No abstract

Purpose Colonoscopy is considered the most reliable method for the diagnosis of juvenile polyps. However, colonoscopic screening is an invasive and expensive procedure. Fecal calprotectin (FCP), a marker of intestinal inflammation, has been shown to be elevated in patients with polyps. Therefore, this study aimed to evaluate FCP as a screening biomarker for the diagnosis of juvenile polyps. Methods This cross-sectional, observational study was conducted at the Pediatric Gastroenterology and Nutrition Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. For children with polyps, colonoscopic polypectomy and histopathology were performed. FCP levels were analyzed before and 4 weeks after polypectomy in all patients. Information was recorded in a datasheet and analyzed using the computer-based program SPSS. Results The age of the children was between 2.5 and 12 years. Approximately 93% of the polyps were found in the rectosigmoid region. Children with juvenile polyps had elevated levels of FCP before polypectomy that subsequently normalized after polypectomy. The mean FCP levels before and after polypectomy were 277±247 µg/g (range, 80–1,000 µg/g) and 48.57±38.23 µg/g (range, 29–140 µg/g) ( p <0.001), respectively. The FCP levels were significantly higher in patients with multiple polyps than in those with single polyps. Moreover, mean FCP levels in patients with single and multiple polyps were 207.6±172.4 µg/ g and 515.4±320.5 µg/g ( p <0.001), respectively. Conclusion Colonic juvenile polyps were found to be associated with elevated levels of FCP that normalized after polypectomy. Therefore, FCP may be recommended as a noninvasive screening biomarker for diagnosis of colonic juvenile polyps.

Background: Esophageal varices (EVs) are a serious complication of portal hypertension in patient with chronic liver disease (CLD). The major portion of ammonia carried by portal blood is shunted into systemic circulation in chronic liver disease. The upper GI endoscopy is currently the best reliable method to diagnose the presence of esophageal varices. But it is invasive, relatively expensive and not easily available. Blood ammonia is a noninvasive and easily accessible laboratory parameter that can predict the presence of esophageal varices. Objectives: To observe the blood ammonia concentration in children with chronic liver disease: a tool for prediction of esophageal varices. Methods: This cross sectional observational study was conducted at the Department of Paediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh from January 2018 to December 2019.  A total of 63 cases of CLD were selected. Study sample were selected according to the inclusion and exclusion criteria. Along with proper clinical history, examination & initial investigation, fasting venous blood ammonia level and upper GI endoscopy were done in all patients. Receiver-Operator Characteristic (ROC) curve was analysis to set up a cut-off value of blood ammonia for prediction of esophageal varices. Sensivity, specificity, positive predictive value, negative predictive value and accuracy were determined to see the performance of blood ammonia value as a diagnostic test for esophageal varices. Results: Among the 63 patients, (74.6%) had esophageal varices. Wilson disease was the most common etiology of CLD (43; 68.3%) among the studied patients. The mean blood ammonia level were 40.5± 18.0 (µmol/L), 50.5± 14.3 (µmol/L), 50.7± 9.9 (µmol/L), 53.1± 26.9 (µmol/L) and 71.9± 19.0 (µmol/L) in absent esophageal varices, grade-I, grade-II, grade-III and grade-IV esophageal varices respectively. The difference was statistically significant (<0.05). Moderate correlation (r= 0.452; p value = 0.001) between blood ammonia level and grades of esophageal varices was found.  It was observed that wasting of thenar and hypothenar muscle was the most common stigmata, seen in 15 (23.8%) cases, 2 (3.2%) had clubbing, 7 (11.1%) had leuconychia, 1 (1.6%) had palmer erythema, 3 (4.8%) had gynacomasia and 1 (1.6%) had testicular atrophy. Wilson disease was the most common 43 (68.3%). It was observed that 45 (71.4 %) patients had raised serum ALT and 45 (71.4%) had low serum albumin (<3.5 g/dl). Low haemoglobin (<9 gm/dl) was found in 47 (74.6%) cases, raised serum bilirubin level (>1.2 mg/dl) in 29 (46.03%) cases, thrombocytopenia (platelet count <1.50×109/mm3) in 36 (57.1%) patients and prolonged INR (>1.5) in 29 (46.03%) cases, blood ammonia was raised (>32 µmol/L) in 52 (82.5%) cases. It was observed that the mean ± SD blood ammonia level was 56.2± 17.9 µmol/L in   esophageal varices present group (n = 47) and 40.5± 18.0 µmol/L in absent esophageal varices group (n = 16). Here p value is 0.004, which is statistically significant. Conclusion: Blood ammonia concentration is a biochemical predictor for assessing the grading of esophageal varices. In the present study, a moderate positive correlation was found between blood ammonia concentration and grades of esophageal varices in children with CLD.

Background:Following initial treatment with rituximab (RTX) full dose (2x1000mg), B-cell numbers are often lower than baseline. The half dose regime (2x500mg) has been reported to be similarly effective [1]; however, there is limited long-term data on the effectiveness of switching to RTX half-dose from the real-world perspective.Objectives:To compare the 3-year RTX regime retention between patients receiving retreatment with half-dose and full-dose of RTX, and assess factors associated with maintenance of 2x500mg, with a view to establish an optimal long-term retreatment strategy in RA.Methods:An observational study was conducted on 755 consecutive RTX-treated RA patients in a single centre for over 20 years. Of these, 165/755 (22%) received at least one cycle of 2x500mg. Long-term effectiveness was assessed using RTX retention rate. Drug survival of patients treated with 2x500mg was compared with 200 RA patients receiving 2x1000mg throughout the study, matched to the number of cycle when the 2x500mg regime was initiated.Results:Of the 165 patients who received 2x500mg, 81.8% were female; mean age was 63.4 (26-91) years; mean disease duration 15.5 (2-53) years; 57 (34.5%) were bDMARDs-naïve; 121 (74%) were on concomitant DMARDs and mean DAS-28 was 3.9 (SD 1.29) at the half dose initiation. At 3 years, the retention rate was 38% for patients recieving 2x500mg compared to 87% for those on 2x1000mg; HR for half dose discontinuation was 6.17 [95%CI (3.91-12.27); p<0.001] (Figure 1A).The main reasons for 2x500mg discontinuation were poor EULAR response (30%); moderate EULAR response (30%); shorter duration of response compared to the full dose (22%); and incomplete B-cell depletion (17%). The majority of these patients (87.9%) were switched back to 2x1000mg, 5.1% received other bDMARDs and 7.1% did not receive further DMARDs.In multivariable analysis, previous TNFi use was associated with 3-year maintenance of the 2x500mg dose [OR 2.63 (1.12-6.10); p=0.024]; while higher plasmablasts at 2x500mg initiation was associated with shorter maintenance of this regime [OR 0.78 (0.67-0.97); p=0.028].There were no significant differences in 5-year RTX retention rates between patients receiving 2x500mg and switched back to 2x1000mg vs those receiving 2x1000mg throughout the study (Log-Rank=0.186) (Figure 1B).Conclusion:The use of RTX half-dose regimen was associated with poor retention at 3 years. Nevertheless, where loss of effectiveness occurs post-2x500mg initiation, switching back to 2x1000mg appears to be a pragmatic option. Patients with previous TNFi exposure and lower plasmablasts may be most suited to be commenced on the 2x500mg dose for long-term disease control.References:[1]Mariette X, et al. ARD 2014Acknowledgements:Leeds CaresDisclosure of Interests:Leticia Garcia-Montoya: None declared, Md Yuzaiful Md Yusof: None declared, Gisela Eugénio: None declared, Jean Baptiste Candelier: None declared, Sudipto Das Speakers bureau: Dr Das has received honoraria from Roche, Edward Vital Speakers bureau: Dr Vital has received honoraria from Roche, Consultant of: Dr Vital has received honoraria a from Roche, Grant/research support from: Dr Vital has received research grant support from Roche, Paul Emery Speakers bureau: Professor Emery has received honoraria from Roche, Consultant of: Professor Emery has received consultant fees from Roche, Grant/research support from: Professor Emery has received research grants paid to his employer from Roche.

This article has no abstract. The first 100 words appear below: A 10-year old boy, the only issue of his deceased parents, was admitted to the department for the management of recurrent episodes of diarrhea and severe wasting for 2.5 months, low grade, irregular fever with evening rise of temperature, anorexia and repeated attack of skin blister for the last 1 year. The patient complained of chronic, painless, non-bloody, profuse watery diarrhea with a weight loss of 10 kg (decrease to 18 kg from 28 kg prior to illness). He also complained of cough for the last seven days. His father was a driver and died at his 1 year of age due to an unknown disease.