Metabolic and Bariatric Endoscopy: A Mini-Review

We are currently in a worldwide obesity pandemic, which is one of the most significant health problems of the 21st century. As the prevalence of obesity continues to rise, new and innovate treatments are becoming available. Metabolic and bariatric endoscopic procedures are exciting new areas of gastroenterology that have been developed as a direct response to the obesity crisis. These novel interventions offer a potentially reversible, less invasive, safer, and more cost-effective method of tackling obesity compared to traditional bariatric surgery. Minimally invasive endoscopic treatments are not entirely novel, but as technology has rapidly improved, many of the procedures have been proven to be extremely effective for weight loss and metabolic health, based on high-quality clinical trial data. This mini-review examines the existing evidence for the most prominent metabolic and bariatric procedures, followed by a discussion on the future trajectory of this emerging subspecialty

Diagnostic approach to Helicobacter pylori-related gastric oncogenesis.

Helicobacter pylori (H. pylori) is a causative agent of peptic ulcer disease and plays an important role in the development of various other upper and lower gastrointestinal tract and systemic diseases; in addition to carcinogenesis and the development of mucosa-associated lymphoid tissue lymphoma, extragastric manifestations of H. pylori are increasingly being unraveled. Therefore, prompt and accurate diagnosis is essential. Within this narrative review we present an overview of the current trend in the diagnosis of H. pylori infection and its potential oncogenic sequelae, including gastric mucosa atrophy, intestinal metaplasia, dysplasia and gastric cancer. Signs of H. pylori-related gastric cancer risk can be assessed by endoscopy using the Kyoto classification score. New technology, such as optical or digital chromoendoscopy, improves diagnostic accuracy and provides information regarding H. pylori-related gastric preneoplastic and malignant lesions. In addition, a rapid urease test or histological examination should be performed, as these offer a high diagnostic sensitivity; both are also useful for the diagnosis of sequelae including gastric and colon neoplasms. Culture is necessary for resistance testing and detecting H. pylori-related gastric dysbiosis involved in gastric oncogenesis. Likewise, molecular methods can be utilized for resistance testing and detecting H. pylori-related gastric cancer development and progression. Noninvasive tests, such as the urea breath and stool antigen tests, can also be implemented; these are also suitable for monitoring eradication success and possibly for detecting H. pylori-related gastric malignancy. Serological tests may help to exclude infection in specific populations and detect gastric and colon cancers. Finally, there are emerging potential diagnostic biomarkers for H. pylori-related gastric cancer

Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma

Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma

Ofeleein i mi Vlaptin-Volume II: Immunity Following Infection or mRNA Vaccination, Drug Therapies and Non-Pharmacological Management at Post-Two Years SARS-CoV-2 Pandemic.

The persistence of the coronavirus disease 2019 (COVID-19) pandemic has triggered research into limiting transmission, morbidity and mortality, thus warranting a comprehensive approach to guide balanced healthcare policies with respect to people's physical and mental health. The mainstay priority during COVID-19 is to achieve widespread immunity, which could be established through natural contact or vaccination. Deep knowledge of the immune response combined with recent specific data indicates the potential inferiority of induced immunity against infection. Moreover, the prevention of transmission has been founded on general non-pharmacological measures of protection, albeit debate exists considering their efficacy and, among other issues, their socio-psychological burden. The second line of defense is engaged after infection and is supported by a plethora of studied agents, such as antibiotics, steroids and non-steroid anti-inflammatory drugs, antiviral medications and other biological agents that have been proposed, though variability in terms of benefits and adverse events has not allowed distinct solutions, albeit certain treatments might have a role in prevention and/or treatment of the disease. This narrative review summarizes the existing literature on the advantages and weaknesses of current COVID-19 management measures, thus underlining the necessity of acting based on the classical principle of "ofeleein i mi vlaptin", that is, to help or not to harm

Association between Helicobacter pylori Infection and Nasal Polyps: A Systematic Review and Meta-Analysis.

BACKGROUND Helicobacter pylori (H. pylori) has definite or possible associations with multiple local and distant manifestations. H. pylori has been isolated from multiple sites throughout the body, including the nose. Clinical non-randomized studies with H. pylori report discrepant data regarding the association between H. pylori infection and nasal polyps. The aim of this first systematic review and meta-analysis was the assessment of the strength of the association between H. pylori infection and incidence of nasal polyps. METHODS We performed an electronic search in the three major medical databases, namely PubMed, EMBASE and Cochrane, to extract and analyze data as per PRISMA guidelines. RESULTS Out of 57 articles, 12 studies were graded as good quality for analysis. Male-to-female ratio was 2:1, and age ranged between 17-78 years. The cumulative pooled rate of H. pylori infection in the nasal polyp group was 32.3% (controls 17.8%). The comparison between the two groups revealed a more significant incidence of H. pylori infection among the nasal polyp group (OR 4.12), though with high heterogeneity I$^{2}$ = 66%. Subgroup analysis demonstrated that in European studies, the prevalence of H. pylori infection among the nasal polyp group was significantly higher than in controls, yielding null heterogeneity. Subgroup analysis based on immunohistochemistry resulted in null heterogeneity with preserving a statistically significant difference in H. pylori infection prevalence between the groups. CONCLUSION The present study revealed a positive association between H. pylori infection and nasal polyps

Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

Background: Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients’ lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety. Methods: A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI). Results: Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31–57; 352/767; I2 = 93.7%), and the respective partial response rate was 30% (95%CI: 20–39; 206/767; I2 = 86.1%). Adverse events were recorded in 14% (95%CI: 8–20; 164/840; I2 = 87.2%) of cases, rated as mild in 10% (95%CI: 5–15; 128/840; I2 = 86.7%), and severe in 4% (95%CI: 3–5; 36/840; I2 = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64–76; I2 = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33–54; I2= 0%) for lauromacrogol, 32% (95%CI: 27–36; I2 = 88.4%) for ethanol, and 13% (95%CI: 4–22; I2 = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13–20; I2 = 91.0%). Conclusion: EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates

Vitamin D Deficiency and Unclear Abdominal Pain in Patients from Low- and Middle-Income Countries.

Background: Abdominal pain is one of the commonest symptoms in emergency departments (EDs). Diagnosis demands full attention and critical thinking, since many diseases manifest atypically and the consequences of overlooking the symptoms may be disastrous. Despite intensive diagnostic procedures, some cases remain elusive and unclear abdominal pain (UAP) is not infrequent. Emerging evidence supports the hypothesis that functional pain might be attributed to vitamin D deficiency (VDD). People with darker or covered skin are predisposed to developing VDD. Patients in Switzerland stemming from low- and middle-income countries (LMIC) are such a population. Aim: To identify cases with UAP in LMIC patients and to compare vitamin D status with a control group. Methods: A retrospective single-center case-control study was carried out from 1 January 2013 to 31 August 2016 in all adult patients (more than 16 years old) stemming from LMIC and presenting at the university ED of Bern with abdominal pain. Vitamin D status was retrieved from these cases when available. The control group consisted of patients without abdominal pain or metabolic diseases and was matched (1:1) to the cases for age, gender, body mass index, geographic distribution, and season of vitamin D estimation. Results: A total of 10,308 cases from LMIC were reported to the ED. In total, 223 cases were identified with UAP. The status of vitamin D was available for 27 patients; 27 matched individuals were subsequently retrieved for the control group. Women made up 56.7% of the UAP group and 43.3% of the control group. The most common origin of the LMIC subjects was southern Europe (20.4%), followed by southern Asia (16.7%) and Eastern Europe (13%). Fourteen UAP patients exhibited severe VDD (< 25 nmol/L) versus one in the control group (p = 0.001). The difference remained significant if the patients were identified as having VDD (<50 nmol/L) or not (p = 0.024). Comparison of the means indicated that the UAP group had lower vitamin D levels than the control group (41.3 vs. 53.7 nmol/L, respectively), but this difference was marginal (p = 0.060) and not statistically significant. After adjustment for potential confounders, including gender, mean vitamin D levels remained non-significantly different between groups. In the sub-group analysis, vitamin D levels were lower in women than in men (p = 0.037), compared to the respective controls. Conclusion: This study showed for the first time that patients from LMIC who presented to ED with UAP displayed VDD. Validation from larger studies is warranted to evaluate the linkage of VDD with UAP

Does COVID-19 Vaccination Warrant the Classical Principle " ofelein i mi vlaptin"?

The current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic warrants an imperative necessity for effective and safe vaccination, to restrain Coronavirus disease 2019 (COVID-19) including transmissibility, morbidity, and mortality. In this regard, intensive medical and biological research leading to the development of an arsenal of vaccines, albeit incomplete preconditioned evaluation, due to emergency. The subsequent scientific gap raises some concerns in the medical community and the general public. More specifically, the accelerated vaccine development downgraded the value of necessary pre-clinical studies to elicit medium- and long-term beneficial or harmful consequences. Previous experience and pathophysiological background of coronaviruses' infections and vaccine technologies, combined with the global vaccines' application, underlined the obligation of a cautious and qualitative approach, to illuminate potential vaccination-related adverse events. Moreover, the high SARS-CoV-2 mutation potential and the already aggregated genetical alterations provoke a rational vagueness and uncertainty concerning vaccines' efficacy against dominant strains and the respective clinical immunity. This review critically summarizes existing evidence and queries regarding SARS-CoV-2 vaccines, to motivate scientists' and clinicians' interest for an optimal, individualized, and holistic management of this unprecedented pandemic

Trimebutine maleate monotherapy for functional dyspepsia: A multicenter, randomized, double-blind placebo controlled prospective trial

Background and Objectives:Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders; it has a great impact on patient quality of life and is difficult to treat satisfactorily. This study evaluates the efficacy and safety of trimebutine maleate (TM) in patients with FD.Materials and Methods: A multicenter, randomized, double-blind, placebo controlled, prospective study was conducted, including 211 patients with FD. Participants were randomized to receive TM 300 mg twice per day (BID, 108 patients) or placebo BID (103 patients) for 4 weeks. The Glasgow Dyspepsia Severity Score (GDSS) was used to evaluate the relief of dyspepsia symptoms. Moreover, as a pilot secondary endpoint, a substudy (eight participants on TM and eight on placebo) was conducted in to evaluate gastric emptying (GE), estimated using a 99mTc-Tin Colloid Semi Solid Meal Scintigraphy test.Results: Of the 211 patients enrolled, 185 (87.7%) (97 (52.4%) in the TM group and 88 (47.6%) in the placebo group) completed the study and were analyzed. The groups did not differ in their demographic and medical history data. Regarding symptom relief, being the primary endpoint, a statistically significant reduction in GDSS for the TM group was revealed between the first (2-week) and final (4-week) visit (p-value = 0.02). The 99 mTc-Tin Colloid Semi Solid Meal Scintigraphy testing showed that TM significantly accelerated GE obtained at 50 min (median emptying 75.5% in the TM group vs. 66.6% in the placebo group,p= 0.036). Adverse effects of low to moderate severity were reported in 12.3% of the patients on TM.Conclusion: TM monotherapy appears to be an effective and safe approach to treating FD, although the findings presented here warrant further confirmation.Galenica A.E. Pharmaceutical Compan

Η επίδραση των βιολογικών παραγόντων στη μεταβολικής αιτιολογίας λιπώδη νόσο του ήπατος σε ασθενείς με ιδιοπαθή φλεγμονώδη νοσήματα του εντέρου

Introduction: Inflammatory bowel diseases (IBD) exhibit intestinal and systematic manifestations. Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common co-existing condition with IBD, possibly contributing to the cardio-metabolic burden and overall morbidity observed in patients with IBD. Εmerging therapeutic choices of biologicals have modified the clinical course of IBD; however, their impact on IBD-associated MASLD has not been extensively evaluated. The prevalence of MASLD varies within patients with IBD, but it appears higher than in the general population in the majority of quality studies. IBD-associated MASLD possibly follows two different patterns, one manifested during the relapses and one during the remissions of IBD. Thus, the pathogenic and risk factors of MASLD may vary upon IBD activity. Dysbiosis of intestinal microbiota, mucosal damage, and cytokine release have been implicated in the pathogenesis during the relapses, whilst metabolic risk factors seem to play a key role during the remissions of IBD. Considering biologicals, although quality data are scarce, those suppressing tumour necrosis factor may offer potential benefits in IBD-associated MASLD, whereas those acting as anti-integrins do not appear to confer any therapeutic advantage to MASLD. Aim: This study primarily aimed to evaluate the six-month effect of infliximab or vedolizumab vs. no treatment with biologicals on hepatic steatosis in patients with IBD. Methods: For the needs of this prospective, open-label, non-randomized trial, patients starting treatment with infliximab or vedolizumab for IBD were recruited in active arms, whereas patients with IBD not receiving biologicals were recruited in the control arm. Parameters regarding IBD activity, hepatic steatosis, fibrosis, and non-invasive indices were also evaluated. Repeated measures ANOVA was used to evaluate the overall tendency of group×time interactions for continuous variables and binary regression analysis adjusted for potential covariates was used for dichotomous variables. Results: Sixty-six naïve patients for biologicals were allocated into three groups: infliximab (n: 26), vedolizumab (n: 14), and control (n: 26). At baseline, steatosis was present in 26.9% (infliximab), 46.2% (vedolizumab), and 23.1% (control). After six months, steatosis reduced in all groups, without significant difference in group×time interactions. Apart from waist circumference, other disease-related covariates and serological markers (adipokines, TNF, PIINP and TIMP-1) did not affect the group×time interactions of primary and secondary endpoints. Conclusion: No positive or negative effects of infliximab or vedolizumab compared to treatment without biologicals on presumed hepatic steatosis in patients with IBD was shown.Εισαγωγή: Τα ιδιοπαθή φλεγμονώδη νοσήματα του εντέρου (ΙΦΝΕ) εκδηλώνονται με εντερικές και συστηματικές εκδηλώσεις. Η λιπώδης νόσος του ήπατος που σχετίζεται με τη μεταβολική δυσλειτουργία (ΜΑΛΝΗ) είναι μια νόσος που συνυπάρχει με τα ΙΦΝΕ, και ενδεχομένως συμβάλλει στον αυξημένο καρδιομεταβολικό κίνδυνο και στη συνολική νοσηρότητα που παρατηρείται στους ασθενείς με ΙΦΝΕ. Οι νέες θεραπευτικές επιλογές με βιολογικούς παράγοντες έχουν τροποποιήσει την κλινική πορεία των ΙΦΝΕ, ωστόσο, ο αντίκτυπός τους στη ΜΑΛΝΗ που σχετίζεται με τα ΙΦΝΕ δεν έχει αξιολογηθεί επαρκώς. Η συχνότητα της ΜΑΛΝΗ ποικίλλει στους ασθενείς με ΙΦΝΕ, αλλά φαίνεται να είναι υψηλότερη από τον γενικό πληθυσμό στην πλειονότητα των ποιοτικών μελετών. Η ΜΑΛΝΗ που σχετίζεται με τα ΙΦΝΕ ακολουθεί πιθανώς δύο διαφορετικά παθογενετικά πρότυπα, ένα που εκδηλώνεται κατά τις υποτροπές και ένα κατά τις υφέσεις των ΙΦΝΕ. Έτσι, όσον αφορά την παθογένεση και τους παράγοντες κινδύνου της ΜΑΛΝΗ, αυτοί ενδέχεται να ποικίλλουν ανάλογα με τη δραστηριότητα των ΙΦΝΕ. Η δυσβίωση του εντερικού μικροβιώματος, η βλάβη του βλεννογόνου και η απελευθέρωση κυτταροκινών έχουν εμπλακεί στην παθογένεση κατά τη διάρκεια των υποτροπών, ενώ οι μεταβολικοί παράγοντες κινδύνου φαίνεται να διαδραματίζουν κυρίαρχο ρόλο κατά τη διάρκεια των υφέσεων των ΙΦΝΕ. Όσον αφορά τους βιολογικούς παράγοντες, αν και τα δεδομένα είναι περιορισμένα, οι παράγοντες που καταστέλλουν τον παράγοντα νέκρωσης όγκων (TNF) μπορεί να προσφέρουν πιθανά οφέλη στη ΜΑΛΝΗ που σχετίζεται με τα ΙΦΝΕ, ενώ οι παράγοντες που δρουν ως αντι-ιντεγκρίνες δεν φαίνεται να παρέχουν κανένα θεραπευτικό πλεονέκτημα. Σκοπός: Αυτή η μελέτη είχε ως πρωτεύοντα στόχο να αξιολογήσει την επίδραση της ινφλιξιμάμπης και της βεντολιζουμάμπης για έξι μήνες, συγκριτικά με τη μη-χορήγηση βιολογικού παράγοντα, στην ηπατική στεάτωση σε ασθενείς με ΙΦΝΕ. Μέθοδοι: Για τις ανάγκες αυτής της προοπτικής, ανοιχτού κώδικα, μη-τυχαιοποιημένης μελέτης στρατολογήθηκαν ασθενείς πριν, οι οποίοι δεν είχαν λάβει προηγουμένως καμία θεραπεία με βιολογικό παράγοντα, την έναρξη θεραπείας με ινφλιξιμάμπη ή βεντολιζουμάμπη για ΙΦΝΕ, ενώ οι ασθενείς που δεν θα λάμβαναν βιολογικό παράγοντα εισήχθησαν στην ομάδα ελέγχου (μαρτύρων). Επιπλέον του βασικού σκοπού, αξιολογήθηκαν παράμετροι σχετικά με τη δραστηριότητα της ΙΦΝΕ, την ηπατική στεάτωση, την ίνωση και μη-επεμβατικοί δείκτες. Χρησιμοποιήθηκε ανάλυση διακύμανσης (ANOVA) επαναλαμβανόμενων μετρήσεων για την αξιολόγηση της συνολικής τάσης των αλληλεπιδράσεων ομάδα×χρόνος για τις συνεχείς μεταβλητές, ενώ, για τις διχοτόμες μεταβλητές, χρησιμοποιήθηκε ανάλυση δυαδικής παλινδρόμησης προσαρμοσμένη για πιθανούς συγχυτικούς παράγοντες. Αποτελέσματα: Εξήντα έξι ασθενείς, που δεν είχαν πριν λάβει θεραπεία με βιολογικούς παράγοντες, κατανεμήθηκαν σε τρεις ομάδες: ινφλιξιμάμπη (n: 26), βεντολιζουμάμπη (n: 14) και μαρτύρων (n: 26). Προ της ενάρξεως της θεραπείας, ηπατική στεάτωση ήταν παρούσα στο 26.9% της ομάδας της ινφλιξιμάμπης, στο 46.2% της βεντολιζουμάμπης και στο 23.1% της ομάδας ελέγχου. Μετά από έξι μήνες, η ηπατική στεάτωση μειώθηκε σε όλες τις ομάδες, χωρίς σημαντική διαφορά στην αλληλεπίδραση ομάδα x χρόνος. Εκτός της περιμέτρου μέσης, άλλοι παράγοντες σχετικοί με τη νόσο και ορολογικοί δείκτες (αδιποκίνες, TNF, PIIΙNP και TIMP-1) δεν επηρέασαν σημαντικά την κύρια και τις δευτερεύουσες εκβάσεις. Συμπέρασμα: Δεν παρατηρήθηκαν θετικές ή αρνητικές επιδράσεις της ινφλιξιμάμπης ή της βεντολιζουμάμπης σε σύγκριση με την απουσία θεραπείας με βιολογικό παράγοντα επί της ηπατικής στεάτωσης σε ασθενείς με ΙΦΝΕ