Introduction

Patients with inflammatory bowel diseases (IBD) often require immunosuppressive therapies which may increase the risk of opportunistic infections.¹
Patients' vaccination status should be investigated at diagnosis and/or before starting any new treatment, and vaccinations against vaccine preventable diseases (VPDs) performed when required.²
Nevertheless, vaccination rates in IBD patients are known to be suboptimal and may also be lower than in the general population.³

Aims & Methods

The aim of this study was to investigate the vaccination coverage, attitude towards vaccinations, and its possible determinants among a national cohort of IBD patients.
An anonymous web-based questionnaire was sent by the Italian IBD patients’ association (AMICI Italia) in February 2021.
The questionnaire consisted of an adapted version of a previously validated questionnaire on vaccine hesitancy [10] and was divided into 2 sections seeking information on: (1) sociodemographic characteristics, lifestyle, and IBD characteristics, (2) attitude towards vaccinations. Patients were asked to self-report their previous vaccinations and their attitudes towards them (with a multiple-choice test), which were defined as opposed to vaccinations, indifferent, or in favor of vaccinations.
The study was approved by the Ethics Committee of AMICI and patients signed a digital informed consent.
Previous vaccination status and patients attitude towards vaccinations were recorded. The factors influencing their attitudes were examined using crude and adjusted odds ratios (AdjORs) with 95% confidence intervals (CIs).

Results

The questionnaire was sent to 4720 patients and had a response rate of 26.5% (1252 patients, 729 women, median age 47.7, interquartile range 37–58, 49% with Crohn’s disease, 48.9% with ulcerative colitis) answering from each of the 20 Italian regions. Of note, 46.7% of the patients were in therapy with biological or immunosuppressive drugs.
Patients declared being vaccinated against the following diseases: 74.1% tetanus, 67.7% flu (during last season), 43.3% (measles, mumps, and rubella) MMR, 37.1% hepatitis B (HBV), 29.1% pneumococcus (pneumococcal conjugated 13-valent vaccine, PCV13, or pneumococcal polysaccharide 23-valent vaccine, PPSV23), 20% meningitis, 16% hepatitis A (HAV), 15.3% varicella-zoster virus (VZV), 7.6% human papillomavirus (HPV). Two hundred and fifty-nine (20.7%) did not remember every previous vaccination.
Among the respondents, 1154 (92.2%) stated they wanted to be vaccinated in the future against VPDs. A previous negative experience with vaccinations, whether personal or referred by relatives, was reported by 163 (13.2%) among the 1238 respondents to this question.
One thousand one hundred and twelve (88.8%) stated a positive attitude towards vaccination, 91 (7.3%) were indifferent, 49 (3.9%) reported being opposed to vaccinations; 456 (36.4%) stated that the main reason for vaccination adherence was due to their IBD.
The belief of possible return of VPDs with decline of vaccination coverage rates was the factor related to a positive attitude towards vaccinations was (AdjOR 5.67, 95% CI 3.45-9.30, p-value <0.001).

Conclusion

Despite a general positive attitude towards vaccinations, there is a low vaccination coverage against some VPDs in Italian IBD patients.
This might suggest a possible role of physicians in under-prescribing vaccinations, or a difficulty in organizing them.
This is one of the biggest IBD cohort investigated both for vaccination coverage and hesitancy. These results should inspire to develope specific campaigns aimed to increase vaccination rates.

References

1) Toruner M, et al. Gastroenterology. 2008;134(4):929-936
2) Kucharzik T, et al. J Crohns Colitis. 2021;15(6):879-913.
3) Malhi G, et al. J Crohns Colitis. 2015;9(6):439-444.

Clinical Case Summary

Introduction. Differential diagnosis between extra-intestinal manifestations of inflammatory bowel disease and side effects of biologics is challenge. Even in the known setting of anti-tumor necrosis factor α agents (anti TNF α), cutaneous T-cell lymphoma (CTCL) carries potential risk to be missed due to indefinite early features mimicking psoriasis or eczema.
Case presentation. Thirty-two years non-smoker female had ulcerative colitis for 13 years. In September 2015, she suffered severe relapse followed by Infliximab introduction (the first dose was administrated on 10 October in 2015). She was good responder, disease remission confirmed on histology. In September 2018, patient reports frequent dermatology visits due to itchy skin lesion on her left earlobe (erythema, erosion, crust, squams) that progressed infiltrating almost half auricle despite local application of steroids and antibiotics. Skin biopsy was performed twice, and acquired samples were examined by two pathologists. First sample is considered for psoriasis. Second sample (acquired afterward) combined with revision of the first sample imposed multiple skin CTCL differentials due to indeterminate histology and biological behavior.
Our patient had her last infliximab administration on 25 February 2019. Since infliximab dismissal, we have followed up patient for 5 years and 2 months. Complete spontaneous regression, absence of CTCL recurrence implied that CTCL was biologics side effect.
Conclusion. Despite multidisciplinary approach diagnosing among justified differentials was a challenge, as follows: extra-intestinal manifestations of ulcerative colitis (Sweet syndrome) versus dermatological side effects of infliximab (eczema, anti TNF induced psoriasis and CTCL). Furthermore, indeterminate histology followed by unpredictable evolution of CTCL created slippery diagnostic path, that could be only hacked through afterward biopsy combined with revision of initial sample.

References

Mariette X, Tubach F, Bagheri H et al. Lymphoma in patients treated with anti-TNF: results of the 3-year prospective French RATIO registry. Ann Rheum Dis. 2010;69(2):400-408.
Mercer LK, Galloway JB, Lunt M et al. Risk of lymphoma in patients exposed to antitumour necrosis factor therapy: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Ann Rheum Dis. 2016
Rojas-Feria M, Eslam M, Castro- Fernandez M, et al. Cutaneous lymphoma in a patient with ulcerative colitis after immunosuppressive therapy. J Crohns Colitis 2011; 5: 608–11

Introduction

HCC is well known complication of liver cirrhosis. The current standard of care for patients with cirrhosis involves systematic 6 monthly screening with ultrasound and serum alpha-fetoprotein testing. (1) The Aberdeen Hepatoma surveillance clinic has been instituted since 2005 and currently 707 patients under screening program. It is a one-stop nurse led clinic wherein the ultrasound scan, blood testing and clinical review is done in a single visit, with sequential visits planned every 6 months. ​

Aims & Methods

In this study we aimed to identify outcome of HCC detected in hepatoma clinic compared to those identified symptomatically. Data collected retrospectively of patients referred to HCC MDT at Aberdeen Royal infirmary over period of 5 years. Diagnosis of HCC was made based on liver ultrasound and serum AFP as per guidelines

Results

130 patients were identified with HCC through both pathways. 17 patients were detected as part of the surveillance programme and the rest were directly referred to the HPB MDT through the symptomatic pathway. The predominant subjects were males 102 (78.4%) and the cause of liver cirrhosis was as follows: MASLD 39%, ARLD 29%, Chronic HCV 11%, HBV 4%, Haemochromatosis 3%, PBC 2%, autoimmune hepatitis and PSC 1%. The mean age of patients detected in the surveillance group was 65 years ± 6.14 SD as opposed to those in the symptomatic group 71 years ± 9.99 SD. AFP was normal in 50% of surveillance group. The BCLC staging in the surveillance group was stage 0-A (20%), stage B 45%, In the symptomatic group patients were in stage 0-A 7%, Stage B 22%, and stage C, D 55% respectively.
Curative options including liver transplant and resection was possible in 20 % of surveillance patients as opposed to 7% in symptomatic patients. Palliative options like RFA, TACE and Sorafenib was offered in 60% of surveillance patients and 42% of symptomatic patients. In 20 % of surveillance patients no treatment could be offered as opposed to 55% symptomatic patients.

Conclusion

The mean age of the patients detected in the surveillance clinic was 5 years less than the symptomatic group suggesting that the programme was picking patients early. More curative and palliative procedures could be offered to this subgroup for this reason. The BCLC staging confirmed that most patients in the surveillance programme were in the early stages as opposed to the symptomatic group. Despite having an entrenched surveillance programme most patients were presenting symptomatically, suggesting that more efforts are needed to identify patients with cirrhosis who are at an added risk for developing HCC.

References

1. European Association for the Study of the Liver. EASL Policy Statement on liver cancer screening. Accessed 31 May 2022. Available from: https://easl.eu/publication/easl-policy-statement-on-liver-cancerscreening/.

Introduction

The consumption of sugar-sweetened beverages is correlated with the development of obesity and type 2 diabetes mellitus which have become major health problems in our century. Consequently, the World Health Organization has proposed sugar reduction as a preventive and therapeutic strategy [1]. The use of artificial low-caloric sweeteners (e.g., sucralose) as sugar alternatives remains controversial due to the mismatch between their sweet taste (rewarding oral effect) and energy content (lack of post-oral satiating effects). Erythritol, a non-caloric bulk sweetener, might be a promising alternative due to its similar sweetness to sucrose and its ability to release gastrointestinal (GI) satiation hormones without affecting glucose or insulin concentrations.
Acquired preference for sweet-flavored beverages could be based on oral (flavor-flavor learning FFL, e.g., sweet taste) and post-oral associations (flavor-nutrient learning FNL, e.g., calories, hormones) [2]. In human studies, evidence is weak whether liking of a novel flavor increases most when it’s paired with sucrose (FFL + FNL_{calories+hormones}) than with an artificial sweetener (only FFL). Furthermore, the rewarding properties of erythritol remain to be determined.

Aims & Methods

The aim of this study was to assess the effect of the non-caloric sweetener erythritol (FFL + FNL_hormones) on the reward responses (liking and wanting), GI hormone release and glycemic control compared to sucrose and sucralose.
In this randomized, double-blind crossover study, 20 participants (10 women, 10 men; mean ± SD; age: 25.8 ± 7.5 years, BMI: 22.3 ± 1.8 kg/m²) rated explicit liking and wanting of three novel and neutral flavored beverages before and after three conditioning visits where the beverages were paired with either erythritol, sucrose or sucralose. Doses of erythritol and sucralose were individually matched to the perceived sweetness of a 10% sucrose solution. After conditioning, participants had to perform a computerized forced choice task to measure implicit wanting. Blood samples were collected to analyze GI hormones (glucagon-like peptide 1 GLP-1, cholecystokinin CCK) and glycemic control (glucose, insulin).

Results

All 20 participants completed the test visits. The results show that: i) explicit liking increased significantly after the conditioning (all p < 0.01) with no differences between the sweeteners (all p_Tukey > 0.4); ii) explicit wanting increased significantly after the conditioning (p = 0.07 for erythritol, p < 0.01 for sucrose and sucralose) with no differences between the sweeteners (all p_Tukey > 0.8); iii) implicit wanting did not differ between the sweeteners (all p_Tukey > 0.5); iv) conditioning with the sweeteners had no effect on GI satiation hormone release and glycemic control.

Conclusion

Erythritol led to similar ratings in explicit liking and wanting compared with sucrose and sucralose. Conditioning with all three sweeteners increased the reward responses. Since erythritol appears to be as rewarding as sucrose and sucralose, this sweetener can be seen as potential sugar alternative. These effects may not to be associated with FNL.

References

1. World Health Organization (WHO). Guideline: Sugars intake for adults and children. 2015.
2. Yeomans, M., et al., Differential hedonic, sensory and behavioral changes associated with flavor-nutrient and flavor-flavor learning. Physiology & behavior, 2008. 93: p. 798-806.

Introduction

The temporal trend of mortality rates among young individuals with gastric cancer has sparked a contentious debate over the past few decades. Additionally, there remains an ambiguous distribution alteration of disease burden among different countries.

Aims & Methods

​​​​This population-based systematic analysis was conducted to investigate changes in health inequality related to mortality caused by young gastric cancer from 1990 to 2019. We performed a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 by extracting cross-sectional data on young gastric cancer (<40 years). The age-specific mortality rate was used to determine deaths attributed to young gastric cancer. A prediction of young gastric cancer mortality rate and case number up to 2030 was performed using the Norpred APC model. The slope index of inequality (SII) and the health concentration index were used to quantitatively measure absolute and relative changes in health inequalities, taking into account the socio-demographic indexes (SDI) level. The data was further analysed across different GBD regions and sexes.

Results

The global mortality rate of young gastric cancer declined from 1.61 (95% Uncertainty interval [UI]: 1.49 to 1.72) per 100,000 in 1990 to 0.94 (95% UI: 0.87 to 1.02) per 100,000 in 2019, with an annual rate of change -0.42% (95% Confidence interval (CI): -0.47 to -0.35). The projected data suggests that the number of global mortality case and rate of young gastric cancer would decrease to 24,450 and 0.761 per 100,000 by 2030. Countries belong to the lower 50% of SDI accounted for 49.9% and 52.3% of the global young gastric cancer deaths in 1990 and 2019, respectively. Although the absolute cross-national inequality (SII) of mortality rate fell from 0.133 (95%CI: -0.533 to 0.416) in 1990 to -0.239 (95%CI: -0.432 to -0.046) in 2019, the relative inequality (concentration index) for global young gastric cancer mortality increased from 1990 (−0.058, 95%CI: −0.532 to 0.416) to 2019 (−0.104, 95%CI: −0.526 to 0.317). The observed rise in absolute health inequality was evident in both sexes, but relative health inequality increased in females only. The regions of Sub-Saharan Africa (including Western and Southern), Central Asia, and Central Europe exhibited an increase in both absolute and relative health disparities in young gastric cancer mortality.

Conclusion

Although there has been a decline in the global young gastric cancer mortality rate, health inequality has increased over the past three decades, especially in females and some low SDI countries. It is imperative to prioritize efforts in addressing inequality to further reduce the global burden of young gastric cancer mortality.