Introduction

There is evidence that suggests proton pump inhibitors (PPIs) are overprescribed across UK Primary Care Networks (PCNs) and that this places a high burden on the NHS¹. This study looked to implement a pilot system to support physicians in identifying inappropriate PPI therapy alongside promoting guideline-appropriate management². Previous data published from this study³ suggests that PPI overprescribing in English PCNs is prevalent with little evidence of structured follow-ups.

Aims & Methods

A system was designed and deployed in 62 surgeries across England, by Interface Clinical Services. Three deployment approaches were trialled: Tier (1) – data platform with resource materials, Tier (2) – Tier 1 and online support, Tier (3) – Tier 2 and pharmacist led mentorship supporting audit. The data platform uses data from the practice clinical system to assess prescribing practice. Patients were stratified according to demographics, PPI dosage, treatment duration and indication. To date, 80,218 patients have been identified of which 77,356 (96.4%) patients were eligible for consideration of PPI dose reduction or deprescribing.

Results

There were ~42,800 patient prescriptions reviewed in Tier 1&2 where it was assumed that 1666 (3.89%) patients were eligible for step down and 41,038 (95.83%) patients were eligible for step off. the remaining 0.28% were ineligible for step down or step off. In Tier 3, there were ~34,500 patients prescriptions reviewed. It was assumed that 1266 (3.67%) patients were eligible for step down and 33,103 (95.86%) patients were eligible for step off. When it came to assessing actual recommendations, 1031 (2.99%) of patients were stepped down, with 7890 (22.85%) patients stepped off.

Conclusion

When a deprescribing specialized pharmacist was deployed in the English PCN to support with medicines audit, an approximate 26% decrease in PPI prescriptions were observed. This data proves that this ‘hands on’ approach to deprescribing is an effect method.

References

1. M. E. S. M. A. L. Abrahami D, "Trends in acid suppressant drug prescriptions in primary care in the UK: a population-based cross-sectional study.," BMJ Open, vol. 10, no. 12, 2020
2. NICE, "Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management," 18 October 2019. [Online]. Available: https://www.nice.org.uk/guidance/cg184. [Accessed 08 June 2022].
3. Plehhova, K. et al., Trends in PPI Prescribing in England Primary Care: Results of a Prospective Education Study [abstract]. World Congress of Gastroenterology 2022, 12 – 14 December; Dubai, UAE. Abstract PP209

Disclosure

K. Plehhova, J. Wray, C. Coyle and A. Dawson are all employees of Reckitt Benckiser Health Ltd.
S. Sutton and J. McArdle are both employees of Interface Clinical Services, an IQVIA buisness.

Introduction

High-definition anorectal manometry (HD-ARM), balloon expulsion test (BET) and magnetic resonance defecography (MR-defecography) are important tools in studying constipation.

Aims & Methods

Evaluate the prevalence of functional defecation disorders and structural anorectal alterations in patients with constipation and compare the findings of HD-ARM and BET with MR-defecography.
Retrospective cohort study including patients with functional constipation (FC) or irritable bowel syndrome with constipation (IBS-C) submitted to HD-ARM, BET and MR-defecography. Patients were divided into three groups: 1) normal anorectal evacuation pattern in HD-ARM and BET; 2) abnormal anorectal evacuation pattern and BET; 3) normal anorectal evacuation pattern and abnormal BET, or abnormal anorectal evacuation pattern and normal BET.

Results

A total of 64 patients were included, 49 with FC (76.6%) and 15 with IBS-C (23.4%). There were 20 patients in group 1 (31.3%), 11 in group 2 (17.2%) and 33 in group 3 (51.5%). In MR-defecography, 47 patients had relevant structural anorectal alterations (73.4%) and 15 had an abnormal contraction of the puborectalis during the defecatory maneuver (23.4%).
Nineteen patients were diagnosed with dyssynergic defecation (29.7%). These patients had significantly higher residual anal pressure and lower percentage of anal relaxation during defecation (109.6±43.2 vs 85.8±29.7 mmHg, p=0.038 and 9% vs 24%, p=0.018, respectively), as well as a lower differential of rectoanal pressure (-32.2±31.4 vs 3.0±29.6 mmHg, p<0.001).
Patients with structural anorectal alterations had a significantly higher body mass index (BMI) (27.4±4.5 vs 23.5±3.3, p=0.002), and all obese patients had structural alterations.
Comparing the findings of HD-ARM and BET with MR-defecography: in group 1, 15 patients had structural alterations (75.0%); in group 2, 8 patients had structural alterations (72.7%); in group 3, 22 patients only had structural alterations (66.7%), 6 only had dyssynergic defecation (18.2%), 2 patients had both (6.0%) and 3 did not have any findings (9.1%). In 24.2% of patients with inconclusive findings in HD-ARM and BET, MR-defecography allowed the diagnosis of dyssynergic defecation.

Conclusion

Patients with structural anorectal alterations had a significantly higher BMI. Almost three quarters of patients with FC and IBS-C had relevant structural anorectal alterations and one third had dyssynergic defecation. Therefore, it is important to combine MR-defecography with HD-ARM and BET in the study of constipation.

Introduction

Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic disorder of the bile ducts, associated with significant morbidity and an increased risk of malignancy. Preclinical studies in mice deficient in the multidrug resistance protein 2 (Mdr2−/−) have demonstrated that the integrin αvβ6 plays a critical role in biliary fibrosis by activating latent transforming growth factor (TGF)-β1, the main profibrotic cytokine in the liver. Moreover, several studies have shown that autoantibodies against integrin αvβ6 exhibit good diagnostic accuracy in ulcerative colitis (UC). The aim of this meta-analysis is to evaluate the diagnostic performance of anti-integrin αvβ6 autoantibodies in PSC.

Aims & Methods

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four electronic databases (PubMed, Scopus, ScienceDirect, and the Cochrane Library) were systematically searched up to February 2025. Eligible studies included those involving patients with PSC as well as non-PSC control groups, in which the overall sensitivity and specificity of serum anti-integrin αvβ6 autoantibodies for the diagnosis of PSC were reported. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated using a random-effects model. Subgroup analyses were conducted based on the presence or absence of concomitant UC. Meta-analyses were performed using RevMan version 5.4.

Results

Four studies, comprising a total of 1,228 participants, met the predefined eligibility criteria. All studies defined the positivity threshold as the mean value in control groups plus three standard deviations (SD). The pooled sensitivity and specificity for the diagnosis of PSC were 0.679 (95% CI: 0.670–0.689) and 0.940 (95% CI: 0.939–0.941), respectively, with high heterogeneity (I² = 99%).
In the subgroup analysis, the sensitivity and specificity of the test for diagnosing PSC in the absence of concomitant UC were 0.075 (95% CI: 0.071–0.080) and 0.940 (95% CI: 0.939–0.941), respectively. In contrast, in the subgroup of patients with both PSC and UC, sensitivity reached 0.960 (95% CI: 0.959–0.961), while specificity was 0.720 (95% CI: 0.713–0.727).
Sensitivity analyses performed to explore the observed heterogeneity revealed that exclusion of one study (Bloeman, 2024) significantly improved diagnostic performance across all subgroups, with a pooled sensitivity of 0.831 (95% CI: 0.8236–0.8384) and specificity of 0.946 (95% CI: 0.9451–0.9468).

Conclusion

Serum anti-integrin αvβ6 autoantibodies demonstrate diagnostic value in PSC, with consistently high specificity across all patient groups and notably high sensitivity in those with concomitant ulcerative colitis. The high specificity supports a strong negative predictive value. Given the supporting preclinical evidence, integrin αvβ6 warrants further investigation not only as a diagnostic biomarker but also as a potential therapeutic target.

Disclosure

​No conflict of ​Interest

Introduction

Gastric outlet obstruction (GOO) is a debilitating condition commonly caused by malignant or benign diseases, impairing gastric emptying and nutritional status. While surgical gastrojejunostomy (SGJ) has traditionally been the standard palliative approach, endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a minimally invasive alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ versus SGJ for the management of GOO.

Aims & Methods

A systematic search of PubMed, Embase, Medline, and Cochrane Library was conducted to identify studies directly comparing EUSGJ and SGJ in adult patients with GOO. Nine retrospective studies comprising 1,086 patients (654 EUSGJ; 432 SGJ) were included. Primary outcomes included technical and clinical success, length of hospital stay (LOS), operative time, and overall complication rates. Secondary outcomes included infection, ileus, hemorrhage, perforation, and re-intervention. Meta-analyses were performed using fixed or random effects models depending on data heterogeneity.

Results

EUSGJ was significantly superior to SGJ in terms of technical success (OR = 0.16; 95% CI: 0.05–0.45; p = 0.0006), shorter operative time (MD = –96.89 minutes; 95% CI: –146.16 to –47.61; p < 0.00001), reduced postoperative LOS (MD = –4.79 days; 95% CI: –6.52 to –3.06; p < 0.0001), lower overall complication rates (OR = 0.24; 95% CI: 0.17–0.33; p < 0.00001), reduced postoperative ileus (OR = 0.07; 95% CI: 0.02–0.17; p < 0.00001), and fewer infections (OR = 0.17; 95% CI: 0.08–0.37; p < 0.00001). No statistically significant differences were found regarding clinical success, re-intervention, hemorrhage, or perforation.

Conclusion

EUSGJ demonstrates superior procedural outcomes and safety profiles compared to SGJ in the management of GOO and represents a valuable tool in expert hands. However, further prospective studies and randomized trials are necessary to validate these findings, assess long-term outcomes, and define its role within individualized patient care and clinical guidelines.

Disclosure

No conflict of interest