Clinical Gastroenterology and Hepatology最新文献

Background and aims: Endoscopic ultrasound guided portosystemic pressure gradient (EUS-PPG) measurement is an increasingly utilized technique that allows for direct measurement of hepatic and portal venous pressures. However, practice variability exists with this novel technique. Using the modified Delphi process, we aimed to establish consensus among international experts regarding best practices and future research for EUS-PPG.

Methods: A steering committee developed consensus statements covering four domains: indications, pre-procedural protocol, intra-procedural technique, and future research. 47 experts (29 advanced endoscopists, 18 hepatologists) were invited to participate via an online survey platform. Consensus for each statement was determined by ≥70% agreement on a Likert scale amongst participants. Statements that did not reach consensus were modified based on feedback and brought for a re-vote.

Results: A total of 53 statements achieved consensus after two rounds. 37 (79% of those invited) experts participated in both rounds. Notable areas of consensus included the following: 1) Clinical indications for EUS-PPG include all indications for hepatic venous pressure gradient (HVPG) and may be preferred in suspected presinusoidal portal hypertension or when another indication for endoscopy is present (e.g. variceal screening). 2) EUS-PPG is safe and well tolerated, 3) EUS-PPG should be performed under monitored anesthesia care or general anesthesia, and 4) Meticulous attention to technical details is required to maximize accuracy. New research frontiers for EUS-PPG were identified.

Conclusion: The results of this modified Delphi process established expert agreement on multiple important issues and provided practical guidance on key aspects of EUS-PPG. This document could provide a roadmap for future research studies.

Background and aims: Celiac disease is severely underdiagnosed, and many identified patients suffer from a long diagnostic delay. Population-based screening could improve this under-recognition, but its practical implementation remains unclear. We studied the most cost-effective screening strategy for celiac disease in childhood.

Methods: A Markov model using primarily Swedish data was developed for comparing the cost-effectiveness of various scenarios. Key considerations included serological testing across ages 3-18, single-time vs. repeated screening, and preliminary genetic testing to identify the at-risk population. Outcomes of the resulting 272 strategies were compared against a no-screening alternative using the incremental cost-effectiveness ratio. Sensitivity analysis was conducted at a €20,000 willingness to pay threshold to determine key factors influencing the optimal screening age(s) and conditions where repeated screening would be preferred.

Results: Untargeted single-time screening was more cost-effective than repeated screening or the combined use of genetic testing in the default scenario. Single-time screening was most cost-effective at age 11 (95% CI 10-14), and repeated screening at ages 4 and 11. Repeated screening was preferred if prevalence of celiac disease at age 12 was ≥5%, diagnosis improved quality of life for asymptomatic patients, screening costs were halved, or a willingness to pay of €50,000 per quality-adjusted life year was adopted. Diagnostic delay was the key factor influencing the optimal screening age(s).

Conclusion: The most cost-effective screening strategy for celiac disease was single-time untargeted serological testing at age 11. The optimal approach is affected by regional factors and may evolve with new evidence. Repeated screening may be preferable for high-risk groups and with high willingness to pay.