Simple endoscopic score Dotaz Zobrazit nápovědu
INTRODUCTION: Two antitumor necrosis factor therapies (infliximab [IFX] and adalimumab [ADA]) have been approved for the treatment of pediatric Crohn's disease (CD) but have not been compared in head-to-head trials. The aim of this study was to compare the efficacy and safety of ADA and IFX by propensity score matching in a prospective cohort of pediatric patients with luminal CD and at least a 24-month follow-up. METHODS: Among 100 patients, 75 met the inclusion criteria, and 62 were matched by propensity score. We evaluated time to treatment escalation as the primary outcome and primary nonresponse, predictors of treatment escalation and relapse, serious adverse events, pharmacokinetics, and effect of concomitant immunomodulators as secondary outcomes. RESULTS: There was no difference between ADA and IFX in time to treatment escalation (HR = 0.63 [95% CI 0.31-1.28] P = 0.20), primary nonresponse (P = 0.95), or serious adverse events. The median (interquartile range) trough levels at the primary outcome were 14.05 (10.88-15.40) and 6.15 (2.08-6.58) μg/mL in the ADA and IFX groups, respectively. On a multivariate analysis, the combination of anti-Saccharomyces cerevisiae antibody negativity and antineutrophil cytoplasmic antibody positivity was a strong independent predictor of treatment escalation (HR 5.19, [95% CI 2.41-11.18], P < 0.0001). The simple endoscopic score for CD, L3 disease phenotype, and use of concomitant immunomodulators for at least the first 6 months revealed a trend toward significance on a univariate analysis. DISCUSSION: Propensity score matching did not reveal substantial differences in efficacy or safety between ADA and IFX. The anti-S. cerevisiae antibody negativity and antineutrophil cytoplasmic antibody positivity combination is a strong predictor of treatment escalation.
- MeSH
- adalimumab škodlivé účinky MeSH
- Crohnova nemoc * diagnóza farmakoterapie MeSH
- dítě MeSH
- imunologické faktory MeSH
- infliximab terapeutické užití MeSH
- lidé MeSH
- prospektivní studie MeSH
- protilátky proti cytoplazmě neutrofilů MeSH
- tendenční skóre MeSH
- výsledek terapie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
OBJECTIVES: In pediatric Crohn's disease (PCD), the benefit of microscopy in disease activity assessment and prediction of clinical outcome is, due to the focality and transmurality of the inflammation, disputable. We investigated whether histopathological scoring system predicts complications in pediatric CD and correlates with endoscopical and clinical scores. METHODS: We performed a retrospective study on 63 patients. Endoscopy in the time of diagnosis was evaluated using the Simple Endoscopic Score (SES) and histopathology with the Global Histology Activity Score, both in its original version (GHAS) and its modification (modGHAS). Pediatric Crohn's Disease Activity Index (PCDAI) was also calculated. The patients were grouped according to the presence or absence of defined complications (intraabdominal abscess or fistula, perianal fistulating disease or stricture impenetrable for endoscope or with prestenotic dilatation) during one year of follow-up, or the necessity to initiate anti-TNF treatment for persisting or relapsing active disease in the same time period. Associations were tested with Cox regression analysis. RESULTS: SES was higher in patients with complications. However, in case of GHAS, modGHAS and PCDAI we did not find any significant association with complicated course of disease. SES above 16 points was revealed as an independent risk factor for complications development in PCD, in contrary to GHAS, modGHAS and PCDAI. We demonstrated only a weak correlation between GHAS, modGHAS and SES and no correlation between the histopathological scoring systems and PCDAI. CONCLUSIONS: In conclusion, the histopathological scoring system cannot be recommended as a reliable predictor of development of complications in children with CD.
- MeSH
- Crohnova nemoc komplikace patologie MeSH
- dítě MeSH
- gastrointestinální endoskopie MeSH
- lidé MeSH
- mladiství MeSH
- prediktivní hodnota testů MeSH
- retrospektivní studie MeSH
- stupeň závažnosti nemoci MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
OBJECTIVES: Owing to the invasiveness of endoscopy, the use of biomarkers, especially faecal calprotectin (FC), has become standard for remission assessment. This study aimed to compare the accuracy for detection of endoscopic activity using recently developed FC home test using smartphone application (FC-IBDoc) against standard enzyme-linked immunosorbent assay (ELISA). METHODS: In all, 102 consecutive observations (89 participants) were included in prospective observational study. FC-IBDoc was performed parallelly with FC-ELISA in paediatric patients with inflammatory bowel disease indicated for endoscopy. Both tests were performed by trained staff. Mucosal healing was defined using Simple Endoscopic Score for Crohn disease (CD) ≤2 in patients with CD (n = 44), ulcerative colitis (UC) Endoscopic Index of Severity ≤4 in patients with UC (n = 27) and Rutgeerts score i0 and i1 without colon involvement in patients with CD after ileocaecal resection (n = 19). RESULTS: Out of 102 endoscopic findings 23 were assessed as mucosal healing. We found an association of the mucosal healing scores of the entire group both with FC-ELISA (P = 0.002) and FC-IBDoc (P = 0.001). The area under the receiver operating characteristic curve for FC-ELISA was 0.883 (95% confidence interval 0.807-0.960), with optimal cut-off at 136.5 μg/g. The area under the receiver operating characteristic curve for FC-IBDoc was 0.792 (95% confidence interval 0.688-0.895) with optimal cut-off at 48 μg/g. The FC-ELISA was more accurate than FC-IBDoc when tested by a Delong test (P = 0.023). CONCLUSIONS: Standard FC-ELISA for FC evaluation is more reliable predictor of mucosal healing than the FC-IBDoc in paediatric patients with inflammatory bowel disease. The cut-off values for both tests were incongruous.
- MeSH
- biologické markery analýza MeSH
- chytrý telefon MeSH
- Crohnova nemoc diagnostické zobrazování metabolismus MeSH
- dítě MeSH
- ELISA MeSH
- feces chemie MeSH
- gastrointestinální endoskopie MeSH
- hojení ran MeSH
- leukocytární L1-antigenní komplex analýza MeSH
- lidé MeSH
- mladiství MeSH
- mobilní aplikace MeSH
- péče o sebe MeSH
- plocha pod křivkou MeSH
- prospektivní studie MeSH
- reagenční diagnostické soupravy normy MeSH
- reprodukovatelnost výsledků MeSH
- ROC křivka MeSH
- střevní sliznice diagnostické zobrazování patofyziologie MeSH
- stupeň závažnosti nemoci MeSH
- ulcerózní kolitida diagnostické zobrazování metabolismus MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
- srovnávací studie MeSH
PURPOSE: To compare anthropometric data (body mass index [BMI]) in patients without lithiasis to patients with symptomatic simple cholelithiasis or choledocholithiasis. METHODS: We retrospectively reviewed data from 147 patients undergoing laparoscopic cholecystectomy between 2001-2015. Complete growth data from 98 patients was compared with anthropometric data from the population of the Czech Republic and a control group (BMI of 100 consecutive patients without biliary stones in abdominal ultrasound who were admitted to a surgical department for suspected appendicitis). RESULTS: The BMI of 75 children with simple cholelithiasis and 23 with choledocholithiasis was compared to the standard Czech pediatric population and to the control group. The median age (simple cholelithiasis and choledocholithiasis) was 16 years, and 35 patients (24%) had a family history of gallstones. Types of lithiasis included multiple (n = 120), solitary (n = 11), and sludge (n = 10). Five cases had polyps and one had gallbladder dysplasia. Patients with simple cholelithiasis had significantly higher BMI compared to the control group without cholelithiasis (p<0.0001) and the standard Czech population (p = 0.03). Patients with choledocholithiasis had a mean BMI significantly higher than that of the general population (p = 0.001) and the control group (p = 0.0001). Patients with choledocholithiasis had significantly higher BMI than those with simple cholelithiasis (p = 0.03). CONCLUSION: Patients with cholelithiasis had significantly higher BMI than the general population, and patients with choledocholithiasis had significantly higher BMI than patients with simple lithiasis. Elevated BMI is a risk factor for developing choledocholithiasis. ERCP and early laparoscopic cholecystectomy in patients with choledocholithiasis offer equivalent outcomes in patients with simple cholelithiasis.
- MeSH
- cholangiopankreatografie endoskopická retrográdní MeSH
- cholecystektomie laparoskopická MeSH
- choledocholitiáza etiologie patologie chirurgie MeSH
- cholelitiáza etiologie patologie chirurgie MeSH
- dítě MeSH
- index tělesné hmotnosti MeSH
- kojenec MeSH
- lidé MeSH
- mladiství MeSH
- obezita komplikace patologie MeSH
- předškolní dítě MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- studie případů a kontrol MeSH
- Check Tag
- dítě MeSH
- kojenec MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- Geografické názvy
- Česká republika MeSH
BACKGROUND: A treat-to-target strategy, in which strictly defined treatment targets facilitate decision making in clinical practice, is advocated as an optimised management approach for some chronic disorders. The aim of the STARDUST trial was to assess whether a treat-to-target strategy with early endoscopy, regular biomarker and clinical symptom monitoring, and dose intensification for persistent inflammatory activity, was more successful in achieving endoscopic improvement at week 48 than a clinically driven maintenance strategy in patients with moderate-to-severe active Crohn's disease receiving ustekinumab. METHODS: This open-label, multicentre, randomised phase 3b trial included adults with active, moderate-to-severe Crohn's disease (Crohn's Disease Activity Index [CDAI] 220-450 and Simple Endoscopic Score in Crohn's Disease [SES-CD] ≥3) for whom conventional therapy or one biologic therapy, or both, had failed. Patients received intravenous ustekinumab approximating 6 mg/kg at baseline and subcutaneous ustekinumab 90 mg at week 8. At week 16, patients with a CDAI improvement of 70 or more points from baseline were randomly assigned (1:1) to receive standard-of-care or treat-to-target maintenance treatment through week 48. Randomisation was balanced by using randomly permuted blocks and was stratified by biologic history status and baseline SES-CD score. All patients who signed informed consent, who were not screening failures, and who received at least one dose of study treatment were included in week 16 analyses. All patients included in week 16 analyses and randomly assigned to one of the maintenance treatment regimens were included in the week 48 efficacy and safety analyses (ie, on an intention-to-treat basis). Patients assigned to the treat-to-target arm received ustekinumab every 12 weeks or every 8 weeks based on SES-CD improvement from baseline and could escalate to every 4 weeks through week 48 if prespecified targets were missed. Patients assigned to the standard-of-care arm received ustekinumab every 12 weeks or every 8 weeks; those receiving treatment every 12 weeks could escalate per European labelling. The primary efficacy endpoint was endoscopic response at week 48 (SES-CD score ≥50% decrease from baseline), analysed by non-responder imputation. This trial is registered at ClinicalTrials.gov, NCT03107793, and is active but not recruiting. FINDINGS: 498 patients received standard induction treatment, of whom 440 were randomly assigned to the treat-to-target group (n=219) or the standard-of-care group (n=221). At week 48, there was no significant difference in endoscopic response (83 [38%] of 219 patients vs 66 [30%] of 221 patients; p=0·087), endoscopic remission (25 [11%] vs 32 [15%]; p=0·334), mucosal healing (31 [14%] vs 37 [17%]; p=0·449), and clinical remission (135 [62%] vs 154 [70%]; p=0·072) between the two groups; clinical response was significantly lower in the treat-to-target group than in the standard-of-care group (149 [68%] vs 172 [78%]; p=0·020). Other endoscopic, clinical, and biomarker outcomes were generally not significantly different between groups. The most commonly reported treatment-emergent adverse events were nasopharyngitis (29 [13%] of 219 patients in the treat-to-target group vs 29 [13%] of 221 patients in the standard-of-care group), abdominal pain (23 [11%] vs 19 [9%]), arthralgia (24 [11%] vs 19 [9%]), and headache (24 [11%] vs 21 [10%]). INTERPRETATION: Timely escalation of ustekinumab therapy for patients with Crohn's disease, based on early endoscopic response, clinical symptoms, and biomarkers, did not result in significantly better endoscopic outcomes at week 48 than symptom-driven decisions alone. Future studies need to confirm if some subgroups of patient might benefit from a treat-to-target strategy with ustekinumab. FUNDING: Janssen-Cilag.
- MeSH
- Crohnova nemoc * terapie MeSH
- dospělí MeSH
- indukce remise MeSH
- intravenózní podání MeSH
- lidé MeSH
- standardní péče MeSH
- ustekinumab * škodlivé účinky MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky, fáze III MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: In multiple sclerosis (MS), dysphagia is an important and common clinical symptom. Although often overlooked and underdiagnosed, it can have a significant impact on a patient's life, including social integration, and it can lead to malnutrition, aspiration pneumonia, and suffocation, i.e., life-threatening complications. Early detection of dysphagia is essential to prevent these risks. However, the optimal screening method and the inter-relationship between different methods used for dysphagia screening are not clear. The aim of this study was to compare the diagnostic performance of a simple question about swallowing problems, the DYsphagia in MUltiple Sclerosis (DYMUS) swallowing questionnaire, and the Timed Water Swallowing Test (TWST) to detect dysphagia in people with relapsing-remitting MS (RRMS). METHODS: Patients with MS were asked about subjective swallowing difficulties and, regardless of their response, completed the DYMUS questionnaire and underwent the TWST at their routine follow-up visit. Patients with at least one positive screening method were offered an objective assessment of swallowing function using the Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The results were statistically analyzed and correlated with demographic and MS-related parameters. RESULTS: Of the 304 people with RRMS enrolled in the study, 46 (15.1 %) reported having subjective difficulty swallowing when asked a simple question. The DYMUS questionnaire was positive in 59 (19.4 %) of the 304 patients; 51 (16.8 %) had an abnormality on the TWST. A clear correlation (r = 0.351, p < 0.01) was found between the DYMUS and TWST results, but a significant proportion of patients (about half) had an abnormality on only one of these tests. The positivity of at least one of the screening methods used (DYMUS or TWST) had a better chance of identifying a patient with dysphagia than a simple question (p < 0.001). Of the patients with a positive result for difficulty swallowing, 37 underwent FEES, which confirmed dysphagia in 94.6% of this subgroup. Patients with higher Expanded Disability Status Scale (EDSS) scores, female gender, and older age were at higher risk of developing dysphagia. CONCLUSION: The DYMUS questionnaire and TWST had a confirmed potential to identify more patients with dysphagia than a simple question about swallowing problems. However, our study found only a partial overlap between DYMUS and TWST; a combination of these two methods was more sensitive in identifying patients with MS at risk of dysphagia. Furthermore, the screening showed excellent specificity: almost 95 % of the positively screened patients had dysphagia confirmed by objective methods. Age, female gender, and a higher EDSS score appear to be potential risk factors for dysphagia in patients with MS.
Cílem této práce je poskytnout přehled o pokroku dosaženém v průběhu minulého roku v prevenci, diagnostice a léčbě akutní pankreatitidy. Nové poznatky Obezita je nezávislým rizikovým faktorem závažnosti akutní pankreatitidy, zatímco těžká konzumace alkoholu je nezávislým rizikovým faktorem rozvoje nekrózy u těžké akutní pankreatitidy. Ověřovaly se další biochemické ukazatele, například bezsacharidový (carbohydrate-deficient) transferin pro diagnózu akutní pankreatitidy vyvolané alkoholem, trypsinogen 2 v moči jako diagnostický ukazatel akutní pankreatitidy a interleukin 6 a prokalcitonin jako ukazatele závažnosti onemocnění. K posouzení závažnosti onemocnění byl popsán nový jednoduchý skórovací systém– skóre „pank 3“. Existují rozporné údaje o použití antibiotické profylaxe u akutní nekrotizující pankreatitidy i o chemoprevenci pankreatitidy po endoskopické retrográdní cholangiopankreatikografii. Standardní zavedenou praxí v časné léčbě akutní pankreatitidy libovolné etiologie je enterální výživa. Jistou úlohu mohou hrát i probiotika a další látky. Souhrn Ve stratifikaci rizika a v léčbě akutní pankreatitidy bylo v průběhu minulého roku dosaženo dalšího pokroku. K dosud nezodpovězeným otázkám patří chemoprevence akutní pankreatitidy vyvolané endoskopickou retrográdní cholangiopankreatikografií, indikace antibiotické profylaxe u těžké akutní pankreatitidy a nutriční podpora probiotiky a synbiotiky.
To review advances over the last year in the prevention, diagnosis and management of acute pancreatitis. RECENT FINDINGS: Obesity is an independent risk factor for severity in acute pancreatitis, and heavy alcohol consumption for the development of necrosis in severe acute pancreatitis. Biochemical markers have been further tested, including carbohydrate-deficient transferrin for the diagnosis of alcohol-induced acute pancreatitis, urinary trypsinogen-2 as a diagnostic marker for acute pancreatitis, and interleukin-6 and procalcitonin as markers of disease severity. A new, simple stratification system, the 'panc 3 score', has been described. There are conflicting data on the use of antibiotic prophylaxis in acute necrotizing pancreatitis, and on the chemoprevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Enteral feeding is established as standard practice early in the management of acute pancreatitis of all aetiologies; probiotics and other compounds may also play a role. SUMMARY: Over the last year, there have been further innovations in the risk stratification and management of acute pancreatitis. Unresolved issues include chemoprevention of endoscopic retrograde cholangiopancreatography-induced acute pancreatitis, the indications for antibiotic prophylaxis in severe acute pancreatitis and nutritional supplementation with probiotics and synbiotics.
