Introduction

Psychological therapies have been shown to be effective for treatment of patients with disorders of gut-brain interaction like irritable bowel syndrome (IBS). However, these therapies are time and personnel demanding which limits the access to this therapeutic option for many patients. Virtual reality (VR) creates an immersive environment where psychological interventions can be self-administered by the patient at home, thereby facilitating the access of these interventions to a large number of patients with minimal costs.

Aims & Methods

Our aim was to evaluate the effect of a psychological intervention delivered using VR on digestive symptoms in patients with IBS. Thirty-six patients with IBS (mean age 42±2 years, 89 % female) were randomized to receive a VR-based psychological intervention or placebo, using a randomized, single blind, parallel study design. The psychological intervention consisted in a 6-week program that started with a session of psychoeducation using a specifically created VR-video, followed by weekly sessions of group psychotherapy applied on-line by a psychologist. During the 6 treatment weeks, patients were asked to perform 15-30-min VR-sessions at home every day following a pre-designed protocol that incorporated progressive psychological interventions using VR-videos developed by a specialized company (XRHealth, Massachusetts, USA). The placebo group took a pill containing 0.3 g of glucose once daily. The primary outcome was the improvement of gastrointestinal symptoms (assessed by IBS-SSS) at the end of the intervention (6 weeks). Secondary outcomes included psychological comorbidities using the HADS (Hospital Anxiety and Depression Scale) and PSS (Perceived Stress Scale) questionnaires.

Results

Twenty-one patients were randomized to VR and fifteen patients to placebo. After 6 weeks of treatment, patients receiving the psychological intervention had a significantly greater reduction in IBS-SSS scores (score change -39±12) compared to patients on placebo (score change 1±19; p= 0.009). When analyzing the specific symptoms, abdominal pain had a significant reduction after psychological intervention (score reduction -8±3; p=0.015) and a tendency was identified for abdominal bloating (score reduction -6±5; p=0.097). Both symptoms remained unchanged after placebo (score change 1±6; p=0.719 and -0±6; p=0.695, pain and distension, respectively).
In addition, psychological intervention was followed by a greater improvement than placebo in HADS scores for anxiety (score change -2.35 ± 0.56; p=0.041 vs score change 0.00 ± 0.85 after placebo) and depression (score change -1.40± 0.71; p=0.005 vs score change 1.36 ± 0.50 after placebo). Stress evaluation using PSS also showed a greater reduction in stress perception in patients on psychological intervention (score change -5.15 ± 1.50) compared with patients on placebo 0.07 ± 1.35 (p=0.023).

Conclusion

A psychological intervention delivered at home using virtual reality is superior to placebo in relieving IBS symptoms, an effect that is associated to a reduction in anxiety, depression and stress in patients with IBS. These findings open the door to development of treatments in patients own home, and should facilitate the access to these treatments in large populations of patients. NTC06318572

Disclosure

No potential conflict of interest of any author

Introduction

The available evidence on the epidemiology of acute pancreatitis (AP) is primarily based on older studies conducted in other countries, limiting its applicability to local settings. This study aims to provide updated data on the clinical characteristics and outcomes of patients with AP in our region thereby improving understanding and management of the disease.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis (AP), consecutively included between March 2017 and June 2019 at a tertiary care hospital. Systematic laboratory testing was performed at admission and again at 48 hours. Clinical management followed standard practice guidelines, including routine abdominal ultrasound after admission and abdominal CT scan in cases of diagnostic uncertainty, clinical deterioration, or lack of improvement. Diagnosis and classification were based on the revised 2012 Atlanta classification.

Results

The most frequent etiology of AP in our setting was biliary lithiasis (65.9%), followed by idiopathic (15.4%) and alcohol-related causes (8.4%). Severe AP accounted for 9% of cases, while 14.3% were classified as moderately severe. Up to 20.2% of patients developed local complications; however, only 4.9% presented with pancreatic necrosis. SIRS was observed in 18.7% of patients at admission, decreasing to 8.7% at 48 hours. Only 3.7% of patients required ICU admission (Table 1). Factors such as smoking, ERCP, antibiotic therapy, acute cholangitis, and SIRS showed significant differences across different etiological groups.

Conclusion

Acute pancreatitis (AP) is a common condition that imposes a significant healthcare burden. Determining the etiology of AP at admission is important not only from an epidemiological standpoint but also due to its profound implications for patient prognosis.
Contrary to what has been reported in the literature, the second most frequent cause of AP in our cohort was idiopathic, surpassing alcohol-related cases. In line with other studies, we observed significant differences between biliary and alcohol-related etiologies regarding smoking habits, development of acute cholangitis, need for ERCP, and use of antibiotic therapy. Patients with alcohol-related AP were significantly more likely to present with SIRS at admission. However, we did not find statistically significant differences in other key clinical outcomes, although patients with alcohol-related AP appeared to have a higher, but not statistically significant, risk of developing local complications, pancreatic necrosis, and SIRS at 48 hours.
This study highlights the importance of tailoring management strategies according to etiology to optimize clinical outcomes.

References

1. Wang, G. J., Gao, C. F., Wei, D., Wang, C., & Ding, S. Q. (2009). Acute pancreatitis: etiology and common pathogenesis. World journal of gastroenterology, 15(12), 1427–1430.
2. Petrov, M. S., & Yadav, D. (2019). Global epidemiology and holistic prevention of pancreatitis. Nature reviews. Gastroenterology & hepatology, 16(3), 175–184.
3. Iannuzzi, J. P., King, J. A., Leong, J. H., Quan, J., Windsor, J. W., Tanyingoh, D., Coward, S., Forbes, N., Heitman, S. J., Shaheen, A. A., Swain, M., Buie, M., Underwood, F. E., & Kaplan, G. G. (2022). Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology, 162(1), 122–134.

Introduction

Oesophageal ulceration (OU) is a frequent finding at oesophago-gastro-duodenoscopy (OGD). Despite limited data on the benefit of a repeat endoscopy, current guidelines recommend a follow-up OGD after six weeks to exclude underlying malignancy¹.

Aims & Methods

Aims: We aimed to explore the utility of a follow-up endoscopy after a diagnosis of oesophageal ulcer and identify predictors of oesophageal malignancy and dysplasia. Secondary aims were to estimate the environmental and financial impact of a follow-up endoscopy.
Methods: We collected demographic, endoscopy, and histology data from patients diagnosed with OU over a 5-year period (from 1^st January 2016 to 31^st December 2020 inclusive) at Leeds Teaching Hospitals NHS Trust. We collected data from the index OGD, follow-up OGD, and from their medical records up to 3 years after a diagnosis of OU at their index OGD. We examined the proportion of patients who were diagnosed with dysplasia or malignancy at follow-up or up to 3 years after their index OGD. Binary logistic regression was performed to identify predictors of oesophageal malignancy or dysplasia at index OGD, follow-up OGD, or 3 years after the index OGD. NHS national cost data for OGD, and carbon dioxide (CO2) emissions were estimated for all unnecessary follow-up OGDs^2,3.

Results

In total, 409 patients were diagnosed with OU. Of these, 33 patients were diagnosed with oesophageal cancer or dysplasia, with 30 diagnoses (90.9%) made at the index OGD and the remaining 3 (9.1%) at either the follow-up OGD or within 3 years of the index OGD. Of those 3 patients, one was diagnosed with oesophageal carcinoma, one with low grade dysplasia, and one with high grade dysplasia, all within a segment of Barrett’s oesophagus already diagnosed at the index OGD. Those who were diagnosed with oesophageal malignancy or dysplasia, compared to those who were not, were more likely to have larger ulcers (mean size (SD), mm, 15.9 (17.2) vs 9.50 (11.1), P = 0.003), endoscopic features suspicious for malignancy (69.7% vs 8.0%, P < 0.001), Barrett’s oesophagus (54.5% vs 14.4%, P < 0.001), and biopsies taken at index OGD (100% vs 64.1%, P < 0.001), and less likely to have a proton pump inhibitor prescribed (57.6% vs 86.4%, P < 0.001) after the index OGD. Following logistic regression controlling for all data, those with endoscopic features suspicious for malignancy (OR = 45.9; 95% CI 10.3 to 204) and those with Barrett’s oesophagus at index OGD (OR = 5.29; 95% CI 1.56 to 18.0) were more likely to be diagnosed with oesophageal cancer or dysplasia up to 3 years after the index OGD. A total of 376 unnecessary OGDs were undertaken over a 5-year period, the costs of which were estimated at £140, 248 and 10.6 tonnes of CO2 emissions.

Conclusion

Repeat OGD to exclude underlying malignancy following a diagnosis of oesophageal ulcer may only be required in those with endoscopic features suspicious for malignancy and those with Barrett’s oesophagus. Larger prospective multi-centre studies, with cost and carbon footprint analyses, are required to confirm our results and to inform guidelines.

References

1. Beg S. et al. (2017). Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS), Gut, 66(11):1886-1899. DOI: 10.1136/gutjnl-2017-314109
2. NHS (2023): National tariff payment system documents, annexes and supporting documents. Available at: https://www.england.nhs.uk/publication/national-tariff-payment-system-documents-annexes-and-supporting-documents/
3. Lacroute, J. et al. (2023), The carbon footprint of ambulatory gastrointestinal endoscopy, Endoscopy, 55(10): 918–926. DOI: 10.1055/a-2088-4062

Introduction

Accurate estimation of cancer risk in patients with Barrett’s esophagus (BE) and low-grade dysplasia (LGD) or indefinite for dysplasia (ID) is difficult, leading to potential under- and over-treatment. We aimed to evaluate the utility of machine learning (ML) and copy number alterations (CNAs) assessed by shallow whole genome sequencing (sWGS) on standard formalin-fixed paraffin-embedded (FFPE) samples for precise risk stratification in this group of BE patients.

Aims & Methods

We conducted a retrospective analysis on a cohort of 164 BE patients encompassing 990 tissue samples with sWGS (~0.4X) data from 2001-2018. These included 215 samples with LGD or ID from 64 patients, of which 38 progressed to high-grade dysplasia (HGD) or cancer at later timepoints (P), and 26 who did not progress (NP). CNAs were quantified using QDNASeq, and outlier bins were determined by Tukey's fences. Subsequently, the CNAs of 64 esophageal cancer driver genes were compared between P and NP groups using t-tests and ranked by p-values. A random forest (RF) ML model was developed on the CNAs of the 64 genes, employing nested 5-fold cross-validation split by patients and iterated 100 times to mitigate bias. The model's performance was compared against routine p53 immunohistochemistry (IHC), a decision tree that incorporates p53 followed by the ML model, and the current ESGE clinical guideline recommending treatment after LGD is identified in two endoscopies. Both the model and model+p53 were assessed across 100 test sets derived from the cross-validation. The guideline's performance was evaluated using a historical extended cohort comprising 253 LGD patients, of which 32 progressed, and underwent at least one surveillance endoscopy after LGD diagnosis and before HGD/cancer diagnosis. According to the guideline, two occurrences of LGD result in a positive prediction.

Results

Significant variance was observed in the distribution of relative CNAs across genomic bins between P- and NP-LGD/ID samples, with the proportions of outliers at 2.15% (95% CI: 1.88%, 2.42%) vs. 1.35% (95% CI: 1.26%, 1.44%). The most divergent genes included TP53, ABCB1, MET, BRAF, and SIN3A, exhibiting higher CNAs in progressed samples. Among the 215 samples, the RF model achieved an average sensitivity of 73.4% and specificity of 80.2%. Of these, 160 samples were tested for p53 IHC staining, where p53 alone showed a sensitivity of 22.1% and specificity of 100%, and a combined analysis of p53 and model increased the sensitivity of model alone (81.5% vs. 78.1%, p<0.001) while maintaining the same specificity at 78.9%. As a benchmark, the performance of the current ESGE guideline on biopsy diagnosed LGD patients demonstrated a sensitivity of 75.0% and specificity of 59.6%.

Conclusion

Our findings affirm the utility of ML and CNAs in predicting progression in BE patients with LGD or ID. Incorporating p53 followed by ML can further improve the performance. Molecular biomarkers would allow anticipation of intervention in high-risk cases and reduction of overtreatment in low-risk cases.

Disclosure

Nothing to disclosure.

Introduction

Irritable Bowel Syndrome (IBS) is a highly prevalent, chronic disorder of the Gut-brain interaction which forces increased demands of healthcare facilitations to manage these symptoms. Several treatment options are available, all with comparable clinical efficacy, such as pharmacotherapy, dietary treatment and psychotherapy. Therefore, the guidance of a physician during consultation is essential for effective decision-making. In our previous study, the most-preferred treatment among IBS patients was dietary intervention, subsequently pharmacotherapy and psychotherapy. The preferences of physicians remain unclear, but could be of major importance to give insight in the management strategy of different physicians and to compare with patients' perspective.

Aims & Methods

The aim of this study was to examine these treatment preferences among different types of physicians and evaluate if treatment wishes differ between subgroups of physicians.
Physicians from the Dutch Association of Specialists for Gastroenterology & Hepatology were invited to participate. A labeled discrete choice experiment (DCE) survey was filled in, containing twelve scenarios with each three alternatives (medication, diet, psychotherapy). Each scenario was accompanied by a patient profile differing in predominant symptom and anxiety symptoms. Five attributes were included in the treatment scenario: effectiveness, time until response, cessation of response following discontinuation of therapy, side effects and treatment burden. The preference weights were analyzed using a mixed logit model.

Results

In total, 52 physicians completed the discrete choice experiment (58% female). The majority of these respondents were gastroenterologists (51.9%), followed by gastroenterology trainees (34.7%). A small amount was general practitioner, pediatric gastroenterologist or gastroenterology nurse practitioner. The average work experience with treating IBS patients was 8.5 years (SD 3.5). The discrete choice experiment showed that the most-preferred treatment was pharmacotherapy, which was chosen in 39.71% of the cases. Dietary intervention was chosen 195 times (31.26%) and psychotherapy in 29.02% of the cases. Effectiveness, treatment burden and mild side effect were reported to be important treatment attributes.
Subgroup analysis regarding gender showed that male physicians preferred pharmacotherapy, while female physicians tend to prefer dietary treatment. Important attributes in female physicians were effectiveness, treatment burden, time to response, mild side effects and time until recurrence regarding psychotherapy. Male physicians reported effectiveness, time until recurrence regarding medication and diet and mild side effects, to be important in IBS treatment.

Conclusion

Pharmacotherapy was the most-preferred IBS therapy among physicians. Revealing physicians' preferences regarding the treatment of IBS raises awareness of the important treatment factors which can contribute to improved shared decision-making during consultation.