Introduction

The best risk-stratification strategy to predict liver-related outcomes (LROs) in the population remains unclear. The Chronic Liver Disease (CLivD) risk score was recently developed and validated to predict LROs in the population. It could thus identify the at-risk population that warrants liver fibrosis screening with non-invasive tests such as FIB-4. The ClivD score is based on age, sex, waist-hip ratio, alcohol use, smoking, diabetes, and gamma-glutamyltransferase measurement.

Aims & Methods

We investigated the combined/sequential use of the ClivD score and FIB-4 for stratifying the risk for LROs in the UK Biobank population.
From the UK Biobank data, we identified 362,330 individuals with no baseline liver disease and data available to calculate the CLivD score and FIB-4. LROs were ascertained through linkage with electronic healthcare registries for hospitalizations, cancers, and deaths related to compensated or decompensated liver cirrhosis or hepatocellular carcinoma. Discrimination performance was assessed by 10-year competing-risk area-under-the-curve (AUC) values and absolute cumulative risks by the cumulative incidence functions considering death without liver disease as a competing-risk event.

Results

Mean age was 56.6 years (SD 8.1), 48% were men, mean BMI 27.2 kg/m2 (SD 4.6), 5% had diabetes, mean alcohol intake was 16.7 g/week (SD 16.6), and 10% were current smokers.
During a median follow-up of 12.6 years (IQR 12.0-13.4), there were 1285 incident LROs. Both the CLivD score and FIB-4 were significantly associated with LROs (P<0.001). The 10-year AUC-value of the CLivD score was 0.80 (95% CI 0.80-0.80) and of FIB-4, 0.75 (95% CI 0.75-0.75) for the prediction of LROs. The predictive performance of FIB-4 improved as a function of increasing CLivD scores: 10-year AUC values of FIB-4 were 0.61 in the minimal-risk CLivD subgroup as compared to 0.81 in the high-risk CLivD subgroup (Table). This effect modification of CLivD for FIB-4’s discrimination performance was also evident for absolute risks. Namely, within the minimal-risk CLivD subgroup, 10-year cumulative incidences of LROs ranged from 0.05% to 0.3% between low and high FIB-4 strata (Table). In contrast, within the high-risk CLivD subgroup, 10-year cumulative incidences of LROs ranged from 1.7% to 21.6% between low and high FIB-4 strata.

Conclusion

Defining the at-risk population by the CLivD score markedly improves the predictive performance of FIB-4. Thus, sequential use of the CLivD score and FIB-4 emerges as a simple way to stratify the population regarding the risk for LRO.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently employed procedure for diagnosing and treating pancreaticobiliary diseases. The selection of an appropriate sedative agent is crucial for ensuring patient comfort and procedural success. An optimal sedative should offer a predictable duration of action and a high safety profile. This study aimed to compare the efficacy and safety of remimazolam and propofol in patients undergoing ERCP procedures.

Aims & Methods

A randomized, single-blind, single center study was conducted comparing remimazolam and propofol for inpatient ERCP sedation. The study medications were administered under the supervision of the endoscopist. A total of 110 patients scheduled for ERCP were randomly assigned to receive either remimazolam or propofol. The primary endpoint was a composite of successful procedure completion and no requirement for rescue medication. Secondary endpoints included sedation efficacy, recovery time, and adverse events.

Results

Of the 110 patients randomized, 108 underwent sedation and ERCP (53 received remimazolam, 55 propofol). The primary endpoint was achieved for 100% of patients in both groups. The incidence and frequency of treatment-emergent adverse events, including desaturation, were comparable between the two groups. ERCP initiation occurred sooner in the propofol group (mean, 63.18 ± 16.56 seconds) compared to the remimazolam group (75.23 ± 32.27 seconds; p-value=0.02). Additionally, the time to full alertness after ERCP completion was significantly shorter in the propofol group than the remimazolam group (304.18 ± 146.25 vs. 448.34 ± 224.09 seconds; p-value<0.001).

Conclusion

This trial demonstrated non-inferiority of remimazolam to propofol in achieving the primary endpoint of successful ERCP completion without the need for rescue medication. The incidence and frequency of adverse events were comparable between the two groups. However, our study also revealed that propofol had a faster onset and recovery time compared to remimazolam. Although this difference may not be clinically significant, it could have practical implications in certain cases. Consequently, remimazolam can be considered a safe and effective alternative to propofol for ERCP sedation, potentially expanding clinicians’ options and improving patient outcomes. Further research is warranted to determine the optimal choice of sedative agents for various patient populations and procedures.

Introduction

Dietary animal protein effect on gastric cancer (GC) taking Helicobacter pylori status into account has rarely been reported and has therefore been investigated in this study.

Aims & Methods

GC patients and healthy subjects were prospectively registered by 6 hospitals from October 2016 to December 2018. Multivariate analysis adjusted for many epidemiological factors (Model I) and additionally H. pylori (Model II) was conducted to investigate dietary protein effect on GC. Dietary animal protein groups included red meat, processed meat, white meat, eggs, and fishes.

Results

A total of 5,535 subjects (1,629 GCs) were enrolled. In Model I, red meat, fish, and eggs showed non-linear associations. Two serving/week for red meat, 1 serving/week for fish, 2-3 serving /week for egg was associated with the lowest risk of GC. Both low (aOR, 1.33) and high intake (aOR, 1.49) of red meat were associated with increased risk of GC. Both low (aOR, 1.76) and high intake (aOR, 1.74) of fish were associated with increased risk of GC. Both low (aOR, 3.07) and high intake (aOR, 1.33) of egg were associated with increased risk of GC. High intake of processed meat was associated with GC (adjusted odd ratio [aOR], 1.78; 95% CI, 1.27-2.49). Frequent intake of white meat was associated with GC risk (aOR, 1.67 for 1 serving/week, 2.15 for 2 servings/week, and 4.16 for ≥3 servings/week). In model II, these non-linear or positive association were sustained. Sub-analysis by sex showed similar association in both men and women.

Conclusion

Dietary animal proteins had non-linear or positive association with GC after adjusted for H. pylori. Nonlinear relationships of some food groups with GC suggests modest intake of such foods may reduce GC risk.

Disclosure

No COI

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc