Clinical Gastroenterology and Hepatology最新文献

Background: Age and comorbidity are key factors in assessing patient prognosis and informing stopping rules for cancer screening eligibility, but their impact has not been rigorously evaluated in patients with hepatocellular carcinoma (HCC).

Methods: We conducted a retrospective cohort study of patients diagnosed with HCC at two health systems between January 2010 and February 2023. We used multivariable logistic regression and Cox proportional hazards models to evaluate the associations between older age (≥65 years) and comorbidity burden (Charlson Comorbidity Index) with early-stage presentation, curative treatment receipt, and overall survival. We performed subgroup analyses in patients with early-stage HCC.

Results: We identified 2002 patients with HCC (median age 61 years, 76% male, 21% early-stage), with a median survival of 15.7 months. In adjusted analyses, curative treatment receipt was associated with higher comorbidity but not older age. Conversely, overall survival was significantly associated with older age (HR 1.25, 95%CI 1.06 - 1.47) but not high comorbidity (HR 0.92, 95%CI 0.77 - 1.09). Older age continued to be associated with worse survival among patients with early-stage HCC (HR 1.99, 95%CI 1.45 - 2.73) and those who underwent curative treatment (HR 1.52, 95%CI 1.10 - 2.10). Median survival for younger vs. older individuals was 20 vs 14 months overall, 65 vs 49 months for patients with early-stage HCC, and 113 vs. 60 months for those with curative treatment.

Conclusion: Older age but not comorbidity burden is associated with worse survival in patients with early-stage HCC. Further studies are needed to define the role of comorbidity in HCC prognostication.

Background & aims: Timely prognostic communication is a critical component of care for patients with decompensated cirrhosis (DC). However, few studies have examined the association of prognostic communication with symptoms, mood, and health-related quality of life (HRQOL) in this population.

Methods: In this cross-sectional study of 218 outpatients with DC, we assessed their self-reported health status (terminally ill vs. not terminally ill), their prognostic communication with their hepatologists (Prognosis and Treatment Preferences Questionnaire), symptom burden (Revised Edmonton Symptom Assessment Scale), psychological distress (Hospital Anxiety and Depression Scale), and HRQOL (Short-Form Liver Disease Quality of Life scale). We used linear regression to examine associations among patients' self-reported health status and prognostic communication, symptom burden, psychological distress, and HRQOL.

Results: Over 75% of patients reported that prognostic communication was helpful for making treatment decisions, maintaining hope, and coping with their disease. However, 81% had never discussed their end-of-life care wishes with their hepatologists. Overall, 36% self-reported a terminally ill health status which was associated with higher symptom burden (B=8.33, p=0.003), anxiety (B=1.97, p=0.001), and depression (B=2.01, p=0.001) and lower HRQOL (B=-7.22, p=0.002). Patients who wished they had more information on their prognosis reported higher symptom burden (B=7.14, p=0.010), anxiety (B=1.63, p=0.005), and depression (B=1.50, p=0.010) and lower HRQOL (B=-7.65, p=0.001).

Conclusions: While most patients with DC highly valued prognostic communication, the majority reported never discussing their end-of-life care preferences with their hepatologists. Self-reported terminally ill health status and inadequate prognostic communication were associated with poorer symptoms, mood, and HRQOL. Interventions to improve prognostic communication while simultaneously providing adequate supportive care are warranted.

Objective: A significant number of post-faecal immunochemical test (FIT) colonoscopies in European organized colorectal cancer (CRC) screening programs are performed beyond the recommended 31-day threshold due to overburdened colonoscopy services. We aimed to develop a simple predictive model to stratify CRC risk of FIT+ patients.

Design: In a cohort of screenees undergoing colonoscopy following a positive ( ≥ 20μg Hb/g. feces) OC-sensor FIT result between 2004 and 2019, we derived and validated logistic regression-based models including variables independently associated with CRC and advanced neoplasms. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results: Overall, 40,276 patients (46% female, mean age 66+4 years) undergoing post-FIT colonoscopy were included. Variables independently associated with CRC were age ≥70 years (OR 1.20, 95%CI 1.03-1.40), male sex (OR 1.23, 95%CI 1.11-1.37), f-Hb level (50 to 199 μg/g.: OR 2.84, 95%CI 2.47-3.27; ≥200 μg/g: OR 6.91, 95%CI 5.99-7.98), and first round of FIT (OR 1.53, 95%CI 1.35-1.73). The discriminative ability of the model was good (AUROC 0.75, 95%CI 0.73-0.77) in the validation cohort. Applying the model would lead to over two thirds decrease in delayed CRC diagnoses, considering various scenarios of timely colonoscopy scheduling after FIT+.

Conclusions: We derived and validated a predictive model for risk stratification of patients with positive FIT in a large CRC screening cohort. Applying our model in screening practice would allow policy makers to effectively prioritize FIT+ individuals based on the risk of CRC, allowing to substantially reduce the rate of delayed CRC diagnosis.

Background and aims: Few data compare topical corticosteroid (tCS) dosing regimens and outcomes. We aimed to compare treatment outcomes in eosinophilic esophagitis (EoE) patients by once or twice daily dosing regimens.

Methods: We conducted a retrospective cohort study utilizing the UNC EoE Clinicopathologic Database of newly diagnosed EoE patients treated with a tCS who had a follow-up endoscopy with biopsy. Baseline data and outcomes were extracted. Bivariate and multivariate analyses compared patients at baseline and following initial tCS given as a once or twice daily dose.

Results: 522 patients met inclusion criteria, 122 patients on once daily dosing (72% male; 91% white) and 400 patients on twice daily dosing (66% male; 89% white). Patients on twice daily dosing were older (28.8 ± 18.2 vs. 24.3 ± 18.0; p = 0.01) and reported more heartburn (40% vs. 25%; p = 0.004). On bivariate analysis, global symptomatic response (78% vs. 76%; p = 0.82), post-treatment eosinophil count (20.8 ± 27.2 vs. 25.6 ± 39.4; p = 0.21), post-treatment EREFS (2.2 ± 1.8 vs. 2.2 ± 2.0; p = 0.92), and histologic response (<15 eos/hpf; 56% vs 58%; p = 0.66) did not differ. Candida was less frequent with daily dosing (2% vs. 8%; p = 0.04). In multivariate analysis, the odds of histologic response did not differ by dose groups (aOR: 1.03; 95% CI: 0.67 - 1.60).

Conclusions: EoE outcomes did not differ by daily or twice daily dosing regimens. These results inform tCS dosing regimens and reassure that both are effective.

Background & aims: A noteworthy proportion of patients with metabolic dysfunction-associated steatotic liver disease (MASLD) have an indeterminate vibration-controlled transient elastography (VCTE). Among these patients, we aimed to identify candidates for MASLD treatment by diagnosing significant fibrosis.

Methods: Real-world prospective study including a large dataset of MASLD patients with paired VCTE and liver biopsy from 6 centers. A total of n=1196 patients were recruited and divided in training (3 centers, Spain), internal validation (2 centers, Spain), and external validation (1 center, United States) cohorts. In patients with indeterminate liver stiffness measurements (LSM:8-12 kPa), a diagnostic algorithm was developed to identify significant fibrosis, defined as histological stage ≥F2. Statistical analysis was performed using gaussian mixture model (GMM) and k-means unsupervised clusterization.

Results: From the eligible population, 33%, 29%, and 31% had indeterminate VCTE in the training, internal and external validation samples, respectively. Controlled attenuation parameter (CAP) allowed the differentiation of GMM clusters with a cut-off of 280 dB/m (AUC:0.89 [95%CI:0.86-0.97]). Within patients with <280 dB/m, a LSM between 8.0-9.0 kPa showed a 93% sensitivity and a 91% negative predictive value to exclude significant fibrosis. Among patients with ≥280 dB/m, a LSM between 10.3-12.0 kPa diagnosed significant fibrosis with a 91% specificity. Applying this algorithm to the validation cohorts, 36% of the indeterminate VCTE were re-allocated. The re-allocated high-risk group showed a prevalence of 86% significant fibrosis, opening the therapeutic window for MASLD patients.

Conclusion: To identify candidates for MASLD treatment among indeterminate VCTE, an algorithm-based on the sequential combination of LSM and CAP thresholds can optimize the diagnosis of moderate-to-advanced fibrosis.

Background & aims: Lacking access to quality food may increase the risk of MASLD. We investigated associations between food environment factors (food deserts and food swamps) and MASLD-related mortality across the United States (US).

Methods: MASLD-related deaths were obtained from the National Vital Statistics System (NVSS) (2016-2020) and food environment factors from Food Environment Atlas (FEA). Food deserts are areas where low-income residents have limited access to affordable and nutritious food due to a scarcity of nearby grocery stores. Food swamps are areas oversaturated with outlets offering limited healthy food options.

Results: Counties in the highest mortality quartile (4th quartile) compared to the lowest mortality quartile (1st quartile) were predominantly located in the South region (78.7% vs. 23.5%) and rural areas (76.1% vs. 26.6%). These counties also had higher rates of elderly residents (19.4% vs. 16.5%), Hispanic residents (13.1% vs. 10.5%), household crowding (2.83% vs. 2.37%), no broadband internet subscription (23.9% vs. 12.7%), no high school diploma (16.1% vs. 9.0%), poverty rates (30.2% vs. 18.5%), unemployment rates (6.4% vs. 4.7%), food deserts (8.7% vs. 5.8%) and food swamp ratio (5.69 vs. 4.28) (all p-values <.001). After adjusting for county socio-demographic and clinical factors and regions, mixed-effects linear regression models showed significant differences in mortality rates (per 100,000) between counties with the highest versus lowest quartiles of food deserts (25.65 vs. 12.75, adjusted difference = 3.66 [95% CI: 2.66-4.72]) and food swamps (27.13 vs. 20.15 per 100,000, adjusted difference = 3.57 [95% CI: 2.44-4.71]).

Conclusions: In the United States, addressing socio-demographic and food environment disparities is paramount to reduce MASLD-related mortality.

Background and aims: Extra-hepatic comorbidities are common in alcohol-related liver disease (ALD). We examined associations between burden of comorbidities, alcohol, and smoking with low health-related quality of life (HRQoL) among patients with ALD.

Methods: Patients with ALD and matched comparators were identified among respondents of the Danish National Health Surveys 2010-2017. Survey data included generic measures of physical and mental HRQoL (12-item Short Form), comorbidities, alcohol and smoking. Low HRQoL in ALD was defined as >1.5 standard deviations worse than the average HRQoL in the comparators. Odds ratios (OR) of low HRQoL was estimated with multivariable logistic regression adjusting for potential confounders.

Results: We included 772 ALD patients, 53% of whom had cirrhosis; 37% had low physical HRQoL and 22% had low mental HRQoL. Disc herniation (found in 21%), osteoarthritis (36%), chronic obstructive pulmonary disease (COPD) (11%), cancer (6%), stroke (1%) and psychiatric disease (9%) were associated with low physical and/or mental HRQoL whereas alcohol use disorder (24%), diabetes (19%), acute myocardial infarction (1%), hypertension (34%) and osteoporosis (12%) were not. For example, osteoarthritis was associated with low physical [OR 2.17 (95% CI: 1.54-3.05)] and low mental HRQoL [OR 1.91 (95%CI: 1.27-2.88)]. For lifestyle factors, drinking > 20 units/week was associated with low physical and smoking > 20 cigarettes/day with low mental HRQoL, when compared to abstainers and non-smokers, respectively.

Conclusion: Common comorbidities including COPD, musculoskeletal and psychiatric disease are associated with low HRQoL in ALD, independently of liver disease severity, and so are alcohol consumption and smoking. These findings highlight the importance of multidisciplinary management of patients with ALD.

Background and aims: Colorectal cancer (CRC) incidence and mortality of China account for nearly 30% of the global attributable fraction. We aimed to estimate the yield and effectiveness of two-sample fecal immunochemical test (FIT)-based screening program in China.

Methods: Eligible individuals were invited for two-sample FIT between 2007 and 2021, with positive ones (cutoff: 40 μg/g before 2013, and 20 μg/g thereafter) referred for colonoscopy. Participation rates, detection rates, and positive predictive values (PPVs) were calculated. Participants were classified into: FIT+ / colonoscopy compliers, FIT+ / colonoscopy non-compliers, and FIT- as controls. We compared CRC incidence and mortality, and calculated the age reaching comparable risk.

Results: Among 246,349 invitees, 150,524 (61.10%) participated in two-sample FIT, with 16,994 (11.29%) identified as FIT+; 12,816 (75.41%) underwent colonoscopy, yielding a detection rate and PPV of 0.57% and 6.70% for advanced neoplasia. Median follow-up was 10.58 years. Compared with FIT- participants, CRC incidence and mortality were relatively similar among FIT+ / colonoscopy compliers with hazard ratio (HR) and 95% confidence interval (CI) of 0.94 (0.75-1.19) and 1.62 (1.09-2.41), but higher among non-compliers with HR and 95% CI of 3.52 (2.85-4.34) and 4.41 (2.96-6.55). Taking CRC incidence and mortality risk of FIT- participants at age 50.0 as the benchmark, FIT+ / colonoscopy compliers reached same risk at 50.6 and 46.1 years, while non-compliers at age 38.0 and 37.9 years, respectively.

Conclusions: Two-sample FIT could effectively identify high-risk populations, and colonoscopy compliance is associated with a lower risk of CRC incidence and mortality. This strategy might facilitate CRC screening practice in countries with large populations.

Background & aims: Functional lumen imaging probe (FLIP) Panometry evaluates esophageal motility at the time of sedated endoscopy and often parallels high-resolution manometry (HRM) performed in awake patients. This study aimed to assess the impact of endoscopic sedation on FLIP evaluation of esophageal motility.

Methods: Adult patients who completed FLIP Panometry during sedated endoscopy and had a conclusive Chicago Classification v4.0 diagnosis on HRM were included in this retrospective study. HRM diagnoses relative to FLIP Panometry motility classifications were compared by sedation type used during FLIP, i.e. conscious sedation (CS) with midazolam and fentanyl or monitored anesthesia care (MAC) with propofol.

Results: 454 patients (mean (SD) age 53 (17) years, 62% female) completed FLIP Panometry under CS (n=174, 38%) or MAC (n=280, 62%; 177/280 MAC included fentanyl). On comparison of CS vs MAC, HRM diagnoses within FLIP Panometry motility classifications did not differ (P=0.306 across all 5 FLIP Panometry classifications; P values 0.202-0.856 within specific FLIP classifications). The proportion of HRM diagnoses within each FLIP Panometry classification also did not differ between FLIP completed with CS vs MAC with fentanyl (P=0.098) or MAC without fentanyl (P=0.0261) CONCLUSIONS: Whether CS or MAC was used as sedation during FLIP did not have a clinically significant impact on the relationship between diagnosis on FLIP Panometry and HRM. This supports the validity of diagnosing esophageal motility disorders using FLIP Panometry during sedated endoscopy.