Cristina Sánchez-Montes

Adalimumab in prevention of postoperative recurrence of Crohn's disease in high-risk patients

AIM To evaluate the effectiveness of adalimumab in preventing recurrence after intestinal resection for Crohns disease in high-risk patients. METHODS A multicenter, prospective, observational study was conducted from June 2009 until June 2010. We consecutively included high-risk Crohns disease patients who had undergone an ileal/ileocolonic resection. High-risk patients were defined as two or more criteria: smokers, penetrating pattern, one or more previous surgical resections or prior extensive resection. Subcutaneous adalimumab was administered 2 wk (± 5 d) after surgery at a dose of 40 mg eow, with an initial induction dose of 160/80 mg at weeks 0 and 2. Demographic data, previous and concomitant treatments (antibiotics, 5-aminosalicylates, corticosteroids, immunomodulators or biologic therapies), smoking status at the time of diagnosis and after the index operation and number of previous resections (type and reason for surgery) were all recorded. Biological status was assessed with C-reactive protein, erythrocyte sedimentation rate and fecal calprotectin. One year (± 3 mo) after surgery, an ileocolonoscopy and/or magnetic resonance enterography was performed. Endoscopic recurrence was defined as Rutgeerts score ≥ i2. Morphological recurrence was based on magnetic resonance (MR) score ≥ MR1. RESULTS Twenty-nine patients (55.2% males, 48.3% smokers at diagnosis and 13.8% after the index operation), mean age 42.3 years and mean duration of the disease 13.8 years were included in the study. A mean of 1.76 (range: 1-4) resections previous to adalimumab administration and in 37.9% was considered extensive resection. 51.7% had previously received infliximab. Immunomodulators were given concomitantly to 17.2% of patients. Four of the 29 (13.7%) developed clinical recurrence, 6/29 (20.7%) endoscopic recurrence and 7/19 (36.8%) morphological recurrence after 1-year. All patients with clinical recurrence showed endoscopic and morphological recurrence. A high degree of concordance was found between clinical-endoscopic recurrence (κ = 0.76, P < 0.001) and clinical-morphological recurrence (κ = 0.63, P = 0.003). Correlation between endoscopic and radiological findings was good (comparing the 5-point Rutgeerts score with the 4-point MR score, a score of i4 was classified as MR3, i3 as MR2, and i2-i1 as MR1) (P < 0.001, r(s) = 0.825). During follow-up, five (17.2%) patients needed adalimumab dose intensification (40 mg/wk); Mean time to intensification after the introduction of adalimumab treatment was 8 mo (range: 5 to 11 mo). In three cases (10.3%), a biological change was needed due to a worsening of the disease after the dose intensification to 40 mg/wk. One patient suffered an adverse event. CONCLUSION Adalimumab seems to be effective and safe in preventing postoperative recurrence in a selected group of patients who had undergone an intestinal resection for their CD.

Long‐term outcome of ‘long‐term liver transplant survivors’

There are few studies focusing on long‐term complications in liver transplant (LT) recipients. The aim of this study was to define the outcome of LT recipients having survived at least 10 years from LT. Of 323 adult LT done between 1991 and 1997, the 167(52%) alive >10 years post‐LT (baseline time) formed the study population. Long‐term outcome measures included the following: immunosuppression, metabolic complications [obesity, arterial hypertension (AH), diabetes, dislypidemia], cardiovascular events (CVE), chronic renal dysfunction‐CRD, and de novo tumors. Median age at LT was 50 years. Most common indication was postnecrotic cirrhosis (89%), mostly because of HCV (46%). At study‐baseline (10 years post‐LT), 29% were obese and AH, diabetes, dislypidemia, and CRD were present in 75%, 30%, 42%, and 36%, respectively. In most cases, these complications were already present 1 year post‐LT; less than one quarter developed them onward. The 6 year cumulative survival since baseline reached 84% (n = 24 deaths), with most deaths related to recurrent graft diseases (mostly HCV) followed by de novo tumors or CVE. 1, 3, 5 and 10 years cumulative rates of CVE and de novo tumors since baseline were 2%, 5%, 10% and 17%, and 1%, 3%, 6% and 13%, respectively. Chronic renal impairment was independently associated with survival and development of CVE since baseline. The medium‐term survival of ‘long‐term survivors’, i.e. patients alive 10 years after LT is good, but metabolic complications and CRD are common and continue to increase afterwards. Cardiovascular events and de novo tumors increase gradually over time and represent a major cause of late mortality.

Comparative Validation of Polyp Detection Methods in Video Colonoscopy: Results From the MICCAI 2015 Endoscopic Vision Challenge

Colonoscopy is the gold standard for colon cancer screening though some polyps are still missed, thus preventing early disease detection and treatment. Several computational systems have been proposed to assist polyp detection during colonoscopy but so far without consistent evaluation. The lack of publicly available annotated databases has made it difficult to compare methods and to assess if they achieve performance levels acceptable for clinical use. The Automatic Polyp Detection sub-challenge, conducted as part of the Endoscopic Vision Challenge (http://endovis.grand-challenge.org) at the international conference on Medical Image Computing and Computer Assisted Intervention (MICCAI) in 2015, was an effort to address this need. In this paper, we report the results of this comparative evaluation of polyp detection methods, as well as describe additional experiments to further explore differences between methods. We define performance metrics and provide evaluation databases that allow comparison of multiple methodologies. Results show that convolutional neural networks are the state of the art. Nevertheless, it is also demonstrated that combining different methodologies can lead to an improved overall performance.

Exploring the clinical potential of an automatic colonic polyp detection method based on the creation of energy maps.

BACKGROUND AND AIMS Polyp miss-rate is a drawback of colonoscopy that increases significantly for small polyps. We explored the efficacy of an automatic computer-vision method for polyp detection. METHODS Our method relies on a model that defines polyp boundaries as valleys of image intensity. Valley information is integrated into energy maps that represent the likelihood of the presence of a polyp. RESULTS In 24 videos containing polyps from routine colonoscopies, all polyps were detected in at least one frame. The mean of the maximum values on the energy map was higher for frames with polyps than without (P < 0.001). Performance improved in high quality frames (AUC = 0.79 [95 %CI 0.70 - 0.87] vs. 0.75 [95 %CI 0.66 - 0.83]). With 3.75 set as the maximum threshold value, sensitivity and specificity for the detection of polyps were 70.4 % (95 %CI 60.3 % - 80.8 %) and 72.4 % (95 %CI 61.6 % - 84.6 %), respectively. CONCLUSION Energy maps performed well for colonic polyp detection, indicating their potential applicability in clinical practice.

Small intestinal bacterial overgrowth in inactive Crohn's disease: influence of thiopurine and biological treatment.

AIM To investigate the influence of thiopurines and biological drugs on the presence of small intestinal bacterial overgrowth (SIBO) in patients with inactive Crohns disease (CD). METHODS This was a prospective study in patients with CD in remission and without corticosteroid treatment, included consecutively from 2004 to 2010. SIBO was investigated using the hydrogen glucose breath test. RESULTS One hundred and seven patients with CD in remission were included. Almost 58% of patients used maintenance immunosuppressant therapy and 19.6% used biological therapy. The prevalence of SIBO was 16.8%. No association was observed between SIBO and the use of thiopurine Immunosuppressant (12/62 patients), administration of biological drugs (2/21 patients), or with double treatment with an anti-tumor necrosis factor drugs plus thiopurine (1/13 patients). Half of the patients had symptoms that were suggestive of SIBO, though meteorism was the only symptom that was significantly associated with the presence of SIBO on univariate analysis (P < 0.05). Multivariate analysis revealed that the presence of meteorism and a fistulizing pattern were associated with the presence of SIBO (P < 0.05). CONCLUSION Immunosuppressants and/or biological drugs do not induce SIBO in inactive CD. Fistulizing disease pattern and meteorism are associated with SIBO.

Efficacy and safety of a combination of hyaluronic acid, chondroitin sulfate, and poloxamer 407 as a submucosal injection solution for endoscopic resection: pilot study on a swine model

Background and aims  Endoscopic resection techniques require use of submucosal injection. The aim of this study was to assess a new solution that combines hyaluronic acid, chondroitin sulfate, and poloxamer 407 for submucosal injection. Methods  A total of 48 gastric submucosal cushions were created in fresh porcine stomachs using gelafundin (n = 16) or the new solution diluted at 50 % (n = 16), or 80 % (n = 16). The duration of mucosal elevation was measured. In an in vivo model, 10 gastric submucosal cushions were created by injecting 2 mL of the new solution at 80 % and the animal was euthanized 30 minutes after the last injection. Results  Submucosal cushions with the new solution at 80 % and 50 % concentration lasted longer than with gelafundin (23.13 ± 15.57, 13.1 ± 6.6, 3.94 ± 1.53 minutes, respectively; P  = 0.000). In the in vivo study, no damage or necrosis was observed in the mucosa or muscularis propria. Conclusion  The combination of hyaluronic acid, chondroitin sulfate, and poloxamer 407 produces a long-lasting submucosal cushion and does not seem to induce acute damage in the tissue making it suitable for submucosal injection.

GTCreator: a flexible annotation tool for image-based datasets

Purpose:Methodology evaluation for decision support systems for health is a time-consuming task. To assess performance of polyp detection methods in colonoscopy videos, clinicians have to deal with the annotation of thousands of images. Current existing tools could be improved in terms of flexibility and ease of use.Methods:We introduce GTCreator, a flexible annotation tool for providing image and text annotations to image-based datasets. It keeps the main basic functionalities of other similar tools while extending other capabilities such as allowing multiple annotators to work simultaneously on the same task or enhanced dataset browsing and easy annotation transfer aiming to speed up annotation processes in large datasets.Results:The comparison with other similar tools shows that GTCreator allows to obtain fast and precise annotation of image datasets, being the only one which offers full annotation editing and browsing capabilites.Conclusion:Our proposed annotation tool has been proven to be efficient for large image dataset annotation, as well as showing potential of use in other stages of method evaluation such as experimental setup or results analysis.

Rate of adverse events of gastroduodenal snare polypectomy for non-flat polyp is low: A prospective and multicenter study

AIM To evaluate the rate of adverse events (AEs) during consecutive gastric and duodenal polypectomies in several Spanish centers. METHODS Polypectomies of protruded gastric or duodenal polyps ≥ 5 mm using hot snare were prospectively included. Prophylactic measures of hemorrhage were allowed in predefined cases. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy. Patients were followed for 48 h, one week and 1 mo after the procedure. RESULTS 308 patients were included and a single polypectomy was performed in 205. Only 36 (11.7%) were on prior anticoagulant therapy. Mean polyp size was 15 ± 8.9 mm (5-60) and in 294 cases (95.4%) were located in the stomach. Hemorrhage prophylaxis was performed in 219 (71.1%) patients. Nine patients presented AEs (2.9%), and 6 of them were bleeding (n = 6, 1.9%) (in 5 out of 6 AE, different types of endoscopic treatment were performed). Other 24 hemorrhagic episodes could be managed without any change in the outcome of the endoscopy and, consequently, were considered incidents. We did not find any independent risk factor of bleeding. CONCLUSION Gastroduodenal polypectomy using prophylactic measures has a rate of AEs small enough to consider this procedure a safe and effective method for polyp resection independently of the polyp size and location.

Indicadores de calidad en la esofagogastroduodenoscopia: estudio comparativo de los resultados tras un programa de mejora en un hospital terciario

INTRODUCTION There is an opportunity for improvement in the recording and measuring of quality indicators. However, no previous experiences exist in our field in terms of their compliance in esophagogastroduodenoscopy (EGD). OBJECTIVE To analyse compliance with EGD quality criteria and evaluate improvement after conducting a training programme. PATIENTS AND METHODS Comparative study of 2 cohorts: one retrospective (control group) and one prospective (intervention group), before and after a training programme consisting of an information session and the report writing improvement programme. The quality indicators proposed by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were used. RESULTS A total of 1,200 EGDs were included in a sequential manner (600 in each group). Following the training programme, a significant improvement was observed in the following indicators: documented indication (93 vs. 99.8%; P<0.01), documented full examinations (94.7 vs. 97.3%; P<0.01), correct performance (63.7 vs. 87.9%; P<0.01), appropriate biopsies according to protocols (57.9 vs. 83.8%; P<0.01), photo-documentation of described lesions (84.1 vs. 94.9%; P<0.01), photo-documentation per segment (52.9 vs. 70.5%; P<0.01) and correct overall assessment (56,9 vs. 90.5%; P<0.01). Biopsies for coeliac disease, documented indication, full examination and correct performance, if it went ahead, exceeded the recommended standard. CONCLUSION A very simple training programme improves EGD quality indicators, with the majority reaching the standards recommended by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology.

Towards Real-Time Polyp Detection in Colonoscopy Videos: Adapting Still Frame-Based Methodologies for Video Sequences Analysis

Colorectal cancer is the second cause of cancer death in United States: precursor lesions (polyps) detection is key for patient survival. Though colonoscopy is the gold standard screening tool, some polyps are still missed. Several computational systems have been proposed but none of them are used in the clinical room mainly due to computational constraints. Besides, most of them are built over still frame databases, decreasing their performance on video analysis due to the lack of output stability and not coping with associated variability on image quality and polyp appearance. We propose a strategy to adapt these methods to video analysis by adding a spatio-temporal stability module and studying a combination of features to capture polyp appearance variability. We validate our strategy, incorporated on a real-time detection method, on a public video database. Resulting method detects all polyps under real time constraints, increasing its performance due to our adaptation strategy.