Fischman M, Godny L, Friedenberg A
… +12 more, Barkan R, White I, Wasserberg N, Rabinowitz K, Avni-Biron I, Banai H, Snir Y, Broitman Y, Pauker MH, Yanai H, Dotan I, Ollech JE
BACKGROUND: Chronic inflammation of the pouch may affect a significant proportion of patients following ileal pouch-anal anastomosis (IPAA), increasingly treated by advanced therapies. Persistence of such agents or evide...BACKGROUND: Chronic inflammation of the pouch may affect a significant proportion of patients following ileal pouch-anal anastomosis (IPAA), increasingly treated by advanced therapies. Persistence of such agents or evidence to guide sequencing is scarce. This study aims to quantify first- and advanced-line drug persistence and identify factors associated with discontinuation. METHODS: This single-center prospective cohort enrolled adults with IPAA (1986-2021) who initiated biologic/small-molecule therapy between 2001-2024. Persistence was defined as treatment continuation at the last follow-up. Kaplan-Meier and Cox models estimated persistence and its predictors. RESULTS: Of 186 patients, 38 (20.4 %) initiated advanced therapy. Overall follow-up was 16.8y. Agents included: adalimumab 21 (32 %), infliximab 17 (26 %), ustekinumab 16 (25 %), vedolizumab 5 (7.7 %), upadacitinib 3 (4.6 %), risankizumab 1 (1.5 %), certolizumab 1 (1.5 %), and golimumab 1 (1.5 %). Advanced treatment commenced at a median of 10.7y after ileostomy closure. Advanced treatments (≥2nd line) were prescribed for 15 patients (40 %). Each additional treatment line doubled the discontinuation risk (HR 2.48, 95 % CI 1.26-4.90). Ustekinumab retained the highest persistence post-failure of a previous advanced therapy. CONCLUSIONS: In inflammatory pouch disorders, biologic/small-molecule persistence falls steeply after first-line failure, underscoring the importance of early drug selection and avoidance of recycled pre-IPAA agents. Ustekinumab shows superior persistence both as first- and second-line therapy.
Viganò M, D'Ambrosio R, Celsa C
… +19 more, Colli A, Coppola N, Daniele B, Degasperi E, D'Offizi G, Di Marco V, Fagiuoli S, Gambato M, Girmenia C, Grossi P, Lampertico P, Lauterio A, Maida M, Marzano A, Provenzano G, Pugliese N, Raimondo G, Toniutto P, Calvaruso V
Immunosuppressants and immunomodulators are increasingly used for the treatment of several oncologic and immune-mediated diseases. However, reducing or inhibiting the immune system's activity can interfere with the natur...Immunosuppressants and immunomodulators are increasingly used for the treatment of several oncologic and immune-mediated diseases. However, reducing or inhibiting the immune system's activity can interfere with the natural mechanisms responsible for Hepatitis B Virus (HBV) control and may potentially induce HBV reactivation (HBVr) in both Hepatitis B surface Antigen (HBsAg) positive patients (overt infection) and HBsAg negative/anti-Hepatitis B core (anti-HBc) positive carriers. Among factors contributing to the persistence of HBVr risk are insufficient awareness, the significant rate of patients not tested for HBV markers before immunosuppression/immunomodulation and the shortcomings in the correct management of anti-HBV therapy or prophylaxis. The risk of HBVr is influenced by the mechanism of action and the duration of immunosuppressants and immunomodulators, the underlying disease for which these drugs are used, and the virological patient's profile. However, HBVr can be prevented by the identification of at-risk patients through HBV screening in order to start anti-HBV therapy or prophylaxis. Following the need to have updated recommendations, primarily targeted to the Italian setting, on the management of HBV in patients on immunosuppressive and immunomodulator therapies, AISF, together with all the Scientific Societies mainly involved in their management, has promoted the drafting of a new dedicated document based upon available evidence at August 2025.
BACKGROUND: Acute pancreatitis (AP) progresses to severe forms in about 20 % of cases, leading to high morbidity and mortality. Traditional clinical scoring systems for severity prediction (e.g., Ranson, BISAP), are limi...BACKGROUND: Acute pancreatitis (AP) progresses to severe forms in about 20 % of cases, leading to high morbidity and mortality. Traditional clinical scoring systems for severity prediction (e.g., Ranson, BISAP), are limited by delayed applicability, and suboptimal diagnostic accuracy. AIMS: To develop and validate machine learning (ML) models for early prediction of moderately severe and severe acute pancreatitis (MSAP-SAP), and to compare them with conventional scores. METHODS: A retrospective cohort of 816 patients (2014-2023) was analyzed. ML models were developed using admission (24-hour) and early (48-hour) data. Models were trained and tested using an 80:20 stratified split and evaluated based on ROC-AUC. F-Anova, Mutual Information and SHapley Additive exPlanations (SHAP) were used for feature selection. SHAP was also used for model interpretability. RESULTS: The XGBoost model with SHAP-based feature selection (XGB) achieved the highest predictive performance with ROC-AUCs of 0.89 (24-hour) and 0.94 (48-hour) on the test cohort. Key predictive features included SIRS, BUN, CRP, creatinine, and pleural effusion. Compared to Ranson and BISAP (both ROC-AUC = 0.72), the XGB models demonstrated superior accuracy and allowed flexible, threshold-based classification. CONCLUSION: The proposed SHAP-enhanced XGBoost model offers a reliable and interpretable tool for early prediction of AP severity, improving clinical decision-making and patient management.
Autoimmune atrophic gastritis (AAG) is a non-self-limiting immune-mediated disorder exerting growing interest. The main autoantigen, the beta subunit of the proton pump (H+, K+-ATPase), is localised on the oxyntic mucosa...Autoimmune atrophic gastritis (AAG) is a non-self-limiting immune-mediated disorder exerting growing interest. The main autoantigen, the beta subunit of the proton pump (H+, K+-ATPase), is localised on the oxyntic mucosa parietal cells, limiting the autoimmune inflammatory damage to this stomach compartment. Clinical manifestations of AAG may occur late, once corpus-fundus atrophy occurs, and are characterised by loss of gastric acidity, impaired iron and/or cobalamin malabsorption, and increased risk of gastric type 1 neuroendocrine neoplasms and possibly gastric adenocarcinoma. Many topics regarding epidemiology, clinical features, pathogenesis, diagnosis, and management remain to be clarified. AAG patients are frequently misdiagnosed or diagnosed with delay. AAG still represents a clinical challenge and a great opportunity for advancing our knowledge on gastrointestinal autoimmune diseases and gastric precancerous conditions. The timely and correct diagnosis of AAG patients is clinically relevant to avoid potentially harmful consequences due to micronutrient deficiencies and related anaemia and neoplastic complications. The current position paper addresses AAG in adults and reflects the views of the Autoimmune gastRitis Italian netwOrk Study grOup (ARIOSO) on its epidemiology, clinical features, pathogenesis, diagnosis, and management. Improving the understanding of AAG would facilitate timely and accurate diagnosis, enhance clinical management and patients' quality of life, and reduce the economic and social burden of this underrecognized condition.
BACKGROUND: Sarcopenia and age are risk factors for poor outcomes in acute pancreatitis (aP). However, the role of sarcopenia independent of patients' age remains unclear, and assessment methods vary. AIMS: This study as...BACKGROUND: Sarcopenia and age are risk factors for poor outcomes in acute pancreatitis (aP). However, the role of sarcopenia independent of patients' age remains unclear, and assessment methods vary. AIMS: This study assessed sarcopenia, using the Hounsfield unit average calculation (HUAC) for the psoas muscle, and its impact on aP outcomes, independent of other risk factors. METHODS: 208 aP patients who received early computed tomography (CT) were classified as sarcopenic or non-sarcopenic based on HUAC. Propensity score matching (PSM) reduced heterogeneity. Clinical outcomes and independent predictors of intensive care unit (ICU) admission were determined by multivariable logistic regression. RESULTS: After PSM, sarcopenic patients (n = 53) had longer hospital (24.9 ± 20.6d vs. 18.2 ± 27.3d; p = 0.0006) and ICU stays (9.5 ± 16.5d vs. 6.2 ± 25.8d; p = 0.0077) than non-sarcopenic patients (n = 53). ICU admission was more frequent (58.5 % vs. 37.7 %; p = 0.0325), and aP-associated morbidity such as pleural effusion occurred more often (p = 0.0019). Independent predictors of ICU admission included pleural effusion or ascites (p = 0.0116) and impaired coagulation (p = 0.0365). CONCLUSION: Sarcopenia identified via HUAC in early aP is associated with a worse clinical outcome. Pleural effusion or ascites and changes in blood coagulation independently predict ICU admission in sarcopenic aP patients. Early nutritional and physical therapy should be considered to prevent and treat sarcopenia in aP patients.
Terrin M, Spadaccini M, Poletti V
… +14 more, De Palma C, Mercurio M, Minini F, Spertino M, Colombo M, Andreozzi M, Bonifacio C, Capretti G, Rossi RE, Fugazza A, Hassan C, Repici A, Zerbi A, Carrara S
BACKGROUND: Management of presumed branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) without worrisome features (WF) or high-risk stigmata (HRS) remains controversial, particularly regarding the duration of...BACKGROUND: Management of presumed branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) without worrisome features (WF) or high-risk stigmata (HRS) remains controversial, particularly regarding the duration of surveillance. METHODS: We conducted a retrospective single-center study including patients with presumed BD-IPMNs without WF or HRS at diagnosis, followed between 2014 and 2023. Clinical, radiological, and pathological data were collected. Outcomes included malignant progression, surgery, and mortality. Subgroup analyses assessed patients with ≥5years of follow-up, potentially meeting discontinuation criteria. RESULTS: 413 patients met inclusion criteria. Median age at diagnosis was 65 years; 64 % were women. Median cyst size was 10 mm, and median follow-up 36 months. WF developed in 20 % of patients and HRS in 0.7 %. Four patients (0.26/100 person-years) experienced malignant progression, all within 30 months from diagnosis; two underwent surgery, revealing adenocarcinoma in both. In 108 patients followed ≥5 years, 89 remained stable. None developed cancer, required surgery, or died from BD-IPMN. Seven developed WF after 5 years. Depending on criteria, 49 % according to Marchegiani and 63 % according to Kyoto would qualify for discontinuation of surveillance. CONCLUSIONS: In real-world practice, malignant progression of presumed BD-IPMNs without WF/HRS is rare and tends to occur early. After 5 years of stability, surveillance discontinuation may be safe in selected subgroups, although prospective validation is needed.
BACKGROUND AND AIMS: A low-volume, fast-acting bowel-cleansing agent may allow for a more convenient single-dose regimen, thereby improving patient adherence and comfort. This study aimed to evaluate the efficacy, safety...BACKGROUND AND AIMS: A low-volume, fast-acting bowel-cleansing agent may allow for a more convenient single-dose regimen, thereby improving patient adherence and comfort. This study aimed to evaluate the efficacy, safety, and acceptability of a novel bowel preparation solution containing D-sorbitol, ascorbic acid, and picosulfate (DAP). METHODS: In this prospective, multicenter, randomized trial conducted at five Korean tertiary hospitals, patients undergoing colonoscopy received either 0.46-L DAP (same-day dosing) or 2-L polyethylene glycol plus ascorbic acid (PEG+Asc; split-dose). Bowel cleansing was assessed using the Harefield Cleansing Scale (HCS) by independent blinded raters, safety, and patient acceptability were evaluated RESULTS: A total of 243 patients (mean age 50.6 years; 39.6 % male) were enrolled, with 122 receiving DAP. Rates of successful bowel cleansing were similar between groups (DAP: 96.8 % vs. PEG+Asc: 96.7 %; p = 1.000). No significant differences were observed in clinical or laboratory safety parameters. The proportion of patients reporting difficulty ingesting the solution was significantly lower with DAP (22.1 % vs. 81.0 %; p < 0.01), and satisfaction scores were notably higher (8.71 vs. 6.22; p < 0.001). CONCLUSION: DAP-based bowel cleansing reduces the volume of solution required without compromising efficacy or safety, allowing for single-dose bowel preparation. This solution is more acceptable to patients, potentially improving adherence with bowel cleansing protocols and leading to a more effective colonoscopy.
BACKGROUND: Acute severe ulcerative colitis (ASUC) is a life-threatening condition. Corticosteroids are the first-line treatment, however, about 30 % of patients may not respond. This network meta-analysis evaluated the...BACKGROUND: Acute severe ulcerative colitis (ASUC) is a life-threatening condition. Corticosteroids are the first-line treatment, however, about 30 % of patients may not respond. This network meta-analysis evaluated the efficacy of advanced therapies and immunomodulators as rescue treatments for steroid-refractory ASUC. METHODS: On March 1, 2025, a systematic search was conducted using four online databases. We included studies that evaluated the use of advanced therapies and other immunomodulators in steroid-refractory ASUC. The primary outcome was the colectomy rate at 1, 3, and 12 months. Odds ratios (ORs) with 95 % confidence intervals (CI) were calculated. For colectomy-free survival, the hazard ratio (HR) was estimated using a stratified Cox model. RESULTS: Eighteen studies, including 2057 patients, were included. Treatment with standard infliximab was associated with improved colectomy-free survival compared to cyclosporine (cyclosporine (Cyclosporine capsules) capsules) therapy (HR: 0.54, 95 % CI: 0.42-0.72, p < 0.001). No differences were observed between standard and either accelerated or intensified infliximab. At 1 month, no differences in colectomy rates were observed across treatments. At 3 months, tofacitinib (OR, 0.14; 95 % CI, 0.02-0.89) and standard infliximab (OR, 0.55; 95 % CI, 0.33-0.89) were associated with lower colectomy rates compared to cyclosporine (cyclosporine (Cyclosporine capsules) capsules). At 12 months, intensified (OR, 0.23; 95 % CI, 0.07-0.75), standard (OR, 0.40; 95 % CI, 0.25-0.64), and accelerated infliximab (OR, 0.44; 95 % CI, 0.20-0.97) were superior to cyclosporine (cyclosporine (Cyclosporine capsules) capsules). CONCLUSIONS: Colectomy rates were similar across treatments at 1 month. At 3 months, standard infliximab and tofacitinib were associated with lower colectomy rates than cyclosporine (cyclosporine (Cyclosporine capsules) capsules). By 12 months, standard, intensified, and accelerated infliximab showed lower rates than cyclosporine (cyclosporine (Cyclosporine capsules) capsules).
Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are chronic immune-mediated conditions of the gastrointestinal tract. Accurate diagnosis, disease monitoring, and prediction...Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are chronic immune-mediated conditions of the gastrointestinal tract. Accurate diagnosis, disease monitoring, and prediction of treatment response remain major challenges. Endoscopic ultrasound (EUS), originally developed for pancreatobiliary indications, offers high-resolution, transmural imaging and is gaining relevance in IBD assessment. This review comprehensively examines the emerging applications of EUS in IBD, including its potential role in diagnosis, in distinguishing CD from UC, in evaluating disease activity and predicting clinical outcomes and therapeutic responses to biologic agents, through parameters such as bowel wall thickness, parietal stratification, vascular patterns and lymphadenopathy. EUS also enables detailed evaluation and characterization of colorectal lesions and supports real-time, minimally invasive therapeutic interventions, including drainage of intra-abdominal fluid collections, management of perianal fistulas, and guidance during endoscopic dilation of strictures. Technological advancements like contrast-enhanced EUS, elastography, and through-the-scope mini-probes have further enhanced diagnostic accuracy and procedural versatility. While promising, widespread adoption of EUS in IBD management is limited by the need for standardized protocols and adequate training. Nonetheless, ongoing technological developments and integration with artificial intelligence are expected to expand its role in precision medicine, ultimately improving patient outcomes through better disease characterization, monitoring, and individualized therapeutic strategies.