Abstract Background Therapeutic drug monitoring (TDM) in patients receiving infliximab (IFX) has a role in assessing treatment and managing outcomes. Infliximab trough levels (ITL) have been suggested as useful markers for treatment optimization in Crohn’s disease (CD).Our goals were: to assess the relationship between ITL and transmural inflammation as assessed by intestinal ultrasound(IUS), following induction therapy with IFX; to assess which clinical, laboratorial or IUS parameters better predicted adequate levels by the end of induction therapy. Methods Prospective multicentric cohort study including patients with active CD starting IFX therapy. Clinical disease activity assessed using the Harvey-Bradshaw index (HBI), C-reactive protein (CRP), fecal calprotectin (FC) were measured at week 0 and after induction therapy (week 14). IUS was performed at week 0 and 14, bowel wall thickness (BWT) from the worst segment was selected for analysis. Ileocolonoscopy was performed at W0 and SES-CD was registered. ITL were measured at W14. Results We included 36 patients with CD (61% male; median age 30 years (range 16–73)). According to Montreal classification, most patients were A2 (69%), had ileocolonic disease (L3 56%) and an inflammatory phenotype (B1 58%).Perianal disease was present in 42%. Combination therapy was used in 61%. After induction therapy, 81% were in clinical remission (HBI <5) and 43% had laboratorial remission (normal CRP and FC). IUS response (decrease >25% in BWT) was observed in 24% of patients and remission (BWT normalization) in 11%. Median ITL were 4.3 (IQR 2.3–8.1) and 64% had ITL >3 ug/ml. There was a good negative correlation between ITL and SES-CD (r=-0.492, p=0.003). Adequate ITL were associated with lower HBI (1.5 vs 4.5, p=0.052), laboratory remission (61% vs 15%, p=0.014), lower BWT (4 vs 5.5 mm, p=0.009) and sonographic response (39% vs 0%, p=0.014) at W14. At the end of induction, we found a fair to good correlation between ITL and HBI (r=-0.430, p=0.009),CRP (r=-0,510, p=0.001), FC (r=-0.590, p=0.001) and BWT (R=-0.506, p=0.002). Receiver operating characteristic (ROC) curve analysis showed that FC at W14 had the largest area under the curve (AUC) in predicting adequate ITL (0.813 vs 0.716 vs 0.739 vs 0.772, p<0.05). Conclusion Patients with higher disease burden measured by ileocolonoscopy at baseline had lower ITL after induction. Adequate ITL were associated with laboratorial remission and sonographic response at the end of induction, with a good correlation with clinical, laboratorial and sonographic parameters. These findings suggest that adequate IFX levels after induction are associated with a better control of inflammation in IBD, so early proactive TDM during induction may be helpful in treatment management.
A 55-year-old male underwent a liver transplantation due to alcoholic cirrhosis. Three years later, a re-transplantation was performed due to refractory biliary strictures related to ischemic cholangiopathy.
We aimed to develop and validate a simple capsule endoscopy (CE) training assessment tool, the Capsule Endoscopy Training Assessment (CETA), and prospectively use it to analyze the learning progression achieved by participants in our CE training program.
According to the guideline published by ESGE/UEG, a high-quality esophagogastroduodenoscopy (EGD) implies the application of some criteria that enable better healthcare outcomes. Although intra-procedural performance measures are dependent on patient factors, there is no reference to sedation practices in the guideline mentioned above.
Abstract Background Capsule endoscopy (CE), is a minimally invasive diagnostic tool critical for evaluating small bowel conditions, particularly Crohn's disease. Detecting ulcers and erosions is essential for assessing disease activity, guiding treatment decisions, and monitoring therapeutic responses. While CE revolutionized lesion detection, its manual interpretation is time-consuming and prone to variability. Artificial intelligence (AI) tools, including convolutional neural networks (CNNs), have emerged as transformative solutions, improving detection accuracy, reducing variability, and enabling faster, more reliable lesion identification. This study aimed to develop and validate an AI model capable of detecting and differentiating small bowel ulcers and erosions across multiple CE devices and clinical centers. Methods A multicenter, prospective study was conducted from January 2021 to April 2024, involving centers in Europe (Portugal and Spain) and the USA. The study utilized two CE devices (PillCamSB3 and Olympus EC-10) and analyzed 137 anonymized CE exams. The AI-assisted readings generated by the deep learning model were compared with standard-of-care (SoC) readings, using expert board consensus as the gold standard. Comparisons between SoC reading and AI-assisted reading were assessd by standard metrics (sensitivity, specificity, PPV, NPV, AUROC). Results Ulcers and erosions were detected in 56 patients (40.9%) during expert board review. SoC had 60.7% sensitivity, 98.8% specificity, 97.1% PPV, 78.4% NPV and 83.2% accuracy for detection of ulcers and erosions. AI-assisted reading detected ulcers and erosions with 94.6% sensitivity, 80.2% specificity, 76.8% PPV, 95-6% NPV and 86.1% accuracy. The AI-assisted model diagnosis was non-inferior (p<0.001) and superior (p<0.001) to conventional SoC diagnosis for detection of ulcers and erosions. The AI model identified 68 lesions compared to 35 detected by SoC demonstrating consistent performance across different CE devices and centers. These results were accompanied by a mean reading time of 239 seconds (SD 138 seconds) per exam with AI-assisted reading. Conclusion The AI-assisted model achieved superior diagnostic performance compared to SoC, with higher sensitivity (94.6% vs. 60.7%) and accuracy (86.1% vs. 83.2%), with a significant decrease in reading time.This landmark study represents the first interoperable, multicenter validation of an AI model capable of detecting and differentiating ulcers and erosions using data from multiple CE devices. By ensuring compatibility and high diagnostic performance across diverse settings, this technology is set to transform endoscopic practice and clinical management in IBD. References Piccirelli, S. et al. New Generation Express View: An Artificial Intelligence Software Effectively Reduces Capsule Endoscopy Reading Times. Diagnostics (Basel) 12 (2022). https://doi.org:10.3390/diagnostics12081783 Mascarenhas, M., Afonso, J., Andrade, P., Cardoso, H. & Macedo, G. Artificial intelligence and capsule endoscopy: unravelling the future. Ann Gastroenterol 34, 300-309 (2021). https://doi.org:10.20524/aog.2021.0606 Cardoso P, Mascarenhas M, Afonso J, et al. Deep learning and minimally invasive inflammatory activity assessment: a proof-of-concept study for development and score correlation of a panendoscopy convolutional network. Therap Adv Gastroenterol. 2024;17:17562848241251569. Published 2024 May 27. doi:10.1177/17562848241251569 Afonso, J. et al. Automated detection of ulcers and erosions in capsule endoscopy images using a convolutional neural network. Med Biol Eng Comput 60, 719-725 (2022). https://doi.org:10.1007/s11517-021-02486-9
Abstract Background Faecal calprotectin (FCal) is considered an intermediate target for monitoring disease activity in IBD. However, it is unknown whether early FCal variations during induction therapy may be a significant predictor of treatment response. We aimed to investigate FCal variation after infliximab induction therapy and its association with clinical, endoscopic, and ultrasonographic remission by the end of one year of treatment. Methods Prospective multicentric cohort study including patients with active CD without previous intestinal surgeries, who were starting IFX therapy and were followed for, 54 weeks. FCal was measured at week, 0 and after induction therapy (week, 14) and relative FCal changes from baseline (%FCal0-14) were calculated. At week, 54, clinical remission (defined as Harvey-Bradshaw index (HBI) <5), endoscopic healing (defined as SES-CD score <3) and transmural healing (defined as bowel wall thickness (BWT) assessed by intestinal ultrasound (IUS) ≤3mm) were evaluated. Results We included, 33 patients (60.6% male; median age, 30 years old (IQR, 24–42)). Most patients were diagnosed between, 17–40 years old (75.8%) had ileocolonic disease (57.6%) and an inflammatory phenotype (57.6%). At week, 54, 90.9% of the patients were in clinical remission, 30.3% had endoscopic healing and, 39.4% had transmural healing. The median FCal value at week, 0 was, 765µg/g (IQR, 312–1313) and at week, 14 was, 124.5µg/g (IQR, 46–432.5). At week, 14, 20 patients (60.6%) had FCal<250µg/g. There was no correlation between FCal at week, 0 and the baseline total SES-CD (r=0.28, p=0.13) and BWT of the most affected segment (r=0.02, p=0.90). Patients who achieved clinical remission had a low variation in %FCal0-14 (87.4% vs, 80.1%, p=0.42), as opposed to patients who achieved endoscopic healing (58.5 vs, 91.3%, p<0.001) and transmural healing (68.6% vs, 84.4%, p=0.16) who had more significant changes in %FCal0-14, although only statistically significant for endoscopic healing. When stratifying %FCal0-14 changes in, 25% quartiles, FCal variation at the end of induction was only able to predict endoscopic healing (OR, 8.13 (95%CI, 1.01–65.46), p=0.049), being non-significant for clinical remission (OR, 0.51 (95%CI, 0.09–2.92), p=0.45) and transmural healing (OR, 1.61 (95%CI, 0.73–3.57), p=0.24). A normalization of FCal below, 250 µg/g was also a predictor of endoscopic healing (OR, 9.82 (95%CI, 1.06–90.59), p=0.04). The AUC for the prediction of endoscopic healing with %FCal0-14 changes was, 0.85 (Figure, 1) and a cut-off of variation of, 80.3% was calculated. Conclusion FCal variation at the end of induction seems to be a good predictor of endoscopic healing at week, 54 but does not seem to be able to predict clinical and ultrasonographic remission.
An 81-year-old woman, without relevant pathologies or usual medication, presented with 3-day history of hematochezia. She denied diarrhea, fever, abdominal pain, similar prior episodes, and previous colonoscopy. No consumption of nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. No family history of colorectal cancer or polyposis syndrome. She was hemodynamically stable. The laboratory examination revealed normal blood urea nitrogen (7 mg/dL), normal creatinine (0.55 mg/dL) and coagulation factors, and an anemia of 10.2 g/dL, normocytic and normochromic. A colonoscopy was performed identifying a 30-mm pedunculated polyp with active bleeding in the proximal descending colon (Figure 1A). An endoloop-assisted polypectomy technique was performed (Figure 1B). Since the stalk had more than 1 cm, hemostasis was reinforced with two hemoclips (Figure 1C) and the polyp recovered for histological evaluation (Figure 2). The patient was hospitalized for a short period of time and there was no hemorrhagic recurrence. Anatomopathological evaluation was compatible with an inflammatory pseudopolyp (Figure 2). Polyps usually induce chronic blood loss being the source of acute lower gastrointestinal bleeding in only a small percentage of patients.1 However, the exact frequency of this event is not known. In literature, only two cases of acute lower gastrointestinal bleeding due to polyps in adults were found and both patients were under anticoagulants.2,3 Risk factors for polyp's bleeding are size greater than 10 mm, presence of a stalk and a cherry-red color.4 The usual histopathological findings include marked vascular congestion and intramucosal blood lakes and these features can be seen in inflammatory pseudopolyps.4 This non-neoplastic polyps usually are found in regenerative and healing phases of inflammation so any form of severe colitis as inflammatory bowel disease, ischemic colitis, or infection colitis can originate them. However, inflammatory pseudopolyps may develop sporadically in up to one third of the cases as happened in this situation.5 We present this case due to the rarity of its etiology in a patient with no coagulation changes or antithrombotic medication. The authors declare no conflict of interest. The patient authorized the publication of the data and the patient's anonymity is preserved in the article. Cláudia Macedo was responsible for the data acquisition and editing, manuscript writing, and reviewed the literature. Nuno Almeida was responsible for the data acquisition and reviewed the manuscript. Pedro Figueiredo reviewed the manuscript.
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