Clinical and Translational Gastroenterology最新文献

Introduction: In a national United States (US)-based group, we sought to describe barriers identified by sexual and gender minority (SGM) patients and primary care providers (PCPs) that challenge the provision of SGM-affirming digestive healthcare via qualitative methodology.

Methods: Forty patient participants and 24 PCPs were recruited from a random sample of 18 states within the 9 principal US Census Divisions and 2 states near the home institution. Patient participants selected completed a virtual semi-structured qualitative interview regarding their experiences with digestive healthcare and their views on barriers to engaging in digestive health care. PCPs were interviewed on treating SGM patients with GI disorders and interactions with GI consultants. Interviews were conducted until thematic saturation was achieved. The study was conducted from November 2023 to August 2024.

Results: Thematic saturation was achieved at 36 patient participants and 21 PCPs. Major themes included SGM discrimination in digestive healthcare, SGM issues in engaging in digestive healthcare, GI symptoms and other aspects of health-specific conditions, and ways to improve digestive healthcare for the SGM community. Participants noted a link between psychological distress in the SGM population and GI symptoms and offered actionable suggestions to improve SGM-focused digestive healthcare.

Conclusion: Systematic deficiencies were identified in the provision of SGM-affirming digestive care, related to bias within healthcare systems and a lack of understanding of unique SGM-related needs throughout the US. Further research studying improved shared clinician and SGM GI patient engagement is needed to address these sources of health inequity.

Introduction: Disparities in hepatocellular carcinoma (HCC) outcomes are shaped by intersecting social determinants of health (SDOH). We hypothesized that patients experience distinct combinations of socioeconomic barriers that cluster into social risk phenotypes associated with differences in diagnosis, treatment, and survival.

Methods: We analyzed data from 4,877 adults diagnosed with HCC in the Indiana State Cancer Registry (2009-2020). Latent class analysis (LCA) was performed using sex, race, insurance, marital status, occupation, neighborhood Social Deprivation Index (SDI), and distances to screening and Indiana University Hospital. Outcomes included early-stage diagnosis, receipt of curative therapy, and two-year mortality.

Results: Among 4,877 patients, 15.8% were non-White and 24.7% were female. LCA identified six distinct risk classes: (1) Minimal Barriers; (2) Publicly Insured - Married Females; (3) Publicly Insured - Unpartnered Males; (4) Rural and Geographically Distant; (5) Structurally Marginalized; and (6) Unseen and Uninsured. Class 1 had the most favorable characteristics (83.7% private insurance, 16.8% professional occupation) and best outcomes: 55.4% early-stage diagnosis, 24.4% curative therapy, and 55.4% two-year mortality. All other classes had significantly worse outcomes. Compared to Class 1, patients in Class 6 had the lowest early-stage diagnosis (39.7%) and curative therapy (10.5%) and highest mortality (83.6%; OR 4.12, 95% CI 3.06-5.54, P <0.001). Classes 4 and 5, reflecting rural and racially marginalized groups, also had significantly lower odds of early diagnosis and treatment.

Conclusion: Social risk phenotypes based on intersecting SDOH were strongly associated with HCC outcomes and may inform future risk-based intervention strategies.

Background: Liver transplantation (LT) recipients are at high risk of developing de novo metabolic syndrome (MetS), which contributes to cardiovascular and cerebrovascular morbidity. This study investigated serum and urinary metabolic changes after LT to identify microbial and metabolic markers associated with MetS development.

Methods: We conducted a prospective, two-center longitudinal study with biospecimen collection pre-LT and at 6 months, 1 year, and 2-9 years post-LT. Nuclear magnetic resonance (NMR) spectroscopy was used to characterize serum and urine metabolomic profiles from 73 and 44 patients, respectively. MetS was defined as BMI >30 kg/m2 plus at least one additional metabolic abnormality.

Results: MetS prevalence increased from 11% pre-LT to 36% post-LT. Post-LT, serum metabolite profiles showed increased phosphocholines and lipid-CH3 (LDL), while urine profiles demonstrated higher levels of trimethylamine-N-oxide (TMAO) and phenylacetylglutamine (PAG). Patients who developed or had persistent MetS exhibited smaller increases in serum phosphocholines and lipid-CH3 but greater elevations in urinary TMAO levels compared with patients who remained MetS-free.

Conclusion: LT is followed by distinct metabolic shifts reflecting changes in both hepatic lipid metabolism and gut-liver microbial co-metabolism. Elevated urinary TMAO, together with reduced serum phosphocholine and lipid-CH3 responses, characterize patients who develop post-LT MetS and may serve as early biomarkers of cardiometabolic risk in LT recipients.

Introduction: Irritable bowel syndrome (IBS) is a chronic gastrointestinal pain condition that has not been thoroughly studied in relation to environmental exposures and other health issues. Veterans are more susceptible to IBS and may experience specific service-related risks for developing the condition. Evaluating the prevalence of IBS and its links to military service, environmental factors, and health conditions in both men and women Veterans could improve our understanding of etiological factors contributing to IBS.

Methods: This observational cohort study, using a large-scale epidemiological sample from the Million Veteran Program, included self-report data from 546,246 Veterans and examined the prevalence of IBS and its association with military service history, environmental exposures, and health comorbidities.

Results: Of the 546,246 Veterans included, 497,287 (91.0%) were men, and 48,959 (9.0%) were women. The prevalence of IBS was higher in women (13.8%) than in men (4.2%) and varied by race and ethnicity, with the highest in White women (14.7%). Veterans with IBS had worse general health, more pain, and greater pain interference. We found associations between IBS and aspects of military service, including service post-September 2001, and environmental exposures, including a history of exposure to chemical and biological warfare and anti-nerve agent pills. Individuals with IBS were at a greater likelihood of digestive, neurological, and psychiatric conditions and greater opioid use.

Discussion: IBS prevalence varied across sex, race, and environmental exposures. IBS was associated with several domains of health conditions, including gastrointestinal, psychiatric, and neurological. Our results highlight the link between IBS and environmental factors, including toxicants, and encourage future research into the mechanisms underlying this association.

Objectives: Celiac disease (CD) may affect quality of life (QoL), healthcare use, and societal costs in various ways both before and after diagnosis. However, detailed evidence remains limited about how costs and QoL change after diagnosis, and which patient characteristics (e.g., symptom duration) influence those changes. The aim of this study was to evaluate CD patients' QoL and societal costs before and after diagnosis.

Methods: In this cross-sectional study, 2,691 patient-members of the Dutch Celiac Society completed a questionnaire about their life before and after diagnosis. Data collection included: sociodemographic and clinical characteristics, healthcare use, non-healthcare costs, and QoL (measured using the EQ-5D-5L). Mean QoL and annual healthcare and societal costs were compared pre and post-diagnosis. Multivariate regression models were used to identify factors associated with QoL and costs in both periods (and difference between periods).

Results: On average, respondents recalled experiencing 4-5 symptoms before diagnosis. QoL improved significantly post-diagnosis, with greater improvements among childhood diagnoses. Annual healthcare and societal costs decreased by 23% and 36% respectively post-diagnosis, except for societal costs in those diagnosed during childhood. Age at diagnosis and the number of pre-diagnosis symptoms were associated with lower and higher recalled pre-diagnosis QoL, respectively. Number of symptoms, comorbidities, and non-adherence to a GFD were associated lower post-diagnosis QoL.

Conclusions: Following CD diagnosis, QoL significantly improved and healthcare and societal costs decreased, except for societal costs among childhood diagnoses. These findings enhance the understanding of CD's burden and economic impact, supporting healthcare and policy efforts for timely CD identification.

Introduction: The risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis has been extensively studied; however, nonpancreatic adverse events, such as cholangitis, bleeding, and cardiopulmonary complications, are under characterized. We aimed to characterize the 30-day incidence and financial burden of nonpancreatic post-ERCP adverse events.

Methods: We performed a cross-sectional analysis using the Merative MarketScan commercial claims database from January 1, 2019 to December 31, 2021. The study included 27,482 patients who underwent 42,318 inpatient and outpatient ERCPs. Primary outcomes were post-ERCP cholangitis, bleeding, and cardiopulmonary complications within 30 days. Financial burden was measured using total direct healthcare costs and out-of-pocket costs during the 30-day period after ERCP. Multivariable logistic regression was used to identify associated risk factors and to estimate adjusted costs.

Results: Among 27,482 patients who underwent a total of 42,318 ERCPs, nonpancreatic adverse events occurred in 5.3% of cases: cholangitis in 3.6% (95% confidence interval [CI] 3.5%-3.8%), bleeding in 1.3% (95% CI 1.2%-1.4%), and cardiopulmonary complications in 1.1% (95% CI 1.0-1.3). In multivariable analysis, adverse events were more common among men and those with higher comorbidity burden. Patients with complications had significantly higher adjusted 30-day costs: cholangitis ($38,512 vs $30,881, difference $7,631), bleeding ($43,702 vs $30,918; difference $12,748), and cardiopulmonary complications ($53,649 vs $30,918; difference $22,930). Out-of-pocket costs varied by region and insurance type but exceeded $1,000 for many patients.

Discussion: Nonpancreatic ERCP adverse events occur in over 5% of cases and can impose a substantial financial burden on both healthcare systems and patients.

Introduction: Colorectal cancer (CRC) remains a leading cause of cancer associated death in the United States and colonoscopy the primary screening strategy for prevention. Rates of adenomatous and serrated neoplasia detection are inversely associated with post-colonoscopy CRC. This crucial quality metric depends on accurate ascertainment of colorectal neoplasia findings from both endoscopy and histopathology records. We aimed to assess the feasibility of a random forest machine learning model to rapidly and accurately categorize colorectal neoplasia from electronic health record data.

Methods: A retrospective cohort study compared neoplasia detection rates among individuals undergoing colonoscopy at a large academic institution to develop a rule-based algorithm to categorize colorectal neoplasia from endoscopy reports and pathology SNOMED II codes. This cohort provided a large training set to develop a natural language processing (NLP) system using a random forest approach to automatically classify unstructured pathology findings into adenoma, serrated, or advanced neoplasms. This system was manually validated through an independent holdout set.

Results: The training set comprised 35,953 unstructured pathology reports with matched SNOWMED II codes from 95,188 unstructured colonoscopy reports. The final model was assessed on an independent holdout set of 337 manually annotated procedures obtaining an AUC of 0.997 (CI 0.994 - 1), 0.99 (CI 0.98-1), and 0.99 (CI 0.98-0.99) for prediction of adenoma, serrated, and advanced lesions respectively.

Discussion: The random forest-based hybrid NLP system for classification of colonoscopy results was both accurate and explainable. NLP combined with effective machine learning algorithms can provide a scalable strategy for colonoscopy quality monitoring.

Introduction: Mucosal exposure devices (MEDs) and computer-aided detection (CADe) systems may both improve adenoma detection through distinct mechanisms: expanding mucosal visualization and highlighting lesions, respectively. This study investigated the efficacy of combining CADe-assisted colonoscopy with a MED compared to CADe-assisted colonoscopy alone.

Methods: This international, multicenter, prospective, non-randomized, single-arm study (NTC05220345) was conducted at three centers that also participated in the previous DISCOVERY II randomized controlled trial, comparing CADe-assisted with conventional colonoscopy. Patients referred for diagnostic, non-fecal immunochemical test screening, or surveillance colonoscopy and underwent CADe-assisted colonoscopy (DISCOVERY™, PENTAX Medical) with a MED using an integrated inflatable balloon (G-EYE™, PENTAX Medical). The primary outcome was adenoma detection rate (ADR); secondary outcomes included sessile serrated lesion detection rate (SSLDR) and withdrawal time without interventions. Outcomes were compared to historical controls of the CADe-arm of the DISCOVERY II study.

Results: Of 196 enrolled participants, 182 were included in the final analysis and compared with 250 participants from the historical CADe-arm. ADR was 47.3% in the CADe + MED-group vs. 38.4% in the CADe-group (p=.066; absolute difference: 8.9%, 95% CI: -0.6-18.3). Mixed-effects logistic regression model adjusting for clustering and confounders calculated an odds ratio of 1.16 (95% CI: 0.74-1.81). Median withdrawal time was slightly longer with CADe + MED compared to CADe-only (10.0 vs. 9.2 minutes, p=.004), while SSLDR was not significantly different (12.6% vs. 18.4%, p=.11).

Conclusions: In this study using historical controls, CADe-assisted colonoscopy combined with a MED did not significantly increase ADR compared to CADe alone, suggesting limited synergistic benefit.

Introduction: Entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF) are first-line nucleos(t)ide analogs (NA) for chronic hepatitis B (CHB). Real-world monitoring of patients on these agents and their comparative renal safety remain poorly characterized. We evaluated guideline-adherent monitoring practices and compared renal dysfunction risk across ETV, TDF, and TAF.

Methods: We retrospectively analyzed patients with CHB who initiated ETV, TDF, or TAF between 2012 and 2022. Levels of serum alanine aminotransferase, total bilirubin, albumin, serum creatinine, hepatitis B virus DNA, and abdominal sonograms were assessed every 6 months during the 36 months of NA treatment. Incidence rates and adjusted hazard ratios (HRs) for renal dysfunction were estimated by Cox regression.

Results: Of the 2,155 enrolled patients, 65.8% received ETV, 23.1% received TDF, and 11.1% underwent TAF. Alanine aminotransferase was monitored in >90% across all groups; other tests (bilirubin, albumin, creatinine, hepatitis B virus DNA, sonogram) were performed in only 20%-80%. After multivariable adjustment, TDF (HR 1.41; 95% confidence interval 0.95-2.08) and TAF (HR 0.91; 95% confidence interval 0.52-2.18) showed no significant difference in renal dysfunction risk vs ETV. Independent predictors of increased renal risk included older age, higher Charlson comorbidity index, fibrosis-4 score, and diuretic use, whereas elevated serum albumin levels were associated with a lower risk.

Discussion: In this real-world cohort, adherence to recommended monitoring for patients with CHB on NAs was suboptimal. ETV, TDF, and TAF demonstrated comparable renal safety profiles over 3 years.