BACKGROUND: Nurses play a key role in inflammatory bowel disease (IBD) management. This randomized controlled trial evaluated intensive nurse-led program in patients with IBD starting advanced therapy. METHODS: Patient...BACKGROUND: Nurses play a key role in inflammatory bowel disease (IBD) management. This randomized controlled trial evaluated intensive nurse-led program in patients with IBD starting advanced therapy. METHODS: Patients were randomized (1:1) to intensive nurse follow‑up (Arm A) or standard care (Arm B). Both arms received baseline nurse education; Arm A additionally had scheduled nurse calls and visits. Primary outcome was reduction in IBD‑Disk score in W12. Secondary outcomes were W52 reduction, robust response (> 20-point improvement), and IBD-Disk remission (score < 40). RESULTS: Overall, 98 patients were randomized (Arm A: n = 50; Arm B: n = 48) with similar baseline characteristics. Mean baseline IBD‑Disk scores were 49.2 ± 20.7 in Arm A and 42.0 ± 19.8 in Arm B (p = 0.07). At W12, both groups improved, with greater IBD-Disk reductions in Arm A (16.1 ± 22.9 vs. 10.1 ± 20.1, p = 0.09). At W52, improvement was greater in Arm A (18.4 ± 20.7 vs 9.4 ± 17.8; p = 0.08). More patients achieved robust response in Arm A (49% vs 21%, p = 0.013) at W12. By W52, IBD-Disk remission was achieved by 22/25 (88%) patients in Arm A vs 18/28 (64%) in Arm B (p = 0.045). CONCLUSIONS: In this pilot randomized trial, intensive nurse-led follow-up did not significantly improve IBD-Disk at week 12, yet favorable trends of functional outcomes were observed. Intensive nurse‑led follow‑up program may improve quality of life in patients with IBD. These findings support the integration of specialist IBD nurses to improve patient‑centered outcomes.
BACKGROUND: Despite the availability of multiple screening options, rates of colorectal cancer (CRC) screening remain suboptimal. With recent approval of a blood test for CRC screening, there is an urgent need to underst...BACKGROUND: Despite the availability of multiple screening options, rates of colorectal cancer (CRC) screening remain suboptimal. With recent approval of a blood test for CRC screening, there is an urgent need to understand screening preferences of populations with low screening rates. METHODS: Between October 2023 and June 2024, we conducted a survey on preferences for CRC screening modalities of stool test, blood test and colonoscopy among adults aged 45-75 at ambulatory primary care clinics across multiple community health centers and federally qualified healthcare centers across the city as well as in community settings regardless of prior screening. RESULTS: A total of 1,014 individuals completed the survey. Respondents were 12.8% Black/African American, 51.6% White, 23.4% Hispanic, 15.8% South Asian, and 4.2% Asian. Overall, the highest test preference was for screening colonoscopy (45.5%) followed by blood test (29.9%). Colonoscopy was preferred by individuals under age 70 (47.5%), while stool-based (20.2%) and blood-based (31.9%) tests were the most preferred among above 70 years (p = 0.0429. Whites (54.6%), Blacks (44.6%), and Hispanics (35.9%, p < 0.001) preferred colonoscopy, while Asians (37.2%) and South Asians (24.4%) favored blood tests. Factors associated with preference for a colonoscopy over other screening tests were younger age: respondents aged below 70 years were more likely to prefer colonoscopy, compared to respondents aged above 70 years (OR 1.72, 95% CI [1.20-2.47], p = 0.003); Nonsmoker compared to former/current smokers (OR 2.04, 95% CI [1.10-3.94], p = 0.028); Having undergone a prior colonoscopy (OR 6.83, 95% CI [4.52-10.6], p = < 0.001) or not having a prior stool test (OR 1.56, 95% CI [1.52-2.11], p = < 0.001). Factors associated with preference for a blood test over other screening tests were education level: respondents without any college experience were more likely to prefer blood test compared to respondents with college experience (OR 1.46, 95% CI 1.02-2.07, p = 0.038); Nonsmoker compared to former/current smokers (OR 1.73, 95% CI [1.00-2.99], p = 0.048); Never undergone a prior colonoscopy (OR 1.76, 95% CI [1.23-2.51], p = 0.002). Factors associated with preference for a stool test over other screening tests were: age over 80 years compared to respondents aged below 80 (OR 3.34, 95% CI 1.67-6.55, p < 0.001); respondents with college experience were more likely to prefer blood test compared to respondents without college experience (OR 1.62, 95% CI 1.02-2.66, p = 0.048). CONCLUSION: Colonoscopy was the preferred test option, followed by blood test. Preferences for screening test varied by age, race, ethnicity, education and prior screening. The study underscores importance of patient preference in deciding which tests to offer based on the patient characteristics. Nonsmokers, those without any college education and those without prior screening preferred blood test for screening.
BACKGROUND: Partially covered self-expandable metallic stents (PCSEMSs) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) provide favorable patency and low migration risk; however, reintervention (RI) r...BACKGROUND: Partially covered self-expandable metallic stents (PCSEMSs) used for endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) provide favorable patency and low migration risk; however, reintervention (RI) remains challenging. OBJECTIVES AND METHODS: We retrospectively evaluated the outcomes of RI after EUS-HGS with PCSEMS placement in 108 patients with malignant biliary obstruction treated between January 2016 and December 2024. Causes of recurrent biliary obstruction (RBO), RI techniques, and post-RI outcomes were analyzed. RESULTS: The median age of patients was 77 years, with pancreatic cancer being the most common (n = 62). RBO occurred in 25 (23%) patients, including those with sludge/food impaction (n = 15) and hyperplasia (n = 10). The median time to RBO (TRBO) was 196 days. RI involved PCSEMS removal and replacement (n = 11), or treatment without removal (n = 12). Post-RI RBO developed in six patients (24%), and the median post-RI TRBO was 185 days. The removal group showed a significantly longer TRBO than the nonremoval group (185 vs. 77 days; p = 0.048). Hyperplasia was an independent predictor of failed stent removal (OR, 18.7; 95% CI, 1.45-240; p = 0.02). CONCLUSIONS: Stent removal during RI is associated with longer post-RI TRBO; however, removal can be challenging, particularly in cases with hyperplasia. Careful selection of a PCSEMS for EUS-HGS is required based on the patient's life expectancy.
OBJECTIVE: Malnutrition is a common complication of acute pancreatitis (AP), and it may adversely affect outcomes. This study aimed to evaluate short-term changes in body composition and the development of sarcopenia in...OBJECTIVE: Malnutrition is a common complication of acute pancreatitis (AP), and it may adversely affect outcomes. This study aimed to evaluate short-term changes in body composition and the development of sarcopenia in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP). METHODS: This single-center, prospective observational study evaluated patients with MSAP and SAP at admission and after eight weeks. Body composition was measured using bioelectrical impedance analysis (BIA). Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People (EWGSOP2) guidelines, with handgrip strength (HGS) used to identify probable sarcopenia and computed tomography (CT)-derived skeletal muscle index (SMI) used to confirm the diagnosis. The primary endpoint was the prevalence of probable and confirmed sarcopenia based on EWGSOP2 criteria. Secondary endpoints included changes in body composition parameters during 8 weeks follow up. RESULTS: Forty patients (22 MSAP, 18 SAP) were included. The mean age was 39.4 ± 14.8 years, and 75% were male. Patients with SAP had significantly higher Bedside Index of Severity in Acute Pancreatitis (BISAP) scores (2.16 vs. 1.04) and rates of organ failure compared to the MSAP group. Over eight weeks, both groups experienced significant reductions in body mass index (BMI), body fat, and visceral fat. SMI declined significantly in both MSAP (47.5 to 41.5 cm/m, p < 0.001) and SAP (48.9 to 41.2 cm/m, p < 0.001). At the eight-week follow-up, the prevalence of confirmed sarcopenia was 31.8% in the MSAP group and 22.2% in the SAP group. HGS did not change significantly in either group; therefore, the rise in confirmed sarcopenia was driven primarily by a progressive decline in SMI crossing the diagnostic threshold in patients with pre-existing low HGS. CONCLUSION: Moderately severe and severe AP lead to rapid, detrimental changes in body composition and a high incidence of sarcopenia within eight weeks. These findings highlight the need for systematic screening and targeted nutritional and physical rehabilitation to mitigate muscle loss in recovering patients.
BACKGROUND/AIMS: Patients undergoing ERCP with chronic kidney disease (CKD), congestive heart failure (CHF), or liver cirrhosis (LC) often experience worse outcomes. It is unclear whether these are driven by procedure-re...BACKGROUND/AIMS: Patients undergoing ERCP with chronic kidney disease (CKD), congestive heart failure (CHF), or liver cirrhosis (LC) often experience worse outcomes. It is unclear whether these are driven by procedure-related events or underlying comorbidity. METHODS: We analyzed the National Inpatient Sample to identify adult ERCP cases. High-risk comorbidities were defined as CKD, CHF, or LC. Primary outcomes were inpatient mortality and morbidity. RESULTS: Among 1,171,973 ERCP admissions, 267,739 (22.8%) were high-risk. Compared with lower-risk patients, high-risk patients had higher inpatient mortality (3.8% vs 0.8%, P < 0.001) and morbidity (71.8% vs 35.7%, P < 0.001). They also had longer LOS (8.5 vs 5.3 days, P < 0.001) and higher charges ($122,635 vs $81,984, P < 0.001). In adjusted models, high-risk comorbidities independently predicted mortality (OR 3.80, 95% CI 3.66-3.94) and morbidity (OR 3.22, 95% CI 3.18-3.26). LC was the strongest predictor of mortality (OR 4.53), while CHF was most associated with morbidity (OR 2.84). Predictive models showed good discrimination (AUC 0.76 for mortality; 0.73 for morbidity). CONCLUSIONS: High-risk comorbidities are present in nearly one-quarter of ERCP admissions and strongly predict worse inpatient outcomes. Most adverse events are likely driven by underlying illness rather than ERCP-specific complications. Our validated predictive models may inform counseling, triage, and peri-procedural management.
BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary liver tumor. Despite efforts to mitigate risk factors and implement surveillance programs in high-risk populations, such as screening, these strategie...BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary liver tumor. Despite efforts to mitigate risk factors and implement surveillance programs in high-risk populations, such as screening, these strategies alone appear insufficient to significantly improve prognosis at diagnosis. The identification of novel prognostic factors remains an underdeveloped field that may play a key role in guiding optimal therapeutic decisions from the initial stages of patient management. AIMS: To develop a machine-learning prognostic model to compare the prognostic performance of different MELD-based scores at the time of HCC diagnosis and to assess their relative clinical applicability in comparison with established prognostic staging systems. METHODS: A multicenter retrospective analysis including 219 patients with HCC was performed. For MELD-based score comparisons and model development, 216 patients with complete MELD, MELD-Na, and MELD 3.0 data constituted the analytic cohort. Clinical and diagnostic variables were analyzed using machine-learning approaches. RESULTS: In the analytic cohort, 148 all-cause deaths occurred during follow-up. Among the MELD-derived models, MELD 3.0 showed higher discrimination than MELD and MELD-Na. EXtreme Gradient Boosting (XGB) algorithm achieved the best overall performance and calibration (AUC 0.94, Brier score 0.13, calibration slope 1.02, CITL 0.03). A parsimonious reduced-feature XGB model including TNM stage, MELD 3.0, ECOG-PS, ALP, and AFP retained most of the discriminatory performance of the full model (AUC 0.91). CONCLUSIONS: These findings suggest that updated MELD-based scores, particularly MELD 3.0, may provide complementary prognostic information at the time of HCC diagnosis. The XGB-based model may represent a feasible tool for exploratory prognostic modeling and may support more precise risk stratification and personalized, data-driven therapeutic decisions in patients with HCC. Further validation in larger, prospective cohorts is warranted before clinical implementation.
BACKGROUND: Acute pancreatitis (AP) is a severe inflammatory disorder characterized by pancreatic acinar cell injury, with ferroptosis, a form of iron-dependent lipid peroxidation-driven cell death, playing a key role in...BACKGROUND: Acute pancreatitis (AP) is a severe inflammatory disorder characterized by pancreatic acinar cell injury, with ferroptosis, a form of iron-dependent lipid peroxidation-driven cell death, playing a key role in disease progression. However, the molecular mechanisms of ferroptosis regulation in AP remain unclear. SRY-related HMG-box 4 (SOX4) has been implicated in ferroptosis regulation in other pathological conditions, but its role in AP has not been fully elucidated. METHODS: In this study, I used caerulein (Cae)-induced primary mouse pancreatic acinar cells as an AP model in vitro, with ferroptosis inhibitor ferrostatin-1 (Fer-1) treatment to assess ferroptotic involvement. I further manipulated SOX4 expression via shRNA-mediated knockdown, and its downstream effects on ferroptosis-related markers were evaluated by qPCR, WB, and lipid peroxidation assays. I also performed chromatin immunoprecipitation (ChIP) and dual-luciferase reporter assays to determine whether SOX4 directly regulates Lysophosphatidylcholine Acyltransferase 3 (LPCAT3), a key enzyme in ferroptosis modulation. RESULTS: I found that SOX4 expression was upregulated in Cae-induced AP cells, correlating with increased ferroptotic markers, including elevated lipid ROS, MDA, and Fe⁺ levels, and corresponding expression changes of ferroptosis-related proteins. SOX4 knockdown mitigated ferroptosis and improved cell viability. Further analysis revealed that SOX4 binds to the promoter region of LPCAT3 and enhances its transcription. Overexpression of LPCAT3 partially reversed the protective effects of SOX4 silencing. CONCLUSION: This study identifies SOX4 as a key regulator of ferroptosis in AP through transcriptional upregulation of LPCAT3. Targeting the SOX4-LPCAT3 axis may represent an advanced therapeutic strategy for mitigating pancreatic injury in AP.
BACKGROUND: Previous investigations demonstrated significant upregulation of ATP-binding cassette subfamily G member 2 (ABCG2) in renal, hepatic, colonic, and intestinal tissues within a 2,4,6-trinitrobenzenesulfonic aci...BACKGROUND: Previous investigations demonstrated significant upregulation of ATP-binding cassette subfamily G member 2 (ABCG2) in renal, hepatic, colonic, and intestinal tissues within a 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced murine model of Crohn's disease (CD). Nevertheless, the regulatory mechanisms governing ABCG2 expression within inflammatory microenvironments and its consequent impact on intestinal barrier integrity remain incompletely elucidated. AIMS: This study aimed to elucidate the signaling pathway responsible for ABCG2 upregulation under inflammatory conditions and to investigate the functional role of ABCG2 in intestinal barrier integrity both in vitro and in vivo. METHODS: Intestinal epithelial barrier integrity was evaluated by measuring transepithelial electrical resistance (TEER), paracellular permeability to fluorescein isothiocyanate (FITC)-dextran, and immunofluorescence/immunoblot analysis of tight junction proteins. Abcg2 mice were utilized to evaluate the contribution of ABCG2 to intestinal barrier homeostasis. RESULTS: ABCG2 expression was observed to be significantly elevated in lipopolysaccharide (LPS)-stimulated intestinal epithelial cells. This induction coincided with enhanced phosphorylation of AKT and P65. Pharmacological inhibition of AKT (LY294002) or NF-κB (BAY117082) attenuated the LPS-mediated upregulation of ABCG2. Functional assessments revealed that pharmacological inhibition of ABCG2 (using Ko143) or its genetic ablation enhanced intestinal barrier integrity. This was evidenced by increased TEER, reduced permeability to FITC-dextran, and restored expression of key tight junction proteins (ZO-1, occludin, and claudin-1) following LPS challenge. Specifically, Abcg2 knockout improved colon length, preserved mucosal architectural integrity, and diminished inflammatory cell infiltration in both dextran sulfate sodium (DSS)-UC and TNBS-induced CD models. CONCLUSIONS: ABCG2 reprents a promising therapeutic target for inflammatory bowel disease (IBD), particularly in patient populations exhibiting dysregulated transporter activity or genetic variants influencing drug response.
BACKGROUND: Choledocholithiasis (CDL) is a common indication for endoscopic retrograde cholangiopancreatography (ERCP). While guidelines use static hepatic biomarker values to estimate pre-test probability, the utility o...BACKGROUND: Choledocholithiasis (CDL) is a common indication for endoscopic retrograde cholangiopancreatography (ERCP). While guidelines use static hepatic biomarker values to estimate pre-test probability, the utility of trending these labs (bilirubin and alkaline phosphatase [ALP]) is unclear. It is unknown if improving biomarker trends reliably indicate stone passage and can help avoid unnecessary procedures. OBJECTIVE: To evaluate whether serial trends in hepatic biomarkers prior to ERCP can predict the presence of suspected CDL in hospitalized patients and guide decisions on ERCP referral. METHODS: We conducted a retrospective study of 198 patients undergoing ERCP for suspected CDL from 2002 to 2018. Patients were categorized based on biomarker trends, primarily into: Group 1 (normalized bilirubin with normalized ALP or ALP falling ≥ 50%) and Group 2 (all other patients). The primary outcome was the diagnostic yield of CDL on ERCP. RESULTS: Among 198 patients, the yield of choledocholithiasis was not significantly different between Group 1 (69.5%) and Group 2 (71.2%) (p = 0.83). Even when redefining Group 1 as patients with "entirely normal hepatic biomarkers," the yield for stones was 55%. The diagnostic accuracy of the final lab values was poor, with an area under the curve of 0.57 for bilirubin and 0.51 for ALP. Patients in Group 1 had a significantly higher rate of post-ERCP pancreatitis (8.5% vs. 0%, p = 0.012) and a lower risk of septic shock. CONCLUSIONS: Normalization or decline in hepatic biomarkers, such as bilirubin and ALP, does not reliably exclude CDL. Over half of the patients with normalized biomarkers were still found to have stones on ERCP. ERCP should be considered when suspicion remains high, regardless of laboratory trends.
BACKGROUND AND AIMS: Despite significant morbidity and mortality, patients with cirrhosis are infrequently referred to palliative care (PC). We developed a hepatology-PC collaborative care program to improve access to PC...BACKGROUND AND AIMS: Despite significant morbidity and mortality, patients with cirrhosis are infrequently referred to palliative care (PC). We developed a hepatology-PC collaborative care program to improve access to PC and quality of care for patients with cirrhosis. METHODS: This mixed methods cohort study included adult patients with cirrhosis who were referred to outpatient PC between 2021 and 2023. Rates of advance care planning (ACP) and health care utilization six months before and after PC program initiation were compared. Clinicians participated in a focus group and completed a survey to provide feedback on the program. RESULTS: A total of 41 patients (44% female, median age 61) were seen by both hepatology and PC teams. A PC physician, nurse, social worker, and/or spiritual care provider addressed non-pain symptoms (81%), ACP (68%), mood (63%), pain (59%), family/caregiver support (34%), social needs (24%), and spiritual concerns (15%). With PC, patients had increased ACP note completion (34% vs. 95%, p < 0.001), surrogate decision maker identification (46% vs. 83%, p < 0.001), and code status documentation (64% vs. 78%, p = 0.03). There were no differences in rates of non-elective hospitalizations or emergency department visits from six months before to six months after PC initiation. In a survey of clinicians who participated in the program (n = 11), all clinicians recommended continuing the co-management program and for other health systems to develop similar collaborations. CONCLUSIONS: Hepatology-PC co-management is feasible and positively received by hepatology and PC clinicians alike. Outpatient PC addresses needs in multiple domains for patients and caregivers and is associated with increased rates of ACP.