Kettering General Hospital

Abstract Background Tumor necrosis factor (TNF) antagonists are central to the management of inflammatory bowel disease (IBD), but concerns regarding long-term safety, infection risk, and costs have prompted interest in treatment de-escalation. Whether discontinuing TNF therapy in patients with sustained remission is safe remains uncertain. Aims We aimed to conduct an updated systematic review and meta-analysis pooling all RCTs published to date on this subject in order to provide a more robust assessment of the risk of relapse, the likelihood of sustained clinical remission, and the incidence of adverse events among patients with IBD in sustained clinical remission on TNF-α antagonists. By synthesizing all available evidence, our study seeks to enhance statistical power and provide more reliable estimates to guide clinical decision-making. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TNF antagonist withdrawal with continuation in IBD patients in sustained remission. Databases including MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched through July 2025. Eligible trials enrolled adults with Crohn’s disease or ulcerative colitis in clinical remission. Primary outcomes were relapse risk and sustained remission. Data were pooled using a random-effects model. Results Four RCTs comprising 485 patients were included. TNF antagonist withdrawal was associated with a significantly higher risk of relapse compared with continuation (RR: 3.00, 95% CI: 1.47–6.11). Time to relapse was also shorter in the withdrawal group (HR: 5.34, 95% CI: 2.05–13.92). Sustained clinical remission did not differ significantly between groups (RR: 0.83, 95% CI: 0.55–1.27). Withdrawal reduced infection risk (RR: 0.47, 95% CI: 0.25–0.90), while rates of gastrointestinal and serious adverse events were comparable. Conclusions Discontinuation of TNF antagonists in IBD patients in remission substantially increases the risk and accelerates the timing of relapse, though it lowers infection risk. Careful patient selection and close monitoring are essential if withdrawal is considered. Funding Agencies None

Objective Risankizumab is an interleukin-23 p19 subunit inhibitor which received approval for Crohn’s disease (CD) by UK licensing authorities in May 2023. Our aim was to evaluate the real-world outcomes of risankizumab in the UK. Design We conducted a retrospective, multicentre, cohort study of patients with CD treated with risankizumab across 25 health boards in the UK between 1 January 2021 and 1 November 2024. Our primary outcome was treatment persistence at 6 months. Our secondary endpoints were steroid-free clinical remission (Harvey-Bradshaw index <5), C-reactive protein (CRP) remission (CRP ≤5 mg) and faecal calprotectin (FCAL) remission (FCAL <250 µg/g). Results We included 763 patients with a median follow-up time of 27 weeks (IQR 18–41 weeks) with a total of 432 and 110 patients having 6-month and 12-month data available. The median number of advanced therapy exposures was 3 (2–4), with 92% (704/763) having failed anti-tumour necrosis factor therapy and 72% (548/763) having failed ustekinumab. Treatment persistence at 6 and 12 months was 95.4% and 89.2%, respectively. Unadjusted persistence rates for ustekinumab-naive versus ustekinumab-exposed patients were 92.7% vs 95.3% and 89.0% vs 74.2% at 6 and 12 months, respectively (p=0.62). Rates of clinical, CRP and FCAL remission were 52% (123/236), 53% (169/319) and 44% (69/156) at 6 months. Rates of clinical remission for ustekinumab naive versus exposed were 57% (29/51) vs 51% (94/185) (p=0.54) 6 months. Adverse events occurred in 17% (n=127) of the cohort, of which 12% (n=92) were serious. Conclusion Risankizumab was effective in a large, real-world, medically refractory CD cohort with excellent persistence and good clinical and biochemical remission rates.

Abstract Aim To investigate ultrasound image findings in patients with gallbladder polyps requiring cholecystectomy and assess the risk of gallbladder malignancy associated with polyps. Method Patients with ultrasound diagnosis of gallbladder polyps who underwent cholecystectomy between January 2019 and September 2023 were included. Histology reports were thoroughly reviewed to find possible diagnosis of gallbladder malignancy. Results A total of 701 patients' records who had cholecystectomy were reviewed, 45 patients were included as per the inclusion criteria, of whom 73% were women. Mean age was 52÷15 years. Average size of the polyps on ultrasound was 7.26mm and approximately 26.7% of polyps were noted to be bigger than 10mm. Overall analysis of the data showed that none of the histology confirmed malignancy. Conclusions Literature review and current ESGAR guidelines suggests that gallbladder polyps, particularly with size > 10mm have significant risk of conversion to malignancy. Nearly a quarter of the patients who underwent cholecystectomy for gallbladder polyp had a polyp size > 10mm however none of them were proven malignant on histology. This study was conducted on small cohort of patients, further studies on larger cohorts are needed in order to draw conclusions.

Abstract Aim To investigate ultrasound imaging findings in patients with gallbladder polyps requiring cholecystectomy and compare them with histopathological results. Method Patients with ultrasound diagnosis of gallbladder polyps who underwent cholecystectomy between January 2019 and September 2023 were included. Results A total of 701 patients' records who had cholecystectomy were reviewed, 45 patients were included as per the inclusion criteria, of whom 73% were women. Mean age was 52÷15 years. Average size of the polyps on ultrasound was 7.26mm and approximately 26.7% of polyps were noted to be bigger than 10mm. Histopathological findings confirmed the presence of polyps in only 46.7%. Out of these, size of the polyps was documented in 62% of histology reports which was compared with ultrasound findings. Mean size on USG was 9.13$2.73mm in comparison to histological size of 6‡2.94mm. Mean difference in measurements was 3.13mm. Conclusions This study examines the relationship between ultrasound imaging and histological findings of gallbladder polyps. From our 45 patients identified with gallbladder polyps the majority were women. Larger sized polyps are more likely to be confirmed on histology and our findings suggest that ultrasound can overestimate polyp-size by up to 3mm. Finally, 53.3% of polyps diagnosed via ultrasound were not confirmed on histological examination. Further studies on larger cohorts are required to validate above findings and refine diagnostic protocols.

Ketamine-induced cholangiopathy (KIC) is a rare but increasingly recognized manifestation of chronic ketamine toxicity, often accompanied by urinary tract injury such as hemorrhagic cystitis. We report the case of a 55-year-old female with recurrent hemorrhagic cystitis and a long-standing history of intermittent recreational ketamine use who presented with asymptomatic cholestatic liver enzyme abnormalities. Hepatobiliary ultrasound revealed hepatic steatosis without ductal dilatation, and magnetic resonance cholangiopancreatography demonstrated multifocal biliary stricturing with a beaded appearance of the intrahepatic bile ducts. Serological testing for autoimmune and infectious etiologies was negative. Cystoscopy revealed inflammatory bladder changes, and histopathology confirmed ketamine-induced hemorrhagic cystitis. Following cessation of ketamine use, the patient demonstrated biochemical improvement. This case emphasizes the multisystem toxic potential of ketamine, highlighting the importance of recognizing KIC with concomitant hemorrhagic cystitis as an emerging cause of cholestasis and urinary tract injury.

Uterine rupture is a rare but life-threatening complication, most commonly associated with labor in women with a prior caesarean scar. Its occurrence in the second trimester, particularly in primigravid women with an unscarred uterus, is exceptionally uncommon. Here, we present a 29-year-old primigravida with a monochorionic-diamniotic (MCDA) twin pregnancy complicated by absent end-diastolic flow in one twin and subsequent intrauterine fetal demise at 21+5 weeks. Induction of labor with misoprostol resulted in delivery at 21+6 weeks. The early postpartum course was complicated by pyrexia, retained tissue, and recurrent heavy bleeding requiring ultrasound-guided surgical evacuation (SEVAC), uterine balloon tamponade, and major obstetric hemorrhage. Thirty-two days post-delivery, the patient collapsed with secondary postpartum hemorrhage. MRI later demonstrated a complete absence of the anterior uterine wall, consistent with rupture/dehiscence. Laparotomy confirmed a large anterior wall defect, which was successfully repaired, preserving fertility. This case gives us insight that second-trimester uterine rupture, though rare, is a potentially devastating condition. Clinicians should remain vigilant regardless of parity or uterine history. “Silent rupture” emphasizes the role of imaging in ambiguous cases. Conservative measures for postpartum hemorrhage must be used judiciously, and prompt surgical management optimizes outcomes and preserves fertility. Larger studies are needed to refine risk stratification and monitoring strategies.

The relationship between myocardial injury after cardiac surgery (MICS), ischemia on electrocardiogram (ECG), and mortality is uncertain. In this study we aimed to determine whether potential ischemic ECG changes after cardiac surgery are associated with 30-day mortality. In a cohort of adults who underwent cardiac surgery, experts interpreted ECGs preoperatively; on postoperative days 0, 1, 2, and 3; and on the last day before discharge (59,539 total ECGs reviewed) for new potential ischemic ECG changes. Among 12,594 patients, 9097 (72.2%) had potential ischemic ECG changes; 259 (2.1%) died within 30 days after surgery. Among patients with troponin elevation meeting MICS criteria, in models adjusting for EuroSCORE II, the hazard ratio (HR) for 30-day mortality was 0.57 (95% confidence interval [CI] 0.35-0.94, P = 0.03) for new Q waves, 2.17 (95% CI 1.14-4.13, P = 0.02) for ST depression ≥ 2 mm, and 0.58 (95% CI 0.39-0.87, P = 0.007) for T-wave inversion 1-1.9 mm. ST elevation was not significantly associated with 30-day mortality. The only ECG change for which coronary artery bypass grafting (CABG) was an effect modifier was new left bundle branch block (LBBB), with an HR of 2.78 (95% CI 1.69-4.60, P = 0.0001) with CABG and an HR of 1.10 (95% CI 0.54-2.21, P = 0.27) without CABG (P value for interaction = 0.03). After cardiac surgery, potential ischemic ECG changes are common and have divergent associations with mortality. ST depression was associated with a higher risk of death, whereas new Q waves and T-wave inversions were associated with a lower risk of death. A new LBBB was associated with a higher risk of death only among patients who underwent CABG. Potential ischemic ECG changes are common after cardiac surgery and lack specificity for the diagnosis of myocardial infarction.

The treatment of urolithiasis is changing quickly by moving away from conventional diagnostic techniques and toward more complex, data-driven strategies. A major part in this change is being played by artificial intelligence (AI) through providing the clinicians with invaluable assistance. This study examines the state of AI applications in urolithiasis today and how they affect everything from treatment planning to initial imaging. AI models are improving the accuracy of computed tomography (CT) and ultrasonography (US) in diagnoses. These techniques provide automatic stone detection throughout the diagnostic process and a precise stone burden calculation, and even assistance in differentiating difficult mimics, such as ureteral stones, from phleboliths. Additionally, sophisticated algorithms and radiomics are demonstrating great promise in determining the composition of stones preoperatively from imaging data or even digital photos. AI has also changed and improved the intervention for kidney stones, which is highlighted by models now capable of predicting the success of procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL), in some cases outperforming traditional scoring systems. Despite this progress, significant hurdles remain, particularly the need for large datasets and ensuring models are reliable and generalizable across different clinical settings. Successfully integrating these powerful tools into daily urological practice will require a concerted effort toward developing best-practice guidelines, robust training programs, and strong interdisciplinary collaboration. This review aims to summarize current AI applications in imaging and intervention for urolithiasis, identify limitations, and outline future research directions.