Introduction

Artificial intelligence (AI) algorithms aid endoscopists in detecting and characterizing colonic polyps in clinical practise and lead to an improved adenoma detection rate. AI may also support therapeutic procedures by detecting and marking anatomical structures during complex procedures like endoscopic submucosal dissection (ESD) ¹. However, a possible effect of AI on the intraprocedural blood vessel detection rate during third space endoscopy remains unclear.

Aims & Methods

This study aimed at evaluating the impact of a newly developped AI algorithm for real time intraprocedural vessel detection on the vessel detection performance of endoscopists during ESD. To this end, 5470 single images from 59 full length third space endsocopy videos were annotated for submucosal blood vessels. Together with 179681 additional unlabeled images this dataset was utilized for the training of a DeepLabV3+ neural network. The trained algorithm detected and marked submucosal blood vessels on the endoscopic image in real time. Consequently, a video test consisting of 101 video clips with 200 predefined blood vessels was used for the evaluation of the algorithm alone, as well as 19 endoscopists with and without AI support.

Results

The algorithm showed a vessel detection rate (VDR) of 93.5% and a median vessel detection time (VDT) of 0.3 sec. AI support was associated with an elevation of endoscopists‘ VDR from 56.4% to 72.4% (p<0.001). VDT decreased from 6.7 to 5.2 sec with AI support (p<0.001). False positive detections were measured on 4.5% of single frames. They had a significantly shorter duration than true positive findings (0.7 vs. 6.0 sec, p<0.001).

Conclusion

AI support led to increased VDR and reduced VDT of endoscopists. False positive findings were easily distinguishable from true positives by their short duration. Future research may elucidate a possible effect of AI on clinical parameters like intraprocedural complication rates or procedure times.

References

1. Ebigbo A, Mendel R, Scheppach MW, et al. Vessel and tissue recognition during third-space endoscopy using a deep learning algorithm. Gut 2022.

Introduction

Informed consent (IC) serves as the ethical foundation for all medical interventions, empowering patients to make informed, autonomous decisions while safeguarding clinicians. Barriers such as limited health literacy and document complexity may hinder comprehension^1,2. This study evaluated the comprehensibility, readability, and effectiveness of the documents provided for IC and instructions for endoscopic procedures.

Aims & Methods

Outpatients undergoing endoscopic procedures completed a questionnaire assessing their understanding of IC, preparation instructions, and adherence to guidelines. Patient confidence and document comprehensibility were assessed through self-reported scales. Readability was assessed using Flesch Reading Ease score adapted for portuguese (FRE-PT)³.

Results

Among 186 participants (mean age: 58.1 ± 16.1 years), 76.9% reported full-extent reading of the provided instructions and IC document. Patients with primary education (≤4th grade) were less likely to read the documents fully (59.2% vs. 83.2%, p < 0.001) and were independently associated with the need for additional assistance (OR 5.65, 95% CI: 1.92 - 16.68, p = 0.002). Full-extent reading was independently associated with greater risk awareness (OR 5.52, 95% CI: 2.37 - 11.55, p < 0.001), reduced need for additional assistance (OR 0.22, 95% CI: 0.09 - 0.51, p < 0.001), and higher compliance with medication guidelines (75.7% vs. 45.8%, OR 3.42, 95% CI: 1.28 - 9.20, p = 0.015). Patients with primary education rated document’s comprehensibility lower (median:8, IQR 7-10) compared to those with higher education (median: 10, IQR 8 - 10, p < 0.001) and reported lower levels of confidence and preparation for the procedure (median: 8, IQR 7 - 10 vs. median: 9, IQR 8 - 10; p = 0.018). Outcomes did not differ significantly between patients aged 65 years or older compared to younger patients. FRE-PT scores classified readability as ‘’very difficult’’ for both upper endoscopy (20.87) and colonoscopy (26.00).

Conclusion

Full-extent reading IC and instruction documents reduces the need for assistance, improves compliance with pre-procedural measures, risk awareness and patient confidence. However, the document’s complexity and difficult readability disproportionately challenge and discourage patients with limited education. Future research should explore strategies to foster more equitable informed decision-making.

References

1. Protheroe J, Rowlands G. Matching clinical information with levels of patient health literacy. Nurs Manag (Harrow). 2013;20(3):20-21. doi:10.7748/nm2013.06.20.3.20.e1095
2. Ley R, Forio T. The use of readability formulas in health care. Psychol Health Med. 1996;1(1):7-28.
3. Martins TBF, Ghiraldelo CM, Nunes MGV, Oliveira Junior ON. Readability formulas applied to textbooks in Brazilian Portuguese. 1996.

Introduction

Metabolic associated steatosis liver disease (MASLD) is the new nomenclature of non-alcoholic fatty liver diseases (NAFLD) which highlights its crucial effect on the cardiometabolic risk factors that lead to the development and progression to liver diseases. Recently SGLT2 inhibitors have been identified to reduce hepatic steatosis in patients with T2DM with MASLD

Aims & Methods

Our aim was to assess the effect of SGLT2 inhibitors on hepatic steatosis in patients with T2DM and MASLD, we enrolled 30 diabetic adults with hepatic steatosis on ultrasound confirmed and quantified by baseline magnetic resonance proton density fat fraction (MRI-PDFF) they started SGLT2 inhibitors added to the standard of care treatment for 6 months and assessment of the percentage change of hepatic steatosis with done by repeat MR-PDFF.

Results

There were statistically significant decreases in the mean body weight and BMI after treatment (86.7Kg, 33.313 Kg/m²) respectively compared to their levels before treatment (90.367kg, 35.144 Kg/m²) respectively, P <0.001. Moreover, the mean serum fasting blood sugar and alanine transaminase decreased significantly after treatment (209.267, 22.633) compared to levels before treatment (220.566, 28.03) (P= 0.017, P=0.03) respectively. Regarding hepatic steatosis there was a statistically significant decrease in the mean MRI-PDFF measurement for hepatic steatosis after treatment (13.297 ±7.15) compared to the mean levels before treatment (15.288 ± 8.72) with a mean difference (-1.9911, P = 0.006) of about 13.16% decrease of steatosis

Conclusion

Addition of SGLT2 inhibitors to the standard treatment in type 2 diabetic patients with MASLD could reduce the hepatic steatosis significantly after 6 months of treatment associated with decrease in body weight, BMI, fasting blood sugar. Thus, the therapeutic use of SGLT2 inhibitors is valuable in type 2 diabetic patients associated with MASLD

Clinical Case Summary

Introduction: Inflammatory bowel disease (IBD) is linked to cutaneous manifestations in 10% of cases. Neutrophilic dermatoses represent a diagnostic and management challenge, as it requires a dual-targeted treatment approach.
Clinical Case: We present a 67-year-old man with A3L1B1 Crohn’s disease (CD) followed in our IBD consultation. His medical history included previous tobacco abuse, hypertension, type 2 diabetes and ischemic cardiopathy with heart failure. He was medicated for his comorbidities and had been treated with budesonide.
Due to evidence of disease progression, increased fecal calprotectin (FC) at 751ug/g and a history of invasive pulmonary aspergillosis, vedolizumab was initiated.
The patient presented with recurrent erythematous, tender, nodular lesions on the abdomen, limbs and face. Dermatological consultation and cutaneous biopsies led to an initial misdiagnosis of infectious panniculitis, as methicillin sensitive Staphylococcus aureus (MSSA) was isolated and the lesions regressed with antibiotics.
Two months later, cutaneous lesions reappeared and histopathology confirmed IBD-associated erythema nodosum-like neutrophilic dermatosis with MSSA isolation. A 10-week doxycycline course induced their regression. However, recurrence transpired 5 months later, associated with an increased FC (816ug/g).
A swap for ustekinumab (UST) resulted only in transient clinical and biochemical improvement (FC 324ug/g). Despite dose escalation to every 4 weeks, nodular/papular lesions with central postulation recently reappeared, prompting initiation of daptomycin with a potential swap to another drug class.
Conclusions: IBD can be associated with neutrophilic dermatoses and its diagnosis can be challenging. This case reports an CD-associated erythema nodosum-like neutrophilic dermatosis, underscoring its complex approach and management.
Note: We are submitting this case with iconography as it underscores a rare IBD manifestation.

References

Photographs of cutaneous lesions (3-4)

Clinical Case Summary

Introduction: Ustekinumab (UST), a human interleukin-12/23 monoclonal antibody, is approved for the treatment of moderate to severe Crohn’s disease (CD) and ulcerative colitis (UC). Some patients may lose response to standard maintenance therapy. Optimization strategies, such as dose escalation and intravenous (IV) re-induction, have been explored in CD, but scarcely studied in UC.
Clinical Case: A 61-year-old woman, with grade III obesity, hypertension, and peripheral venous insufficiency, diagnosed with UC and associated peripheral arthropathy, was initially treated with high-dose corticosteroids (CTS) for a severe exacerbation. She developed CTS dependence and suffered an osteoporotic fracture.
A combined therapy with methotrexate and an accelerated infliximab (IFX) induction regimen was initiated, but a severe exacerbation occurred after the second induction dose. Despite an early third dose, clinical, biochemical and endoscopic (Mayo score 3) activity persisted.
The patient was swapped to UST with maintenance therapy every 4 weeks. After IV infusion, free-CTS clinical and biochemical (fecal calprotectin (FC) <10 ug/g) remission were achieved, but, over time, there was a loss of response, with a FC 4817 ug/g.
Given the initial positive response to IV UST infusion and insights from CD studies, a 520mg IV UST re-induction followed by 4-week maintenance dose was administered. Eight months later, the patient remains in free-CTS clinical remission, with improved arthralgia, biochemical remission (FC 80 ug/g) and endoscopic response.
Conclusions: This case highlights the potential efficacy of IV UST re-induction in recapturing remission in refractory UC. While recognized in CD, UST re-induction may prove beneficial for UC patients with loss of response to standard UST therapy, serving as an alternative before swapping. Further exploration through randomized, multicenter studies is crucial to assess the efficacy and safety of this strategy in UC patients.

Clinical Case Summary

Introduction: Ulcerative colitis (UC) is a chronic inflammatory disease characterized by remitting and relapsing patterns, necessitating multifaceted therapeutic interventions, among which mesalazine, or 5-aminosalicylic acid (5-ASA), is prominently utilized. Despite its typically favorable tolerability profile, mesalazine may occasionally precipitate severe adverse events, such as myocarditis.
Case presentation: A 46-year-old male recently diagnosed with UC presented with a moderate UC flare-up and was initiated on 5-ASA therapy upon admission.
Within a span of two days following initiation of oral therapy, he developed acute chest pain, palpitations, dyspnea, and desaturation, necessitating intensive care due to cardiogenic shock.
Paraclinical assessments revealed elevated troponin levels, along with electrocardiographic and echocardiographic abnormalities, including left ventricular dysfunction and reduced ejection fraction.
Discontinuation of mesalazine resulted in symptom improvement and reduction of cardiac markers. Subsequent evaluations demonstrated a recovery in cardiac function, establishing a causal relationship between myocarditis and the administration of 5-ASA. Consequently, a therapeutic switch to mercaptopurine was instituted.
Conclusion: This case underscores the infrequent yet significant hazard of mesalazine-triggered myocarditis, emphasizing the critical necessity for vigilant patient monitoring during this therapy and prompt consideration of alternative therapeutic options in the presence of severe cardiac complications.

Introduction

High-risk human papillomavirus (hr-HPV) has been associated with a subset of Barrett’s dysplasia (BD) and oesophageal adenocarcinoma (OAC).^1,2,3,4 The L1 major capsid protein has been closely linked to disease regression and is a prognostic factor in HPV driven cancers of the cervix and anus.​^5,6​​​​ The progression of cervical intraepithelial neoplasia to invasive cancer is accompanied by a loss of viral L1 capsid protein expression.

Aims & Methods

Thus, in a retrospective, cross-sectional study, we investigated L1 protein expression in HPV-positive patients representing the oesophageal squamous (controls) [Group1]-Barrett’s metaplasia [Group 2]-low-grade dysplasia [Group 3]-high-grade dysplasia [Group 4]-adenocarcinoma [Group 5] sequence. L1 protein immuno-histochemical staining was correlated with p16 overexpression and E6/E7 mRNA in-situ hybridization. The association between the 5 patient groupings and L1 expression was analysed using the Chi-square test. Multivariable logistic regression was undertaken to investigate the above association with adjustment of potential confounders (age, gender, BMI, ever smoked and excess alcohol). Adjusted odds ratio (95% CI) was calculated.​​​​​

Results

^​​​​​​Of 116 HPV DNA-positive patients [(age range: 19-90, mean (SD), 63.2 (13.5)], 88 males and 28 females), 73 (62.9%) were genotype 16, 37 (31.9%) genotype 18 and 6 (5.2%) were genotype 6. L1 nuclear staining was observed in 64 individuals. L1 expression was detected in 84.9% (28/33) of controls; 94.1% (16/17) of BO patients; 50% (7/14) of LGD subjects; 38.1% (8/21) of HGD individuals and 16.1% (5/31) of OAC patients; [adjusted P < 0.0001]. Conversely, p16 was present in 9.1% (3/33) of controls, 17.7% of BO (3/17), 57.1% (8/14) in LGD individuals, 61.9% (13/21) of HGD patients and 64.5% (20/31) of OAC subjects [p<0.0001]. Corresponding figures for E6/E7 mRNA positivity was 6.1% (2/33), 23.5% (4/17), 28.6% (4/14), 38.1% (8/21) and 45.2% (14/31) respectively [p=0.008]. Expression of HPV-L1 and p16 or L1 and E6/E7 mRNA was largely mutually exclusive.

Conclusion

HPV L1 capsid expression is incrementally lost with increasing oesophageal disease severity as in viral driven anal and cervical lesions. Utility of L1 alone or in combination with p16/E6/E7 mRNA in stratifying HPV-positive oesophageal lesions for treatment should be further explored.

References

1. Rajendra S, Wang B, Snow ET, et al. Transcriptionally active human papillomavirus is strongly associated with Barrett’s dysplasia and esophageal adenocarcinoma. Am J Gastroenterol 2013;108:1082–1093.
2. Rajendra S, Yang T, Xuan W, et al. Active human papillomavirus involvement in Barrett's dysplasia and oesophageal adenocarcinoma is characterized by wild-type p53 and aberrations of the retinoblastoma protein pathway. Int J Cancer. 2017;141(10):2037-2049.
3. Li X, Gao C, Yang Y, et al. Systematic review with meta-analysis: the association between human papillomavirus infection and oesophageal cancer. Aliment Pharmacol Ther. 2014;39(3):270-281.
4. Rajendra, S., W. Xuan, N. Merrett, et al. Survival Rates for Patients With Barrett High-grade Dysplasia and Esophageal Adenocarcinoma With or Without Human Papillomavirus Infection. JAMA Netw Open. 2018; 1: e181054.
5. Choi YS, Kang WD, Kim SM, et al. Human papillomavirus L1 capsid protein and human papillomavirus type 16 as prognostic markers in cervical intraepithelial neoplasia 1. Int J Gynecol Cancer 2010;20(2):288-293.
6. Hernandez J, Elahi A, Siegel E, Coppola D, Riggs B, Shibata D. HPV L1 capsid protein detection and progression of anal squamous neoplasia Am J Clin Pathol 2011; 135: 436-41.

Disclosure

None