Endoscopic Scoring System Research Articles

Endoscopic scoring system for gastric atrophy and intestinal metaplasia: correlation with OLGA and OLGIM staging: a single-center prospective pilot study in Korea

Background/Aims We aimed to develop an endoscopic scoring system to evaluate gastric atrophy and intestinal metaplasia using narrow-band imaging (NBI) and near focus mode (NFM) to compare endoscopic scores with the Operative link for gastritis assessment (OLGA) and the Operative link for gastric intestinal metaplasia assessment (OLGIM). Methods A total of 51 patients who underwent diagnostic esophagogastroduodenoscopy were prospectively enrolled and endoscopic scoring using NBI and NFM was performed. Four areas (the lesser and greater curvatures of the antrum and the lesser and greater curvature side of the corpus) were observed and biopsies were taken. The degree of atrophy was scored from 0 to 2 according to the Kimura-Takemoto classification. The degree of intestinal metaplasia was scored from 0 to 4 according to the location and the extent of the intestinal metaplasia. Results The correlation coefficient for atrophy between the endoscopic and histologic scores was 0.70 (95% CI: 0.52–0.81 p < .001) and for intestinal metaplasia, it was 0.75 (95% CI: 0.60–0.85; p < .001). For atrophic gastritis, an endoscopic score >1 correlated with OLGA stage III and IV with a sensitivity, specificity, positive predictive value, negative predictive value, and agreement of 88, 74, 75, 87, and 80.4%, respectively, and for intestinal metaplasia, an endoscopic score >1 correlated with high OLGIM stage III and IV with 100, 59, 69, 100, and 78.4%, respectively. Conclusions Endoscopic scoring for gastric atrophy and intestinal metaplasia using NBI-NFM likely correlates with histologic staging in Korea, a high-risk region for gastric cancer.

Diagnosis and Treatment of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.

P428 A Phase IB/IIA study of remestemcel-L, an allogeneic bone marrow derived mesenchymal stem cell product, for the treatment of medically refractory Crohn’s colitis: A preliminary analysis

Abstract Background Mesenchymal stem cells (MSCs) have been successfully used for the treatment of perianal Crohn’s fistulizing disease by direction injection. However, no studies have looked at the direct injection of MSCs for luminal Crohn’s disease. Methods Following screening and informed consent, patients with medically refractory Crohn’s colitis who had a washout of at least, 4 weeks from monoclonal antibody treatment were randomized in a, 2:1 fashion to receive remestemcel-L, an ex vivo expanded allogeneic bone marrow derived MSC product versus placebo. If randomized to treatment, patients received, 150 million MSCs delivered via direct injection using a, 23 G sclerotherapy needle at the time of colonoscopy. Patients were included if they had medically refractory Crohn’s colitis defined as an established diagnosis for at least, 6 months prior to study enrollment and had lost response to at least one monoclonal antibody in the past, no small bowel involvement, and no colorectal stricture. Patients were evaluated with validated clinical and endoscopic scoring systems at, 2 weeks, 6 weeks, and, 3 months. Patients randomized to control crossed over at, 3 months to receive MSC treatment. Results A total of six patient have been enrolled;, 4 treatment and, 2 controls. There were, 7 reported adverse events, none of which were related to the investigational product (2 with eye pain, 1 with hiatal hernia, 1 with abdominal pain, 1 with partial small bowel obstruction, 1 with arthritis symptoms, 1 with Crohn’s flare requiring hospital admission and treatment with infliximab and intravenous corticosteroids). With regard to efficacy, in the treatment group (n=4), the SES-CD dropped from, 17 at baseline to, 5 by, 3 months, the CDAI from, 228 to, 200, and the fecal calprotectin from, 231 to, 67. In the control cohort, the SES-CD increased from, 15.5 to, 25, the CDAI increased from, 146 to, 158, and the fecal calprotectin increased from, 330 to, 505. Conclusion MSCs offer a safe alternative therapeutic for the treatment of medically refractory Crohn’s colitis. Early data suggests improved clinical and endoscopic scores by as early as two weeks following MSC delivery.

P407 A Phase IB/IIA study of remestemcel-L, an allogeneic bone marrow derived mesenchymal stem cell product, for the treatment of medically refractory ulcerative colitis: An interim analysis

Abstract Background Direct injection of mesenchymal stem cells (MSCs) have been used for the treatment of perianal Crohn’s fistulizing disease. However, no studies have looked at the direct injection of MSCs for luminal ulcerative colitis (UC). Methods Following screening and informed consent, patients with medically refractory UC were randomized in a, 2:1 fashion to receive remestemcel-L, an ex vivo expanded allogeneic bone marrow derived MSC product, at a dose of, 150 or, 300 million MSCs versus placebo delivered via direct injection using a, 23 G sclerotherapy needle at the time of colonoscopy. Patients were included if they had medically refractory UC defined as an established diagnosis for at least, 6 months prior to study enrollment and had lost response to at least one monoclonal antibody in the past. Patients were evaluated with validated clinical and endoscopic scoring systems at, 2 weeks, 6 weeks, and, 3 months post MSC delivery. Patients randomized to control crossed over at, 3 months to receive MSC treatment and followed the same schedule for post MSC evaluation. Results A total of six patients were enrolled and treated;, 4 were randomized to treatment and, 2 to placebo. All had been on prior anti-TNF or anti integrin-therapy. There were no adverse and serious adverse events related to investigational product. In the treatment group (n=4), the Mayo score and Mayo endoscopic severity score decreased in all patients by two weeks after MSC delivery. By six weeks post MSC treatment, all treated patients had achieved clinical and endoscopic remission as defined by the Mayo score and Mayo endoscopic severity score. Patient reported number of daily bowel movements decreased as did urgency and presence of blood in the stool. With regard to patient reported outcomes, at three months, based on the inflammatory bowel disease patient reported treatment impact (IBD-PRTI), all patients were extremely satisfied or satisfied with their MSC treatment. Treated response was described as excellent or good in all patients. In the control group (n=2), the Mayo score did not decrease. Patient reported number of daily bowel movements increased as did the number reporting blood in their stool; urgency remained unchanged. With regard to patient reported outcomes, at three months, based on the IBD-PRTI, one patient was neutral, and one patient was dissatisfied. Treated response was described as poor or unchanged in control patients. Conclusion MSCs offer a safe alternative therapeutic for the treatment of medically refractory UC. Early data suggests improved clinical and endoscopic scores by as early as two weeks following MSC delivery.

DOP17 Evaluating segmental healing with the modified Mayo endoscopic score (MMES) has a clear additional value in predicting long-term outcome in patients with Ulcerative Colitis: Results from a prospective cohort study

Abstract Background Most endoscopic scoring systems (including the Mayo endoscopic subscore, MES) do not consider the extent of inflammation and can therefore not pick up segmental endoscopic improvement. The modified Mayo endoscopic score (MMES) was developed to overcome this limitation. We examined the predictive value of the MMES in addition to the MES on long-term clinical outcome in ulcerative colitis (UC). Methods Between 2014 and 2017, patients initiating biologic therapy for active UC (baseline MES ≥2) were recruited. Patients without assessment of the upper margin of inflammation or with a clinical follow-up &amp;lt;12 months were excluded. We conducted a clinical and endoscopic assessment at baseline and week 8 (adalimumab, ADM) or 14 (golimumab, GOL; infliximab, IFX; vedolizumab, VDZ). Clinical response was defined as a decrease in the adapted Mayo score (excluding physician global assessment) with ≥2 points and ≥30%, plus a decrease in rectal bleeding score ≥1 or an absolute rectal bleeding score ≤1. We classified patients by evolution of endoscopic activity at week 8/14 in group A (endoscopic healing, MES ≤1), group B (segmental healing, MES &amp;gt;1 but decrease in MMES ≥30%) and group C (MES &amp;gt;1 and no drop in MMES ≥30%). Clinical relapse-free, discontinuation-free and colectomy-free survival was estimated by Kaplan-Meier analysis with log-rank test. Results A total of 150 UC patients were included (52% male, median age 42 years, median disease duration 7 years) with a median (IQR) follow-up of 61 (48–68) months. An anti-TNF was initiated in 74 (35 IFX, 23 ADM, 16 GOL), and VDZ in 76 patients. A significant reduction in MES and MMES was observed at week 8/14 (cf. table). In group A 67/69 (97%) patients achieved clinical response compared to 15/27 (55%) in group B and 11/54 (20%) in group C. During follow-up 60/93 (65%) patients maintained clinical response, 83/150 (55%) patients discontinued treatment due to primary non-response or loss of response and 33/150 (22%) patients underwent colectomy. The ΔMMES demonstrated to be of additional predictive value: there was a significant difference between groups B and C regarding clinical relapse, drug persistence and need for colectomy (cf. figure). Conclusion Although MES ≤1 remains the best predictor of long-term outcome, the MMES - identifying a subgroup with a segmental endoscopic response - demonstrated a clear additional value predicting long-term outcome in UC. These promising results merit inclusion of the MMES in future clinical trials. Table The MMES is calculated by multiplying the Mayo endoscopic subscore for the different colon segments with the maximal extent of inflammation (in decimeters) divided by the number of segments with active inflammation (Lobatón T, et al. JCC 2015; 9:846–52.) Figure

Early postoperative endoscopic score can predict the long-term endoscopic outcomes in eosinophilic chronic rhinosinusitis (ECRS) patients

ObjectiveEosinophilic Chronic Rhinosinusitis (ECRS) is refractory and recurrent, requiring long-term follow-up after Endoscopic Sinus Surgery (ESS). Endoscopic evaluation is common during postoperative assessment, but how the findings vary over time in postoperative ECRS patients who were treated by the recent standardized management is unclear. We assessed the long-term change in postoperative endoscopic score in ECRS patients using a novel endoscopic scoring system (Escore). MethodsThis retrospective study included 80 ECRS patients who underwent full-house ESS and were followed for longer than 1-year. Endoscopic procedures were repeated at every follow-up visit and postoperative Escores were assessed from 3-months up to 5-years (median follow-up period was 3-years). ResultsThe Escore did not significantly change from that at 3-months (3m-Escore). The Escore at the final observation point (f-Escore) among 80 patients was 9.2 ± 5.6 and there was no significant difference from the 3m-Escore (8.5 ± 4.1, p = 0.363). Twenty-one patients (21/80, 26.3%) were considered to have endoscopically uncontrolled ECRS at their final observation points and the 3m-Escore was identified as an independent predictive factor by multivariate logistic regression analysis. The 3m-Escore cut-off value that was able to predict endoscopically uncontrolled ECRS after long-term follow-up was ≥12. ConclusionWe demonstrated the long-term endoscopic outcomes after full-house ESS and continuous outpatient treatment. Early endoscopic findings (3m-Escore) were a potential predictive factor for the later endoscopic outcome, and a 3m-Escore of 12 or higher may be an indicator of the poor long-term prognosis of sinus mucosa. Level of evidence4.

Increased modified DUBLIN scores are associated with serious ulcerative colitis and treatment failure

Grading of endoscopic lesions is important for determining the severity of ulcerative colitis and developing treatment strategies, but the commonly used methods are not sufficient. This study aimed to investigate whether new endoscopic scoring systems incorporating lesions and disease extent are associated with clinical disease severity and maintainable remission. This was a retrospective study. In all, 110 patients with ulcerative colitis were included and 87 completed 12-month follow-up. Colonoscopy was performed within 1 week before blood samples were taken. Degree of ulcerative colitis burden of luminal inflammation (DUBLIN) scores were calculated as the product of Mayo endoscopic score (MES) by disease extent and ulcerative colitis endoscopic index of severity was used to replace MES when calculating modified DUBLIN scores. DUBLIN and modified DUBLIN scores were increased in the moderate and severe groups significantly (p < 0.05). Both of increased scores contributed to the detection of serious diseases, and the clinical cutoff values of DUBLIN and modified DUBLIN were 3[area under the curve (AUC) = 0.809, p = 0.001) and 7(AUC = 0.815, p = 0.001), respectively. They were with high sensitivity, but the specificity of DUBLIN was lower. Both scores were correlated to partial Mayo scores, C-reactive protein and erythrocyte sedimentation rate positively, and they were correlated to the albumin negatively (p < 0.05). Higher modified DUBLIN scores (>7) were associated with an increased risk of treatment failure (hazard ratio = 4.96, 95% confidence interval: 1.17-21.00, p = 0.03), but there were no association between DUBLIN scores and long-term remission (p > 0.05). Increased DUBLIN and modified DUBLIN scores were conducive to screening serious disease, but only modified DUBLIN scores had the potential to assist in making an upgraded therapeutic schedule.

Endoscopic Scoring System for T2 Invasion in Colorectal Cancer

Background and AimsThe depth of tumor invasion in colorectal cancer (CRC), especially T1b or T2, is crucial in treatment decision-making. However, their differences are not well-characterized. Thus, this study aimed to investigate the predictive endoscopic findings in tumor invasion of CRC. MethodsData from patients with T1b or T2 CRCs resected endoscopically or surgically were reviewed retrospectively. The patients were divided into 2 groups: T1b (n = 298) and T2 (n = 267) tumor invasion. A scoring system was established based on the endoscopic findings in each group, and the accuracy of the system was assessed using a receiver-operating-characteristic (ROC) curve analysis. ResultsT2 invasion was predicted by tumor size, irregular bottom of depression, existence of depression, expansion appearance, convergency of folds, and erosion or white coat. The risk scoring system was developed using the regression coefficient values of the above variables. The area under the ROC curve was 0.894 (95% confidence interval, 0.868-0921). Cases with a score ≥4 had a high risk of T2 (sensitivity, 84.5%; specificity, 78.9%). ConclusionOur scoring system was useful for the diagnosis of T1b and T2, and a score ≥4 could predict T2 invasion. Additional studies are warranted to confirm these results before our scoring system can be applied clinically.

Analysis of Endoscopic Evaluation Reliability for Ulcerative Colitis in Histological Remission.

The Mayo endoscopic subscore (MES) is a major endoscopic scoring system used to assign a status of mucosal inflammation and disease activity to patients with ulcerative colitis (UC). Using interobserver reliability (IOR), this study clarified the difficulties for endoscopic observers imposed by MES parameters used for the endoscopic evaluation of UC in histological remission. First, 42 endoscopists of four observer groups examined each MES parameter, which were evaluated from endoscopically obtained images of 100 cases as Grade 0 or 1 of the Nancy histological index of histopathological inflammation. Then, IOR was assessed using multiple κ statistics for each finding of MES. The results showed that IOR among all the observers was slight or fair for all the parameters, indicating a low IOR. The experts of the UC practice group had “moderate” or higher IOR for seven of the nine parameters, whereas “slight” or “fair” results were found for all parameters by the trainee group. The IOR for each MES parameter was calculated separately for the observer groups. All the groups showed “slight” or “fair” for “Erythema” and “Decreased vascular pattern”. Large differences between the endoscopists were found in the IOR for the MES parameters in UC in histological remission. Even among UC practice experts, the IOR was low for “Erythema” and “Decreased vascular pattern”.

S383 Proposed Endoscopic Scoring System for Achalasia: The Delayed Esophageal Clearance in Achalasia (DECA) Score

S383 Proposed Endoscopic Scoring System for Achalasia: The Delayed Esophageal Clearance in Achalasia (DECA) Score

Correlation of Clinical Symptoms With Nasal Endoscopy and Radiological Findings in the Diagnosis of Chronic Rhinosinusitis: A Prospective Observational Study.

Introduction: In the diagnosis of chronic rhinosinusitis (CRS), computed tomography (CT) of the nose and paranasal sinuses (PNS) remains the gold standard investigation. Though the diagnostic nasal endoscopy (DNE) is an equally effective and easily available investigation for diagnosis of CRS, its reliability and clinical significance to that of patient’s symptoms have to be proven.Objective: The purpose of this study is to determine the correlations between the symptom severity score, radiological score, and the endoscopic score in the diagnosis of CRS. Methods: This prospective observational study included 70 patients with CRS. It was conducted in a tertiary care institute from January 2019 to June 2020. All patients were subjected to DNE and CT nose and PNS. Symptom score was assessed using Visual Analogue Scale (VAS) score of 0-10. DNE and CT scores were calculated using the Lund-Kennedy endoscopic scoring system and the Lund-Mackay CT scoring system, respectively. The correlation between these scores were done using Pearson’s correlation coefficient (p-value).Results: The mean and standard deviation of the symptom score by VAS was 7 ± 1.7; the Lund-Kennedy score was 7.6 ± 2.3, and the Lund-Mackay score was 14.3 ± 6.5, respectively. The symptom score had moderate correlation with the Lund-Kennedy Score (r = 0.643, p < 0.001) and high degree of correlation with the Lund-Mackay Score (r = 0.835, p < 0.001). The Lund-Kennedy score had a positive correlation with The Lund-Mackay score.Conclusion: DNE can be utilized as an early diagnostic tool in the clinical evaluation of CRS and is equally effective as CT in diagnosing the same. At the same time, a CT scan can be done in patients with positive symptoms and can be reserved as a second-level investigation for those patients with negative endoscopic findings but who become symptomatic on follow-up.

P180 Endoscopic scoring systems for Crohn’s Disease and Ulcerative Colitis and their correlation with histological and clinical outcomes

Abstract Background Endoscopy and histopathology are vital for evaluating disease activity and treatment response in inflammatory bowel disease. Correlation between endoscopic and histological indices has not been fully examined. The primary aim of this study was to examine the correlation of endoscopic scores with histological assessment and association with flare/hospitalisation in the ensuing 12 months. Methods We selected 100 random colonoscopies performed for IBD surveillance/assessment in 2019. Adult patients with a complete colonoscopy were included. All reports were blindly scored by 2 expert endoscopists using SES CD or Mayo score as appropriate. Histology was retrieved from HistoLab database and classified as normal, mild, moderate and severe. Clinical demographics, CRP, fecal calprotectin levels, flare episodes and hospitalisations were recorded. Correlation between endoscopic and histologic activity was tested. Comparisons were made between patients in histologic and endoscopic remission v those with endoscopic and histologic activity regarding association with flare/hospitalisation. Results 100 IBD patients (median age 49 IQR 22; 54% female; 50% Crohn’s disease) were included. A wide range of SES-CD scores were noted (median score 2 and IQR 6). 48% were in remission (0–2), 34% mild with score 3–6, 18% moderate with score 7–15 and 4% severe disease activity scoring &amp;gt; 16. Of those in endoscopic remission, 87.5% had normal histology. Of the 9 with moderate endoscopic disease all ranges of histological status were described. All levels of the Mayo scale (median score 1) were represented. Similar to the Crohn’s group, 87.5% of those in endoscopic remission also had normal histology. In total 42 patients were in both endoscopic and histological remission, and only 7% experienced a flare of disease activity in the following 12 months, with no hospitalisations. In total 40 patients had both endoscopically and histologically active disease, and 45% of these had a flare in the ensuing 12 months with two hospitalisations.The ROC curve for SES-CD score and histological remission is 0.73 +/- 0.07 95%CI 0.59 -0.87 and for the Mayo score and histological remission 0.87 +/- 0.05 95%CI 0.78- 0.97. Conclusion Accurate assessment of disease activity guides therapy choices and helps assess response to treatment in our IBD cohort. In this study the SES-CD and Mayo endoscopic scores showed good correlation with histological assessment. Those with active endoscopic and histologic disease experienced more flares and had higher rates of hospitalisation than those in remission. Further investigation with higher study numbers and incorporation of a standardised histological grading system are required.

Visual analogue score and endoscopic domain analysis to assess the outcome of microdebrder in sinonasal diseases

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;The use of microdebrider in various sinonasal diseases have been sparingly understood. The present study aims to find out the effectiveness of a microdebrider in different sinonasal diseases by using each domain of visual analogue scale (VAS) and confirming the findings by diagnostic nasal endoscopy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A prospective observational study was done among patients with sinonasal disease between January 2019 to March 2020 in our tertiary care hospital. A subjective visual analogue scale (VAS) was completed by every patient for all domains according to Lund and Mackay symptom scoring system. Using Lund Kennedy scoring, polyp, edema and discharge were assessed preoperatively. Patients were followed up for 1 week, 6 weeks and 3 months. At 3 months both VAS and Lund Kennedy scoring was done. Post operatively scarring and crusting were assessed separately.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results: &lt;/strong&gt;There was a significant improvement in domains post operatively in all the diseases considered (p=0.001). In Lund Kennedy endoscopic scoring system there was significant improvement in all the domain that was taken into consideration (p=0.001). Inter-disease domain comparison was also made.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The study substantiates the use of microdebrider in various sinonasal disease. Microdebrider being a modern multipurpose instrument plays a significant role in complete clearance of the disease with good postoperative outcome.&lt;/p&gt;

Efficacy of Carragelose® Nasal Spray Impregnated Versus Mupirocin Ointment Impregnated Nasal Packs on Mucosal Healing after Endoscopic Sinus Surgery: A Double-Blind, Non-Randomized, Right-Left Side Comparison

ABSTRACTObjective: To determine the efficacy of carragelose® nasal spray versus mupirocin ointment impregnated nasal packs on postoperative mucosal healing among chronic rhinosinusitis with nasal polyposis (CRSwNP) patients after endoscopic sinus surgery (ESS).&#x0D; Methods:Design: Double-Blind, Non-Randomized, Right-Left Side ComparisonSetting: Tertiary Government Training HospitalParticipants: Fifteen (15) patients diagnosed with chronic rhinosinusitis with nasal polyposis (CRSwNP) who had ESS were included in the study. Nasal packs (Netcell®) impregnated with carragelose® nasal spray or mupirocin ointment were respectively applied in right and left nostrils. Postoperative mucosal healing was graded by a blinded consultant using the Lund-Kennedy Endoscopic Scoring System and Perioperative Sinus Endoscopy (POSE) scoring system.&#x0D; Results: Six patients (12 nasal sides) completed the study. Comparing nasal packs impregnated with carragelose® nasal spray mupirocin ointment, the carragelose® group had lower Lund- Kennedy median scores than the mupirocin group on the 7th post-operative day; and this was statistically significant (p = .027). There were no significant differences in Lund-Kennedy postoperative scores on days 4 (p = .217), 14 (p = .171) and 28 (p = .151).&#x0D; Conclusion: Carragelose® nasal spray impregnated nasal packs may be comparable with, and may be an alternative to mupirocin ointment impregnated nasal packs in terms of postoperative mucosal healing among ESS patients with CRSwNP.

Artificial intelligence-assisted endoscopy changes the definition of mucosal healing in ulcerative colitis.

The relevance of endoscopic monitoring of ulcerative colitis (UC) has been translated into the new concept of “mucosal healing (MH)” as the therapeutic goal to achieve because a large amount of scientific data have revealed the favorable prognostic value of a healed mucosa in determining the clinical outcome of UC. Recent interest in MH has skewed toward not only endoscopic remission but also histological improvement (so called histological MH). However, we should recognize that there have been no prospectively validated endoscopic scoring systems of UC activity in previous clinical trials. Artificial intelligence (AI)‐assisted endoscopy has been developed for gastrointestinal cancer surveillance. Recently, several AI‐assisted endoscopic systems have been developed for assessment of MH in UC. In the future, the development of a new endoscopic scoring system based on AI might standardize the definition of MH. Therefore, “The road to an exact definition of MH in the treatment of UC has begun only now”.

S0865 Simultaneous Monitoring of the Inverse Relationship Between Endoscopic Healing Index Scores and Therapeutic Drug Monitoring Across Biologics in Crohn's Disease

INTRODUCTION: Endoscopic healing index (EHI): MONITR (Prometheus, San Diego, CA) scoring is a proprietary, non-invasive serologic test which compares favorably with the Crohn’s disease (CD) endoscopic scoring system, SES-CD, often considered a gold standard in clinical assessment. The relationship between same day EHI testing performance and therapeutic drug monitoring across multiple biologic agents in the CD patient population is not fully understood. Given the pressing need for non-invasive remote monitoring and optimization of clinical status in the CD patient population, we explored the relationship between simultaneous serum patient clinical monitoring and therapeutic drug monitoring (TDM) as part of standard of care practice. METHODS: Adult patients (N = 25) were evaluated retrospectively from a cohort of samples seen in an inflammatory bowel disease clinic. The relationship between EHI and TDM concentration was assessed via numeric score for EHI from 0 to 100 and multiple concentrations of different biologics at a single lab. The analysis was done on multiple biologic agents as part of standard of care practice and the deidentified data compiled. RESULTS: There were 25 CD patients who formed the study population (5 infliximab, 3 adalimumab, 3 vedolizumab and 14 ustekinumab). Across all biologics, increased drug levels were associated with EHI scores < 50. Additionally, within the ustekinumab group (N = 14) the average drug levels for the patients with an EHI score >50 and considered to have moderate to severe disease was 1.98 ug/mL (n = 4) vs 5.17 ug/mL (n = 7) in patients with a score < 40 and considered to have mild to moderate disease. CONCLUSION: Amongst the biologic treated CD patients, there was evidence of lower drug levels across all biologics in patients with higher EHI scores (>50). Additional studies are necessary to determine if biologic therapy guided by home EHI will improve longterm clinical trajectories in CD patients and this study will serve as a baseline for prospective analysis of EHI scoring serially and changes in disease status with adjustment of biologics.Table 1Figure 1Figure 2

Risk Factors and Assessment Using an Endoscopic Scoring System for Postoperative Respiratory Complications after Anterior Cervical Decompression and Fusion Surgery.

Introduction Postoperative respiratory complications (PRC) are one of the most serious complications. Potentially life-threatening accidents can occur after an anterior cervical discectomy and fusion (ADF), such as airway obstruction and aspiration pneumonia. Despite numerous studies, preoperative predictive and preventive methodology has yet to be established. As reported in our previous study, the evaluation of preoperative dysphagia using the eating assessment tool (EAT-10) and a flexible endoscopic evaluation of swallowing (FEES) is useful for predicting the incidence and risk factors of dysphagia after ADF. Methods This prospective study comprised 60 consecutive patients who underwent ADF. An otolaryngologist and a speech-language-hearing therapist preoperatively and 1 week postoperatively evaluated dysphagia using EAT-10 and Hyodo-Komagane (H-K) scores during FEES. Patient demographics, comorbidities, and pre- and postoperative dysphagia were compared between patients with and without PRC. Results Seven of 60 (11.6%) patients had preoperative dysphagia diagnosed using the H-K score. A significant positive correlation existed between the pre- and postoperative H-K scores. Of all 60 cases, eight (13.3%) had PRC. Among them, two required reintubation due to airway obstruction and six had aspiration pneumonia. The PRC(+) group was significantly older and more prone to diabetes and asthma. The preoperative H-K score of the PRC(+) group was significantly higher than that of the PRC(−) group. Postoperatively, but not preoperatively, EAT-10 was significantly higher in the PRC(+) group. Conclusions Preoperative dysphagia may potentially exacerbate postoperative dysphagia after ADF. A preoperative evaluation of dysphagia using the H-K score during FEES is a useful method for predicting and reducing the risk of PRC. Level of Evidence: 3

Outcomes of Endoscopic Sinus Surgery in Geriatric Patients: An Institutional Study.

The aim of this study was to investigate the efficacy and safety of Endoscopic Sinus Surgery (ESS) as a treatment modality for chronic rhinosinusitis refractory to maximal medical therapy in the elderly population. ESS has gained importance over the past 2-3 decades. A prospective review of outcome was done in fifty seven patients over age of 60years who underwent ESS. They were evaluated preoperatively and postoperatively at 3, 6, and 12months with a rigid nasal endoscopy scoring system, and the Sino Nasal Outcome Test-20 questionnaire. Data analysis was performed using the Student's t test to compare mean scores. All complications were noted. All of the patients in the study reported postoperative symptomatic improvement. And it was concluded that ESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis which is refractory to medical therapy.

Pureed diets containing a gelling agent to reduce the risk of aspiration in elderly patients with moderate to severe dysphagia: A randomized, crossover trial.

The aim of this study was to evaluate the effectiveness of adding a gelling agent to pureed diets to prevent aspiration pneumonia in elderly patients with moderate to severe dysphagia. Pureed diets are often used to reduce aspiration in patients with dysphagia. However, the ideal texture of a pureed diet to prevent aspiration pneumonia remains unclear. We prospectively conducted a randomized, crossover trial of pureed rice with or without a gelling agent in patients with moderate to severe dysphagia (ClincialTrials.gov number, NCT03163355). The primary outcome measure was pharyngeal residuals using an endoscopic scoring system. The secondary outcome was the sense of material remaining in the throat following swallowing. Sixty two patients (58% men), mean age 83 ± 9 years with moderate to severe dysphagia were included. Residuals in the throat were significantly less likely with pureed rice with than without the gelling agent (median cyclic ingestion score (range); 1 (0-4) vs 2 (0-4); P = .001). Irrespective of the presence or absence of the gelling agent, the sense of material remaining in the throat was significantly less frequent in older patients (87 ± 7.6 vs 75 ± 9.1 years, P < .01; 86 ± 7.3 vs 75 ± 8.6 years, P < .01). Pureed diets containing a gelling agent may reduce the risk of aspiration pneumonia possibly by decreasing pharyngeal residues in elderly patients with moderate to severe dysphagia.

Correlation between Clinical Symptoms and Lab Tests with Endoscopic Severity Indexes in Patients with Inflammatory Bowel Diseases.

BACKGROUND The Crohn’s Disease Endoscopic Index of Severity (CDEIS) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) are two validated endoscopic scoring system to evaluate patients with inflammatory bowel diseases (IBD). We conducted this study to evaluate the correlation between clinical symptoms and lab tests with these indexes in patients with Crohn’s disease (CD) and ulcerative colitis (UC). METHODS In this analytical study, 373 consecutive patients referred to Shahid Mohammadi Hospital with IBD were enrolled. All patients underwent complete ileocolonoscopy, and the endoscopic severity indexes (CDEIS and UCEIS) were calculated, and their relation with clinical symptoms and lab tests was evaluated. RESULTS Fever observed only in six patients (1.6%). It was associated with significantly higher CDEIS and UCEIS (p = 0.02 and p < 0.001, respectively). Also, diarrhea was correlated with significantly higher UCEIS (p < 0.001). The mean fecal calprotectin was 647.64 ± 409.37 µg/g in CD and 567.30 ± 342.49 µg/g in UC patients. Higher calprotectin level was observed in patients with higher CRP level (p = 0.001), erythrocyte sedimentation rate (ESR) level, CDEIS, and UCEIS (r = 0.438; 0.473; and 0.517; respectively, all with p < 0.001). CONCLUSION Our study showed that although fever and diarrhea are associated with higher endoscopic severity scores in patients with IBD, no clinical symptom could reliably predict the endoscopic results, alone. Furthermore, higher fecal calprotectin level is associated with higher ESR and C reactive protein levels, CDEIS, and UCEIS.