Blue Notes
2022; Elsevier BV; Volume: 20; Issue: 8 Linguagem: Inglês
10.1016/j.cgh.2022.05.004
ISSN1542-7714
Autores Tópico(s)Gastrointestinal disorders and treatments
ResumoThe application of endoscopic clips to close polypectomy defects decreases the rate of bleeding after resection of large (≥ 20 mm) polyps in the proximal colon. It is not clear whether this benefit applies to all types of polyps, and particularly to large serrated polyps (LSP) that tend to occur in the proximal colon. In this post-hoc analysis of a randomized trial of prophylactic clipping after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, investigators identified 179 participants with 199 LSPs (96% sessile serrated lesions) and 730 participants with 771 adenomatous polyps.1Crockett S.D. Khashab M. Rex D.K. et al.Clip Closure Does Not Reduce Risk of Bleeding After Resection of Large Serrated Polyps: Results From a Randomized Trial.Clin Gastroenterol Hepatol. 2022; 20: 1757-1765Abstract Full Text Full Text PDF Scopus (3) Google Scholar Bleeding occurred in 5 patients with LSP (4 of 5 polyps were in the proximal colon), and the rate was no different between patients in the clip and the control groups (2.3% vs 3.3%, p = 1.00). The results were unchanged in a subgroup analysis restricted to patients taking antithrombotics. Among those with adenomas, clipping was associated with a lower risk of post-procedure bleeding (3.9% vs 7.6%), but the benefit was restricted to the proximal colon. This is convincing evidence that clipping to decrease bleeding risk after large serrated polyp EMR is not necessary. The EMR technique in the parent trial employed electrocautery, and the findings are even more pertinent in the setting of cold EMR, which is becoming the procedure of choice for LSP resection. See page 1757. The primary goal of treatment in autoimmune hepatitis (AIH) is to achieve complete biochemical remission. Previous studies assessing the effect of treatment response on survival have yielded inconsistent results, and have been limited by immortal time bias. To help mitigate this limitation, investigators conducted a landmark analysis (where follow-up starts at different predefined time points) of a cohort of 301 patients with AIH type 1.2Biewenga M. Verhelst X. Baven-Pronk M. et al.Aminotransferases During Treatment Predict Long-Term Survival in Patients With Autoimmune Hepatitis Type 1: A Landmark Analysis.Clin Gastroenterol Hepatol. 2022; 20: 1776-1783Abstract Full Text Full Text PDF Scopus (1) Google Scholar They reported that over median follow-up of 99 months, 15 patients underwent liver transplantation and 14 died of liver-related causes. In univariate Cox regression analysis, baseline ALT (HR 0.56; p<0.001) and AST (HR 0.70; p=0.005) were associated with lower risk of death or liver transplantation, but elevated levels at 12 months were associated with higher risk of death or liver transplantation (HR 1.56; p=0.020 for ALT; HR 1.86; p<0.001 for AST). Conversely, IgG level at diagnosis or at 12 months was not associated with mortality or liver transplantation. In multivariable analysis adjusting for age, cirrhosis, and baseline transaminase levels, the AST and ALT levels were significantly associated with mortality or liver transplantation at the 6, 12, 24, and 36-month landmarks (hazard ratios ranging from about 2 to 3). Persistent elevation of transaminases during treatment of AIH portends a worse prognosis, and should lead to adjustment of therapy. IgG levels do not appear to be of prognostic value in the first year of treatment. See page 1776. Tofacitinib is an oral small molecule Janus kinase inhibitor that is used for treatment of moderately to severely active ulcerative colitis (UC). Previous studies have shown that tofacitinib 10 mg BID induction for 8 weeks, followed by maintenance for 52 weeks, is more effective than placebo. This study presents subgroup analyses from the tofacitinib UC clinical program, assessing the efficacy and safety of extended induction with an additional 8 weeks of tofacitinib 10 mg BID, in 295 patients who had not responded to initial induction.3Sandborn W.J. Peyrin-Biroulet L. Quirk D. et al.Efficacy and Safety of Extended Induction With Tofacitinib for the Treatment of Ulcerative Colitis.Clin Gastroenterol Hepatol. 2022; 20: 1821-1830Abstract Full Text Full Text PDF Scopus (7) Google Scholar The clinical response rate was 52.2% (154/295). When combining delayed responders with patients that had responded to the initial 8-week induction, the total response rate was nearly 75%. In the open-label study (OCTAVE Open), 70% of 148 delayed responders maintained clinical response at 12 months, while about 57% and 45% had endoscopic improvement and remission, respectively. At month 36, these rates were 56%, 52%, and 45%. The safety profile of the extended induction period was similar to that of the first 8 weeks. Two patients had serious infections and one patient had herpes zoster, but no thromboembolic events were reported in the induction non-responders during the additional 8 weeks of induction. Extended induction with tofacitinib is beneficial in about half of patients who do not respond to the initial 8-week treatment course. See page 1821. Whether chronic constipation is a risk factor for colorectal cancer (CRC) is controversial, as prolonged contact time between stool and the colonic mucosa has been cited as potentially carcinogenic. To help address this question, investigators conducted a population-based case-control study using nationwide data from Sweden.4Staller K. Olén O. Söderling J. et al.Chronic Constipation as a Risk Factor for Colorectal Cancer: Results From a Nationwide, Case-Control Study.Clin Gastroenterol Hepatol. 2022; 20: 1867-1876Abstract Full Text Full Text PDF Scopus (4) Google Scholar Cases with CRC were matched at the time of diagnosis/biopsy on age, sex, calendar year and county with up to 5 controls without CRC. Chronic constipation was defined as 2 or more laxative prescriptions with 6 or more months between prescriptions, with the first prescription occurring ≥2 years and the second ≥6 months before the CRC diagnosis in cases. There were 3,943 patients with CRC and pre-existing chronic constipation, with rates of constipation of 9.5% among cases and 8.8% among controls. After adjustment for education there was a modest association between chronic constipation and CRC (OR=1.10, 95% CI=1.06-1.14). However, this association dissipated when CRC patients were compared to their siblings (to account for familial confounding), with OR of 1.04 (95%CI 0.97-1.13). Sensitivity analyses varying the definition of chronic constipation yielded similar results. These findings should provide reassurance to clinicians and patients that chronic constipation, as an isolated symptom, is not a risk factor for CRC. See page 1867. Efficacy and Safety of Extended Induction With Tofacitinib for the Treatment of Ulcerative ColitisClinical Gastroenterology and HepatologyVol. 20Issue 8PreviewTofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). The efficacy and safety of tofacitinib were demonstrated in a dose-ranging phase 2 induction trial, 3 phase 3 randomized, placebo-controlled trials (OCTAVE Induction 1 and 2; and OCTAVE Sustain), and an ongoing, open-label, long-term extension trial (OCTAVE Open) in patients with moderately to severely active UC. Here, we assessed short- and long-term efficacy and safety of extended induction (16 weeks) with tofacitinib 10 mg twice daily (BID) in patients who failed to respond to initial induction (8 weeks) treatment. Full-Text PDF Open AccessChronic Constipation as a Risk Factor for Colorectal Cancer: Results From a Nationwide, Case-Control StudyClinical Gastroenterology and HepatologyVol. 20Issue 8PreviewProlonged colon transit times may increase the contact time between potential carcinogens in the stool and the colonic mucosa. Nonetheless, previous studies have yielded conflicting results connecting chronic constipation with the risk of colorectal cancer (CRC). We examined the association between chronic constipation and later CRC. Full-Text PDF Clip Closure Does Not Reduce Risk of Bleeding After Resection of Large Serrated Polyps: Results From a Randomized TrialClinical Gastroenterology and HepatologyVol. 20Issue 8PreviewSerrated polyps are important colorectal cancer precursors and are most commonly located in the proximal colon, where post-polypectomy bleeding rates are higher. There is limited clinical trial evidence to guide best practices for resection of large serrated polyps (LSPs). Full-Text PDF Aminotransferases During Treatment Predict Long-Term Survival in Patients With Autoimmune Hepatitis Type 1: A Landmark AnalysisClinical Gastroenterology and HepatologyVol. 20Issue 8PreviewBiochemical remission, important treatment goal in autoimmune hepatitis (AIH), has been associated with better long-term survival. The aim of this study was to determine the independent prognostic value of aminotransferases and immunoglobulin G (IgG) during treatment on long-term transplant-free survival in AIH. Full-Text PDF Open Access
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