Non-alcoholic fatty liver disease screening in type 2 diabetes mellitus: A cost-effectiveness and price threshold analysis.

INTRODUCTION: The cost-effectiveness of screening asymptomatic non-alcoholic fatty liver disease (NAFLD) patients remains debatable, with current studies assuming lifelong benefits of NAFLD screening while neglecting cardiovascular outcomes. This study aims to assess the cost-effectiveness of NAFLD screening among type 2 diabetes mellitus (T2DM) patients, and to establish a price threshold for NAFLD treatment, when it becomes available. METHOD: A Markov model was constructed comparing 4 screening strategies (versus no screening) to identify NAFLD with advanced fibrosis among T2DM patients: fibrosis-4 (FIB-4), vibration-controlled transient elastography (VCTE), FIB-4 and VCTE (simultaneous), and FIB-4 and VCTE (sequential). Sensitivity analyses and price threshold analyses were performed to assess parameter uncertainties in the results. RESULTS: VCTE was the most cost-effective NAFLD screening strategy (USD24,727/quality-adjusted life year [QALY]), followed by FIB-4 (USD36,800/QALY), when compared to no screening. Probabilistic sensitivity analysis revealed a higher degree of certainty for VCTE as a cost-effective strategy compared to FIB-4 (90.7% versus 73.2%). The duration of expected screening benefit is the most influential variable based on incremental cost-effectiveness ratio tornado analysis. The minimum duration of screening benefit for NAFLD screening to be cost-effective was at least 2.6 years. The annual cost of NAFLD treatment should be less than USD751 for NAFLD screening to be cost-effective. CONCLUSION: Both VCTE and FIB-4 are cost-effective NAFLD screening strategies among T2DM patients in Singapore. However, given the lack of access to VCTE at primacy care and potential budget constraints, FIB-4 can also be considered for NAFLD screening among T2DM patients in Singapore.

Efficacy of small-volume simethicone given at least 30 min before gastroscopy.

AIM: To evaluate the efficacy of 5 mL simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy. METHODS: This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior surgical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score (TMVS) which was evaluated using McNally score. The sample size was calculated to be 24 per group (SD 2.4, 80% power, P < 0.05, 2-sample t test). RESULTS: Fifty-four patients were randomised to receive either simethicone [1 mL liquid simethicone (100 mg) in 5 mL of water] or placebo (5 mL of water) at least 30 min before their gastroscopy. Six accredited consultants conducted the gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo (5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4 (no bubbles at all) to 5 (only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam. CONCLUSION: With a premedication time of at least 30 min, 5 mL simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.

A multicenter randomized comparison between high-definition white light endoscopy and narrow band imaging for detection of gastric lesions.

OBJECTIVE: Narrow band imaging (NBI) is generally considered to be useful for lesion characterization, but not enhanced detection of gastric lesions, because of the dark endoscopic view. We tested whether the new generation of NBI (190-NBI or 290-NBI), which is twice as bright as the previous version, would improve detection of premalignant gastric lesions compared with high-definition white light endoscopy (HD-WLE). PATIENTS AND METHODS: This was a multicenter prospective randomized study involving five tertiary institutions in the Asia-Pacific region. A total of 579 patients aged older than 50 years who underwent diagnostic upper gastrointestinal endoscopy were randomized to either HD-WLE or NBI. The outcome measurements were detection of intestinal metaplasia (IM), focal gastric lesions, and gastric cancers. RESULTS: Focal gastric lesions were detected in 83/286 (29%) and 119/293 patients (40.6%) by HD-WLE and by NBI, respectively (P=0.003). IM was detected in 22/286 patients (7.7%) by HD-WLE and in 52/293 patients (17.7%) by NBI (P<0.001). Gastric cancer were found in 7/286 (2.4%) and 3/293 patients (1%) in HD-WLE and NBI groups, respectively (P=0.189). CONCLUSION: NBI increased the detection rate of IM compared with HD-WLE.

The utility of narrow band imaging in improving the endoscopic diagnosis of gastroesophageal reflux disease.

BACKGROUND & AIMS: Narrow band imaging (NBI) facilitates mucosal surface evaluation and may improve the endoscopic diagnosis of gastroesophageal reflux disease (GERD). We investigated the utility of NBI in improving the endoscopic diagnosis of GERD when compared with conventional endoscopy. METHODS: A total of 107 subjects (nonerosive reflux disease [NERD], 36; erosive reflux disease [ERD], 41; controls, 30) were recruited prospectively. The mucosal morphology at the squamocolumnar junction (SCJ) in GERD and controls was visualized using conventional endoscopy and NBI. The main outcome measurements were as follows: (1) The differences in mucosal morphology at the SCJ between conventional endoscopy and NBI; and (2) the differences in mucosal morphology at the SCJ between GERD and controls with NBI. RESULTS: Micro-erosions, increased vascularity, and pit patterns at the SCJ not seen on conventional endoscopy were well seen with NBI. Compared with controls, ERD and NERD had a significantly higher prevalence of micro-erosions (ERD, 100%; NERD, 52.8%; controls, 23.3%), and increased vascularity (ERD, 95.1%; NERD, 91.7%; controls, 36.7%), but a lower prevalence of round pit pattern (ERD, 4.9%; NERD, 5.6%; controls, 70%). ERD and NERD were similar in terms of increased vascularity and pit patterns. Increased vascularity with absence of round pit pattern was useful to distinguish NERD from controls (sensitivity, 86.1%; specificity, 83.3%). Interobserver agreement was good for increased vascularity (kappa = 0.95) and micro-erosions (kappa = 0.89), but lower for pit pattern (kappa = 0.59). CONCLUSIONS: NBI enhanced mucosal morphology at the SCJ and appeared useful for improving the endoscopic diagnosis of GERD.

Helicobacter pylori eradication versus prokinetics in the treatment of functional dyspepsia: a randomized, double-blind study.

BACKGROUND: This randomized, double-blind study compared the efficacy of Helicobacter pylori eradication against prokinetics in H. pylori-infected functional dyspepsia patients. METHODS: Patients with moderately severe or severe dyspepsia fulfilling the Rome II criteria were randomized to either H. pylori eradication for 1 week and 6 weeks of placebo prokinetics or 6 weeks of prokinetics and placebo H. pylori eradication in the first week. Symptoms were assessed at baseline and at 6 and 12 months using the Glasgow Dyspepsia Severity Score (GDSS). Global response to treatment was assessed at 12 months. RESULTS: Altogether 130 patients were enrolled (H. pylori eradication, 71; prokinetics, 59). The mean baseline GDSS was 9.3 for the H. pylori eradication group and 8.9 for the prokinetic group. At 6 months, the score was 3.6 and 4.1, respectively, and it remained at 3.5 and 3.8, respectively, at 12 months. With H. pylori eradication, 31.0% had complete symptom resolution (GDSS 0 or 1) at 12 months compared with 23.7% with prokinetics (a nonsignificant difference). At 12 months, global symptomatic improvement was seen in 62.0% of the H. pylori eradication group compared with 67.8% of the prokinetics group. CONCLUSIONS: Both H. pylori eradication and prokinetic therapy resulted in symptom improvement in two-thirds of dyspeptic patients at 1 year. More patients tended to achieve complete symptom relief with H. pylori eradication.

Epinephrine injection therapy versus a combination of epinephrine injection and endoscopic hemoclip in the treatment of bleeding ulcers.

AIM: To assess the efficacy of hemoclip application in combination with epinephrine injection in the treatment of bleeding peptic ulcers and to compare the clinical outcomes between patients treated with such a combination therapy and those treated with epinephrine injection alone. METHODS: A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. Of these, 202 patients (152 males, 50 females) received epinephrine injection therapy while 91 patients (59 males, 32 females) received combination therapy. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-d mortality were the outcome measures studied. RESULTS: Patients who received combination therapy were significantly older (mean age 66+/-16 years, range 24-90 years) and more suffered from chronic renal failure compared to those who received epinephrine injection therapy alone (mean age 61+/-17 years, range 21-89 years). Failure to achieve permanent hemostasis was 4% in the group who received epinephrine injection alone and 11% in the group who received combination therapy. When the differences in age and renal function between the two treatment groups were taken into account by multivariate analysis, the rates of initial hemostasis, rebleeding rates, need for surgery and 30-d mortality for both treatment options were not significantly different. CONCLUSION: Combination therapy of epinephrine injection with endoscopic hemoclip application is an effective method of achieving hemostasis in bleeding peptic ulcer diseases. However, superiority of combination therapy over epinephrine injection alone, could not be demonstrated.

Clinical profile of primary sclerosing cholangitis in Singapore.

BACKGROUND AND AIM: Primary sclerosing cholangitis (PSC) is a rare chronic disease in Singapore and its epidemiological profile has not been described previously. The present study aimed to define the demographic and clinical profile of patients with PSC in Singapore. METHODS: The case records of patients with PSC seen at Changi General Hospital were analyzed in terms of demographic profile, clinical presentation, clinical course, treatment and complications. RESULTS: Ten cases of PSC were diagnosed over a 10-year period. The male:female ratio was 9:1. The median age of diagnosis was 49.5 years (mean: 50.9 years; range: 35-63 years). With regards to clinical presentation, seven patients had hepatobiliary sepsis, two patients had asymptomatic liver biochemistry abnormalities while one patient had cholestatic jaundice. Prevalence rate of perinuclear antineutrophil cytoplasmic antibody (pANCA) was 20%. Symptomatic inflammatory bowel disease (IBD) was diagnosed in 20% of PSC cases. Eight patients (80%) had intrahepatic ductal involvement while two patients (20%) had combined intrahepatic and extrahepatic ductal involvement on endoscopic retrograde cholangiopancreatography (ERCP). The prevalence rate of recurrent cholangitis was 30% while that of recurrent liver abscess, cirrhosis and common bile duct stricture were all 10%. The mean duration of follow up was 6.6 years with one death from liver failure. CONCLUSION: The clinical profile of patients with PSC in Singapore appears to differ with other published data, with a greater number presenting with hepatobiliary sepsis and less frequent association with IBD and pANCA. It is hypothesized that this may be related to differences in environmental triggers and genetic susceptibility.