 per quality-adjusted life-year willingness to pay.

RESULTS

One-time index EUS has a sensitivity of 71.25% and specificity of 99.82% to detection to detect high-risk lesions. Screening with index EUS was cost-effective, particularly at lifetime pancreatic cancer probabilities of greater than 10.8%, or at lower probabilities if life expectancy after resection of a lesion that was at least 16 years, and if missed, lesion rates on index EUS are 5% or less.

CONCLUSIONS

Pancreatic cancer screening can be cost-effective through index EUS, particularly for those individuals at high-lifetime risk of cancer.

Colonic diverticular disease in autosomal dominant polycystic kidney disease: is there really an association? A nationwide analysis

PURPOSE

Colonic diverticulosis, diverticulitis, and diverticular bleeding are reportedly more common in patients with autosomal dominant polycystic kidney disease (ADPKD). Other studies have questioned this association. The objectives of our study are to clarify this association using a larger patient population and to identify risk factors in general to develop diverticular disease.

METHODS

The Nationwide Inpatient Sample weighted discharges from 2003 to 2011 were used to assess for the prevalence of diverticular disease in the population with ADPKD compared with the general population without ADPKD. A multivariable direct logistic regression model was constructed to determine independent predictors of diverticular disease in the general population.

RESULTS

The prevalence of diverticulosis, diverticulitis, and diverticular bleeding were considerably increased in patients with ADPKD compared with the general population without ADPKD. The prevalence of colonic surgery was less in ADPKD patients with diverticulitis. In patients with kidney transplant, the prevalence of diverticulitis was increased in the ADPKD group, but colonic surgery was not significantly different between both groups. The prevalence of diverticular bleeding was slightly elevated in patients with ADPKD, but colonic surgery was significantly increased in patients with ADPKD. NSAID use, hypertension, constipation, and ADPKD had increased odds ratios for diverticular disease during multivariate analysis.

CONCLUSION

There is an increased prevalence of colonic diverticular disease in the population with ADPKD.

Risk of Early Colorectal Cancers Needs to Be Considered in Inflammatory Bowel Disease Care

BACKGROUND

Current guidelines recommend starting colorectal cancer (CRC) surveillance 8-10 years after inflammatory bowel disease (IBD) onset. Recent studies report that the incidence of CRC within 8-10 years of IBD onset (i.e., early CRC) ranges from 12 to 42%.

AIMS

To describe the current prevalence of early CRC in a tertiary care center IBD cohort with CRC and to identify associated risk factors.

METHODS

We performed a single-center observational study of IBD patients diagnosed with CRC from 2005 to 2015. We compared characteristics of patients with early CRC (diagnosis of CRC within 8 years of initial IBD onset) to those with CRC diagnosed later in their IBD course.

RESULTS

Ninety-three patients met inclusion criteria. Eleven (11.8%) patients developed CRC within 8 years of initial IBD onset. On multivariable logistic regression, age greater than 28 at IBD onset (adjusted OR 12.0; 95% CI 2.30, 62.75) and tobacco use (adjusted OR 8.52; 95% CI 1.38, 52.82) were significant predictors of early CRC. A validation cohort confirmed calibration and discrimination of the model.

CONCLUSIONS

One out of every eight IBD patients with CRC developed their malignancy prior to the currently recommended timeframe for the initiation of surveillance colonoscopy. IBD onset at 28 years or older and tobacco use were identified as predictors of early CRC. Early CRC should be considered in discussions of cancer surveillance in this population. Prospective cohort studies are necessary to further analyze the impact of early CRC in IBD.

Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites

OBJECTIVE

Early paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP.

DESIGN

Pre-post study of a QI initiative.

SETTING

A tertiary care hospital in a major metropolitan area.

PATIENTS

Hospitalised patients with cirrhosis and ascites.

INTERVENTIONS

We targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis.

RESULTS

76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention.

CONCLUSION

A multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.

Delays in Initiating Post-operative Prophylactic Biologic Therapy Are Common Among Crohn's Disease Patients

BACKGROUND

Studies have shown that prophylactic biologic therapy can reduce post-surgical Crohn's disease recurrence.

AIMS

We aimed to identify the frequency of delay and risk factors associated with a delay in the initiation of prophylactic post-surgical biologic therapy in high-risk patients.

METHODS

We performed a cohort study of Crohn's disease patients who underwent a bowel resection. We identified those at risk of recurrence and explored multiple characteristics for those with and without a delay post-operatively.

RESULTS

A total of 84 patients were included in our analysis of which 69.0% had a greater than 4-week delay and 56.0% a greater than 8-week delay in post-surgical biologic prophylaxis. Publicly insured patients had a 100% delay in post-surgical prophylaxis initiation (p = 0.039, p = 0.003 at 4 and 8 weeks, respectively). Patients on a biologic pre-surgery were less likely to have a delay (p < 0.001) in post-operative prophylaxis. Care at an inflammatory bowel disease (IBD) center was associated with timely therapy when considering a post-operative immunomodulator or biologic strategy.

CONCLUSIONS

There are a substantial number of delays in initiating post-operative prophylactic biologic therapy in high-risk patients. Identifying susceptible patients by insurance type or absence of pre-operative therapy can focus future improvement efforts. Additionally, consultation with IBD-specialized providers should be considered in peri-surgical IBD care.

Perianal Fistulas in Patients With Crohn's Disease, Part 2: Surgical, Endoscopic, and Future Therapies

The treatment of perianal fistulas remains a clinical challenge despite the significant advances that have been made in the management of luminal inflammatory bowel disease. In combination with medical therapies, surgical management of perianal fistulas is important for both infection control and definitive repair. Older surgical techniques include the placement of draining and cutting setons and endorectal advancement flaps. Newer surgical techniques that utilize lasers and video-assisted technology are being studied to help patients with chronic, refractory perianal fistulas. In addition to surgical management, less-invasive endoscopic techniques, including endoscopic fistulotomy and endoscopic clipping, are being investigated. Looking forward, allogeneic and autologous adult mesenchymal stem cells are being evaluated to induce fistula healing and improve rates of fistula closure. Here, in the second of a 2-part series on perianal fistulas in patients with Crohn's disease, we discuss the current surgical management of perianal fistulas as well as newer endoscopic techniques and future therapies.

Cost Effectiveness of Gastric Cancer Screening According to Race and Ethnicity

BACKGROUND & AIMS

There are marked racial and ethnic differences in non-cardia gastric cancer prevalence within the United States. Although gastric cancer screening is recommended in some regions of high prevalence, screening is not routinely performed in the United States. Our objective was to determine whether selected non-cardia gastric cancer screening for high-risk races and ethnicities within the United States is cost effective.

METHODS

We developed a decision analytic Markov model with the base case of a 50-year-old person of non-Hispanic white, non-Hispanic black, Hispanic, or Asian race or ethnicity. The cost effectiveness of a no-screening strategy (current standard) for non-cardia gastric cancer was compared with that of 2 endoscopic screening modalities initiated at the time of screening colonoscopy for colorectal cancer: upper esophagogastroduodenoscopy with biopsy examinations and continued surveillance only if intestinal metaplasia or more severe pathology is identified or esophagogastroduodenoscopy with biopsy examinations continued every 2 years even in the absence of identified pathology. We used prevalence rates, transition probabilities, costs, and quality-adjusted life years (QALYs) from publications and public data sources. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/QALY.

RESULTS

Compared with biennial and no screening, screening esophagogastroduodenoscopy with continued surveillance only when indicated was cost effective for non-Hispanic blacks ($80,278/QALY), Hispanics ($76,070/QALY), and Asians ($71,451/QALY), but not for non-Hispanic whites ($122,428/QALY). The model was sensitive to intestinal metaplasia prevalence, transition rates from intestinal metaplasia to dysplasia to local and regional cancer, cost of endoscopy, and cost of resection (endoscopic or surgical).

CONCLUSIONS

Based on a decision analytic Markov model, endoscopic non-cardia gastric cancer screening for high-risk races and ethnicities could be cost effective in the United States.

Perianal Fistulas in Patients With Crohn's Disease, Part 1: Current Medical Management

Despite significant advances in the treatment of luminal inflammatory bowel disease, the treatment of perianal fistulas remains a clinical challenge. Perianal fistulas are traditionally described using the Parks classification based on their relationship to the external and internal anal sphincters. Traditional therapy for perianal fistulas focuses on antibiotics such as metronidazole or ciprofloxacin. However, medical management has expanded over the years to include immunomodulators and, most recently, biologic agents. Newer techniques such as intrafistulous biologic injections are also being explored as potentially effective treatments for patients with fistulizing disease. Here, in the first of a 2-part series on perianal fistulas in patients with Crohn's disease, we discuss the anatomy and classification of perianal fistulas as well as current medical therapies, including antibiotics, immunomodulators, biologic agents, and novel therapeutic agents. The second part of the series will focus on the surgical modalities that are available for patients with perianal fistulas in addition to novel endoscopic techniques and future therapies that are being investigated for the treatment of fistulizing Crohn's disease.

A single-operator learning curve analysis for the endoscopic sleeve gastroplasty

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is a novel, incisionless technique for gastric volume reduction to promote weight loss. Our aim was to describe the learning curve for performing ESG using a prospective case series.

METHODS

Using a prospective case series design, we analyzed the first 128 consecutive patients at a tertiary care academic medical center who underwent ESG performed by a single operator from August 2013 to December 2016. Efficiency (refining performance to decrease procedure time) and mastery (absence of outliers) for performing ESG was evaluated by using a penalized basis-spline regression and cumulative sum analysis.

RESULTS

Efficiency for ESG was attained after 38 ESGs, with mastery after 55 procedures. At 12 months, the mean percent total body weight loss was 15.8% (standard deviation, 9.47%). A total of 71.7% of patients achieved successful weight loss. When using multiple linear regression analysis, both number of sutures and baseline weight were significantly associated with procedure time. Other patient characteristics, such as age, sex, and race, did not significantly affect procedure time. In addition, number of sutures, baseline weight, and endoscopist achieving efficiency were not correlated with successful weight loss at 12 months.

CONCLUSIONS

Mastery of ESG by a single operator is suggested after sufficient endoscopic experience and may help guide widespread clinical adaptability.

Risk Stratification for Prevention of Recurrence of Postoperative Crohn's Disease

Although there have been significant advances in medical therapies to treat Crohn's disease, an estimated 50% of patients will require surgery within the first decade of disease duration. Of these patients, a substantial number will develop recurrent symptoms within the first postoperative year. To prevent disease recurrence, many physicians use postoperative prophylactic therapy. Randomized, controlled trials, although limited in number, have demonstrated that a prophylactic postoperative strategy is effective at reducing recurrence (both clinical and endoscopic) in high-risk patients. This article reviews the frequency of and risk factors for postoperative Crohn's disease recurrence and the current evidence in favor of postoperative Crohn's disease management strategies. Future studies must be conducted to establish a gold standard as to who should receive postoperative prophylaxis and which therapies and time course are ideal.

Association Between Cirrhosis and Stroke in a Nationally Representative Cohort

Importance

Cirrhosis is associated with hemorrhagic and thrombotic extrahepatic complications. The risk of cerebrovascular complications is less well understood.

Objective

To investigate the association between cirrhosis and various stroke types.

Design, Setting, and Participants

We performed a retrospective cohort study using inpatient and outpatient Medicare claims data from January 1, 2008, through December 31, 2014, for a random 5% sample of 1 618 059 Medicare beneficiaries older than 66 years.

Exposures

Cirrhosis, as defined by a validated diagnosis code algorithm.

Main Outcomes and Measures

The primary outcome was stroke, and secondary outcomes were ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage as defined by validated diagnosis code algorithms.

Results

Among 1 618 059 beneficiaries, 15 586 patients (1.0%) had cirrhosis (mean [SD] age, 74.1 [6.9] years; 7263 [46.6%] female). During a mean (SD) of 4.3 (1.9) years of follow-up, 77 268 patients were hospitalized with a stroke. The incidence of stroke was 2.17% (95% CI, 1.99%-2.36%) per year in patients with cirrhosis and 1.11% (95% CI, 1.10%-1.11%) per year in patients without cirrhosis. After adjustment for demographic characteristics and stroke risk factors, patients with cirrhosis had a higher risk of stroke (hazard ratio [HR], 1.4; 95% CI, 1.3-1.5). The magnitude of association appeared to be higher for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5-2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7-3.5) than for ischemic stroke (HR, 1.3; 95% CI, 1.2-1.5).

Conclusions and Relevance

In a nationally representative sample of Medicare beneficiaries, cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. A potential explanation of these findings implicates the mixed coagulopathy observed in cirrhosis.

Cost-Effectiveness Analysis of Probiotic Use to Prevent Clostridium difficile Infection in Hospitalized Adults Receiving Antibiotics

Background

Systematic reviews with meta-analyses and meta-regression suggest that timely probiotic use can prevent Clostridium difficile infection (CDI) in hospitalized adults receiving antibiotics, but the cost effectiveness is unknown. We sought to evaluate the cost effectiveness of probiotic use for prevention of CDI versus no probiotic use in the United States.

Methods

We programmed a decision analytic model using published literature and national databases with a 1-year time horizon. The base case was modeled as a hypothetical cohort of hospitalized adults (mean age 68) receiving antibiotics with and without concurrent probiotic administration. Projected outcomes included quality-adjusted life-years (QALYs), costs (2013 US dollars), incremental cost-effectiveness ratios (ICERs; $/QALY), and cost per infection avoided. One-way, two-way, and probabilistic sensitivity analyses were conducted, and scenarios of different age cohorts were considered. The ICERs less than $100000 per QALY were considered cost effective.

Results

Probiotic use dominated (more effective and less costly) no probiotic use. Results were sensitive to probiotic efficacy (relative risk <0.73), the baseline risk of CDI (>1.6%), the risk of probiotic-associated bactermia/fungemia (<0.26%), probiotic cost (<$130), and age (>65). In probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100000/QALY, probiotics were the optimal strategy in 69.4% of simulations.

Conclusions

Our findings suggest that probiotic use may be a cost-effective strategy to prevent CDI in hospitalized adults receiving antibiotics age 65 or older or when the baseline risk of CDI exceeds 1.6%.

Advances in the Diagnosis and Management of Colonic Dysplasia in Patients With Inflammatory Bowel Disease

The prevalence of colorectal cancer (CRC) in inflammatory bowel disease (IBD) is estimated at 3.7%. Risk factors for CRC include more severe disease (as reflected by the extent of disease and the duration of poorly controlled disease), family history of CRC, pseudopolyps, primary sclerosing cholangitis, and male sex. In addition, both early and late onset of IBD have been shown to be risk factors in different studies. Most societal guidelines recommend initiation of surveillance colonoscopy at 8 to 10 years after IBD symptom onset, followed by subsequent surveillance in 1- to 2-year intervals. A recent paradigm shift has led to a focus on targeted biopsies using high-definition colonoscopy or chromoendoscopy rather than traditional white-light endoscopy, as most dysplasia has proven to be visible with these advances in technology. With this shift, endoscopic resection of focal dysplasia, rather than early recommendation for colectomy, has become commonplace. Future studies should focus on newer methods of dysplasia detection, along with comparative effectiveness trials, to determine the optimal approach. Individual risk stratification may also prove beneficial in determining optimal surveillance strategies and intervals.

Discharge Disposition After Stroke in Patients With Liver Disease

BACKGROUND AND PURPOSE

Liver disease is associated with both hemorrhagic and thrombotic processes, including an elevated risk of intracranial hemorrhage. We sought to assess the relationship between liver disease and outcomes after stroke, as measured by discharge disposition.

METHODS

Using administrative claims data, we identified a cohort of patients hospitalized with stroke in California, Florida, and New York from 2005 to 2013. The predictor variable was liver disease. All diagnoses were defined using validated diagnosis codes. Ordinal logistic regression was used to analyze the association between liver disease and worsening discharge disposition: home, nursing/rehabilitation facility, or death. Secondarily, multiple logistic regression was used to analyze the association between liver disease and in-hospital mortality. Models were adjusted for demographics, vascular risk factors, and comorbidities.

RESULTS

We identified 121 428 patients with intracerebral hemorrhage and 703 918 with ischemic stroke. Liver disease was documented in 13 584 patients (1.7%). Liver disease was associated with worse discharge disposition after both intracerebral hemorrhage (global odds ratio, 1.28; 95% confidence interval, 1.19-1.38) and ischemic stroke (odds ratio, 1.23; 95% confidence interval, 1.17-1.29). Similarly, liver disease was associated with in-hospital death after both intracerebral hemorrhage (odds ratio, 1.33; 95% confidence interval, 1.23-1.44) and ischemic stroke (odds ratio, 1.60; 95% confidence interval, 1.51-1.71).

CONCLUSIONS

Liver disease was associated with worse hospital discharge disposition and in-hospital mortality after stroke, suggesting worse functional outcomes.

The Cost-Effectiveness of Vedolizumab for Inflammatory Bowel Disease: A Review of the Current Literature

The United States spends a greater share per gross domestic product on health care than any other developed country in the world. Cost-conscious, high-value care has an important role in the practice of medicine. Inflammatory bowel disease (IBD) affects 1.6 million people in the United States and is responsible for significant health care costs, with estimates as high as $31.6 billion annually, a large portion of which is attributable to the use of biologic therapies. As the number of therapeutic targets for IBD expands, gastroenterologists can anticipate the arrival of novel therapeutic agents on the market, and these may carry significant costs. Vedolizumab, a monoclonal antibody directed against the gut-selective integrin α4β7, is a novel biologic agent approved for the treatment of Crohn's disease and ulcerative colitis. Cost-effectiveness is an area of research that aims to assess the added value (in terms of both cost and utility) of diagnostic or therapeutic interventions. This article reviews the current literature evaluating the cost-effectiveness of vedolizumab for the treatment of IBD.

Influence of operating conditions on nitrous oxide formation during nitritation and nitrification

Nitrous oxide (N2O), a strong greenhouse gas, can be produced by ammonium-oxidizing bacteria (AOB) as a by-product of ammonium oxidation and can potentially be formed in all types of nitrification processes. However, partial nitritation has been reported to cause significantly higher N2O emissions than complete nitrification. In the study presented here, the mechanisms and factors that drive N2O formation by AOB were investigated with respect to different operational strategies to achieve nitrite accumulation base on combined evaluation of oxygen uptake rate (OUR) and N2O formation rate. On the one hand, N2O formation during partial nitritation and nitrification in a continuously stirred tank reactor (CSTR) with continuous aerobic conditions was observed. On the other hand, the effect of intermittent aeration on N2O formation during nitrification was investigated. The presence of nitrite, the extend of sludge-specific ammonium loading, low oxygen concentration, and transition from aerobic to anoxic conditions significantly increased N2O formation in this reactor independently from each other, indicating that different formation pathways, supposedly via nitrite or hydroxylamine, were active.

Determination of the nitrous oxide emission potential of deammonification under anoxic conditions

Various studies have been performed to determine nitrous oxide (N2O) emissions from conventional biological nitrogen removal processes in wastewater treatment like nitrification and denitrification in the main stream. However, with respect to the overall emissions of a wastewater treatment plant, part-stream treatment for high-strength wastewater (e.g., sludge liquor) is also expected to hold a significant emission potential because of high concentrations and extreme boundary conditions. This paper presents results from a laboratory-scale study on nitrous oxide production by biomass from a deammonification process (nitritation + anammox) under anoxic conditions. It was discovered that N2O formation results from incomplete endogenous denitrification rather than anammox and is dependent on substrate availability. Based on direct measurements of the dissolved N2O concentrations in a sequencing batch reactor, the dynamic behavior of N2O production is characterized in more detail. The results show that, during anoxic conditions, the N2O emission potential of deammonification is significantly lower than from conventional denitrification.

Determination and evaluation of the phosphorus load of an artificial shallow lake

Enhanced eutrophication of lakes due to high nutrient loads from anthropogenic sources has become a worldwide problem. Dying ecosystems and limitation of uses are the consequences. In Bochum, Germany, Lake Umminger is an integral part of a recreation area, but also receives high nutrient loads from the local sewer system, as could be shown with the help of water and nutrient balances. Mass algae growth, the dying of fish and production of digestion gas implied a demand to rehabilitate the lake. Primarily, the urgency and sanitation potential as well as the applicability of external and internal enhancement measures had to be evaluated. The trophic classification needed was based upon the German guideline for the classification of the water quality of natural lakes according to trophic criteria, mainly using Vollenweider's eutrophication model. This paper focuses on a description and analysis of the problems that arose during the application of this model to Lake Umminger, stating that shallow, artificial lakes cannot be evaluated correctly with the existing methods. Although some suggestions for further improvement are given, the development of new evaluation criteria was not in the scope of the study presented.

Polyamine metabolism in primary human colon adenocarcinoma cells (SW480) and their lymph node metastatic derivatives (SW620)

The natural polyamines are multifunctional constituents of all eucaryotic cells. The objective of this work was to compare aspects of polyamine metabolism in two related cell lines with the idea to investigate whether metabolic differences can be attributed to functional differences of the cells. The human colon carcinoma-derived cell lines SW480 and SW620 were chosen as models. SW480 cells were isolated from the primary tumour, SW620 cells from a lymph node of the same patient. SW620 cells grow faster, and the key regulatory enzymes of polyamine biosynthesis (ODC and AdoMetDC) are more active in the metastatic cells. Moreover, their ability to accumulate polyamines from the environment is more important than of SW480 cells. Likewise polyamine concentrations were markedly higher in SW620 cells, although they are much smaller than SW480 cells, and have a particularly small cytoplasmic space. Both cell lines show a striking diminution of ODC and AdoMetDC activities and changes in the polyamine patterns at the transition from exponential to non-exponential growth--most probably as a consequence of high cell density. Depletion of putrescine and spermidine due to inactivation of ODC by DFMO causes accumulation of cells in G1, and a proportional decrease of S-phase cells in both cell lines. Based on morphologic and other criteria SW480 and SW620 cells were typified as poorly differentiated. In agreement with their low grade of differentiation they exhibit a low alkaline phosphatase activity. However, the time-dependent decrease of alkaline phosphatase is not typical of differentiation patterns of other adenocarcinoma-derived cell lines or of normal enterocytes. The high capacity of de novo polyamine biosynthesis and of polyamine uptake is presumably a prerequisite for the rapid growth and invasiveness. The fact that these properties were more accentuated in the case of SW620 cells and paralleled enhanced metastatic properties indicate relationships between basic parameters of polyamine metabolism and malignancy.

Double-blind, placebo-controlled study with sublingual immunotherapy in children with seasonal allergic rhinitis to grass pollen

Sublingual immunotherapy (SLIT) has been recognized as a viable alternative to subcutaneous immunotherapy for respiratory allergies both in adults and children, but clinical documentation about safety and efficacy in children is still poor. The purpose of this study was to assess the efficacy and tolerance of SLIT in children who are sensitized to grass pollen.

METHODS

Children with a clinical history of intermittent rhinoconjunctivitis, with or without mild asthma and positive skin prick tests to grass pollen, were selected to participate in a 2-year double-blind, placebo-controlled study with SLIT, using a grass extract (ALK-Abellò).

RESULTS

22 children were analyzed at the end of the study. No relevant side effects occurred in the active group. A statistically significant difference (p = 0.05; Mann-Whitney test) in favor of the active group (n = 10) could be shown for drug consumption during the second year, as well as a significant improvement as compared to the first year of SLIT (p = 0.05; Wilcoxon test).

CONCLUSIONS

Despite the small number of patients, our data suggest that SLIT with a grass pollen extract is well tolerated in children and is able to significantly reduce drug consumption during the second year of treatment. Studies in larger groups of children sensitized to both grass and tree pollens are needed to definitively assess the role of SLIT in intermittent, seasonal rhinitis and pollen asthma.

Resveratrol inhibits intestinal tumorigenesis and modulates host-defense-related gene expression in an animal model of human familial adenomatous polyposis

We studied the effect of oral administration of resveratrol, a natural constituent of grapes, on tumorigenesis in Min mice. Min mice are congenic mice genetically predisposed to develop intestinal tumors as a result of a mutation of the Apc gene. Resveratrol (0.01% in the drinking water containing 0.4% ethanol) was administered for seven weeks to Min mice starting at five weeks of age. The control group was fed the same diet and received water containing 0.4% ethanol. Resveratrol prevented the formation of colon tumors and reduced the formation of small intestinal tumors by 70%. Comparison of the expression of 588 genes in the small intestinal mucosa showed that resveratrol downregulated genes that are directly involved in cell cycle progression or cell proliferation (cyclins D1 and D2, DP-1 transcription factor, and Y-box binding protein). In addition, resveratrol upregulated several genes that are involved in the recruitment and activation of immune cells (cytotoxic T lymphocyte Ag-4, leukemia inhibitory factor receptor, and monocyte chemotactic protein 3) and in the inhibition of the carcinogenic process and tumor expansion (tumor susceptibility protein TSG101, transforming growth factor-beta, inhibin-beta A subunit, and desmocollin 2). Our data highlight the complexity of the events associated with intestinal tumorigenesis and the multiplicity of the molecular targets of resveratrol. The high potency and efficacy of resveratrol support its use as a chemopreventive agent in the management of intestinal carcinogenesis.

Suppression of azoxymethane-induced preneoplastic lesions and inhibition of cyclooxygenase-2 activity in the colonic mucosa of rats drinking a crude green tea extract

We determined the effects of a crude green tea extract given as drinking fluid on the promotion/progression phase of colon carcinogenesis in rats after induction of the neoplastic process by azoxymethane. Adult Wistar rats were given azoxymethane (15 mg/kg i.p.) once a week for two weeks. One week after the second injection, the rats were randomly divided into two groups. One group (n = 8) received daily prepared aqueous solutions of green tea extracts (GTE; 0.02%, wt/vol); the control group (n = 8) received tap water. After six weeks, rats receiving GTE showed a 60% reduction in the number of colonic preneoplastic lesions (aberrant crypts). The number of individual crypts per aberrant crypt focus (crypt multiplicity) was significantly reduced in the GTE group; the majority (80%) of the remaining aberrant foci contained only one or two preneoplastic crypts. A significant and selective decrease of cyclooxygenase (COX)-2 activity was observed in the colon of rats receiving GTE (23 +/- 3 vs. 117 +/- 30 mU/mg protein in controls), whereas COX-1 showed no alterations. Our data demonstrate that GTE reduces COX-2 and suppresses the formation of colonic preneoplastic lesions. They provide new insights into the mechanism of chemopreventive and anti-inflammatory properties of green tea.

Cytotoxic effects of the polyamine oxidase inactivator MDL 72527 to two human colon carcinoma cell lines SW480 and SW620

N1,N4-bis(2,3-butadienyl)-1,4-butanediamine (MDL 72527) was considered to be a selective inactivator of FAD-dependent tissue polyamine oxidase. Recently MDL 72527 was reported to induce apoptosis in transformed hematopoietic cells through lysosomotropic effects. Since it is the only useful inhibitor of polyamine oxidase available at present, the re-evaluation of its properties seemed important. Human colon carcinoma-derived SW480 cells and their lymph node metastatic derivatives (SW620) were chosen for our study because they differ in various aspects of polyamine metabolism but have similar polyamine oxidase activities. MDL 72527 inhibited cell growth in a concentration-dependent manner, depleted intracellular polyamine pools, and caused the accumulation of N1-acetyl derivatives of spermidine and spermine. SW620 cells were more sensitive to the drug than were SW480 cells. At 150 micromol/L MDL 72527, SW620 cells accumulated in S-phase of the cell cycle, showed decreased polyamine transport rate, and showed no increase of polyamine N1-acetyltransferase activity. In contrast, SW480 cells were not arrested in a particular phase of the cell cycle, showed enhanced polyamine uptake, and showed a mild induction of acetyltransferase. The results suggest that MDL 72527 retains its value as a selective tool in short-term experiments only at concentrations not exceeding those necessary for the inactivation of polyamine oxidase. At concentrations above 50 micromol/L and at exposure times longer than 24 h, it may derange cell functions nonspecifically, and thus blur the results of studies intended to elucidate polyamine oxidase functions.