Gastroenterology/Hepatology: What You May Have Missed in 2023.

This article summarizes clinically important gastroenterology developments from 2023 for internal medicine specialists. In colorectal cancer screening, a new RNA fecal screening test is on the horizon, as well as a new analysis on the benefits of using artificial intelligence in screening colonoscopy to detect more polyps. There is new evidence for management of gastrointestinal bleeding, a new drug for treatment of recurrent small-intestinal angiodysplasia, and a new endoscopic treatment method in patients with gastrointestinal tumor bleeding. The authors feature a randomized trial about amitriptyline as treatment for patients with irritable bowel syndrome by primary care providers and bring you news about new biologic agents for inflammatory bowel disease and eosinophilic esophagitis. Finally, they review 2 important articles on new terminology and management of metabolic dysfunction-associated fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) in Filipino North American patients: Results from a multi-ethnic cohort.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is more prevalent in certain ethnicities due to a combination of genetic, environmental, and metabolic factors. North American Filipino populations may have lifestyle and metabolic risk factors for NAFLD; however, the prevalence of NAFLD in this group is unknown. We sought to determine whether Filipino patients are over-represented in a multi-ethnic NAFLD cohort and describe their clinical presentation, primarily compared to other ethnicities in the same geographical region and secondarily compared to Manila-based Filipino patients. METHODS: A cross-sectional study was conducted with patients with NAFLD who were followed at the Hepatology Clinic at Vancouver General Hospital, Canada, from January 2015 to August 2018. Data were extracted for clinicodemographic data, ethnicity, anthropometric measures, blood work, and transient elastography (TE). External comparison data was obtained online from the Metro Vancouver census and a NAFLD study conducted in Manila, Philippines. RESULTS: Of 317 patients meeting inclusion criteria for the study, 224 patients had complete datasets. The mean age was 51.1 years, and 50% were female. There were 139 (62%) Caucasian and other ethnicity patients, 55 (25%) Asian patients, and 30 (13%) Filipino patients. Compared to other ethnic groups, the Filipino group had similar clinical characteristics, including NAFLD fibrosis scores and TE. Of included NAFLD patients, the proportion of Filipino patients (13.39%) was significantly greater than the proportion of Filipino residents in Metro Vancouver (5.52%, p <0.01). Our Filipino Canadians seemed to be younger, with fewer females and a lower proportion of diabetes mellitus, but a higher proportion of hypertension than the previously reported cohort from Manila. CONCLUSIONS: While Filipino patients have not previously been examined in multi-ethnic NAFLD studies, they may represent a high-risk population. Further research is needed to clarify the prevalence and presentation of NAFLD in Filipino Canadian patients, as this appears to be a significant health issue in this community.

Elevated serum ferritin in non-alcoholic fatty liver disease is not predictive of fibrosis.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is common with widely ranging severity. Non-invasive risk scores for risk stratification are recommended but misclassify a significant proportion of patients. In situations where non-invasive risk scores do not provide guidance, referral is typically made to a Hepatologist for transient elastography or liver biopsy. Serum ferritin is elevated in many patients with NAFLD related to dysmetabolic and inflammatory hyperferritinemia. Ferritin is widely available and part of a standard workup for chronic liver disease. METHODS: To explore the association of ferritin and risk of fibrosis in NAFLD, we reviewed patients diagnosed with NAFLD at the hepatology clinic of the Vancouver General Hospital between the years of 2015 and 2018. We collected data on 317 patients retrospectively assessing for a relationship between serum ferritin and elastography score. RESULTS: Two hundred twenty-four patients were included in the final analysis. Median ferritin was 145 µg/L (IQR 62-311). Median liver stiffness was 5.2 kPa with 14.3% of patients having liver stiffness ≥8.7 kPa and 17.4% ≥ 8.0 kPa. ROC curve analysis using a liver stiffness ≥8.0 kPa as a cutoff for F2 fibrosis showed an AUROC of 0.54 for serum ferritin levels. At a cut-off of both 300 µg/L; and 450 µg/L median liver stiffness did not differ significantly in those with ferritin above the cutoff (ferritin ≥300 µg/L; p = 0.099, ferritin ≥450 µg/L; p = 0.12). Ferritin was significantly higher in male patients (198 versus 91 µg/L; p = 0.0001). There was a weak linear association between AST and ferritin levels. CONCLUSION: In this cohort of 224 patients with NAFLD, serum ferritin was not predictive of significant liver fibrosis.

The Carbon Cost of Travel to a Medical Conference: Modelling the Annual Meeting of the Canadian Association of Gastroenterology.

Objectives: We estimated and compared the travel related carbon emissions of the annual meeting of the Canadian Association of Gastroenterology between the two most common geographical locations of the meeting. Methods: We modelled the car, train and flight travel journey of each registrant to two annual meetings. One was held in Toronto, close to where the majority of Gastroenterogists live, the other in Banff in the west of the country. We used validated carbon emission outputs per kilometer of travel. Results: The average per capita distance travelled to the Toronto meeting was 2845 km, resulting in 0.540 tonnes (t) of CO2equivalent (CO2e) emitted per person. When the meeting was held in Banff emissions were 41% higher than those in Toronto with an average distance travelled of 3949 km and 0.760t of CO2e emitted per person. Almost all of the travel related carbon emissions for both meetings were generated by flying. Conclusions: Even when held close to the largest population centre, there is a large environmental impact from travel to annual meetings. Importantly, choice of meeting location has a very big impact on difference in carbon emissions. Societies need to consider the site of meetings and reduce the number of in-person attendees if they wish to reduce their carbon footprint. Hybrid models participants should be considered. Our analysis also suggests, other medical societies who wish to model their annual meetings can use a simplified model, using flying distance only, to estimate travel-related emissions.

Comparing the performance of Fibrosis-4 and Non-Alcoholic Fatty Liver Disease Fibrosis Score with transient elastography scores of people with non-alcoholic fatty liver disease.

Background: With the rate of non-alcoholic fatty liver disease (NAFLD) on the rise, the necessity of identifying patients at risk of cirrhosis and its complications is becoming ever more important. Liver biopsy remains the gold standard for assessing fibrosis, although costs, risks, and availability prohibit its widespread use with at-risk patients. Transient elastography has proven to be a non-invasive and accurate way of assessing fibrosis, although the availability of this modality is often limited in primary care settings. The Fibrosis-4 (FIB-4) and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) are scoring systems that incorporate commonly measured lab parameters and BMI to predict fibrosis. Method: In this study, we compared FIB-4 and NFS scores with transient elastography scores to assess the accuracy of these inexpensive and readily available scoring systems in detecting fibrosis. Results: Using an NFS score cut-off of -1.455 and a FibroScan score cut-off of ≥8.7 kPa, the NFS score had a negative predictive value of 94.1%. Using a FibroScan score cut-off of ≥8.7 kPa, the FIB-4 score had a negative predictive value of 91.6%. Conclusion: The NFS and FIB-4 are non-invasive, inexpensive scoring systems that have high negative predictive value for fibrosis compared with transient elastography scores. These findings suggest that the NFS and FIB-4 can provide adequate reassurance to rule out fibrosis in patients with NAFLD and can be used with select patients to circumvent the need for transient elastography or liver biopsy.

Depression in neurodegenerative diseases: Common mechanisms and current treatment options.

Major depressive disorder (MDD) is a highly prevalent psychiatric disorder and a major cause of disability worldwide. This neurological condition is commonly associated with neurodegenerative diseases such as Alzheimer's disease (AD), Parkinson's disease (PD) and Huntington's disease (HD), and has a significant impact on the increasing burden of these neuropathologies. Over the past decades, some of the pathophysiological and molecular mechanisms that contribute to these diseases have been elucidated and these findings indicate that, despite presenting distinct features, there are several similarities between the neurobiological alterations that lead to MDD and neurodegeneration in AD, PD, and HD. For instance, disturbances in monoaminergic transmission and the hypothalamic-pituitary-adrenal (HPA) axis, increased oxidative and neuroinflammatory events, and impaired trophic support are thought to contribute to neuronal atrophy and death in all these diseases. In addition, neuroimaging findings have helped elucidate the structural and functional changes implicated in the relationship between depression and neurodegeneration, thus establishing a neuroanatomical signature to explain, at least in part, the comorbidity between MDD and AD, PD, and HD. The present review summarizes these findings and the current evidence regarding the effectiveness of common antidepressant therapies for the treatment of MDD in patients with these neurodegenerative diseases. This population is particularly vulnerable to the drawdowns of conventional antidepressant therapy (namely inadequate response and high risk of side effects), and the development of emerging therapeutic approaches to treat MDD in patients with AD, PD, and HD is thus of paramount importance to improve the quality of life of these individuals.

Annual Incidence and Phenotypic Presentation of IBD in Southern New Zealand: An 18-Year Epidemiological Analysis.

BACKGROUND: The aim of this study was to describe the incidence of inflammatory bowel disease (IBD) and changes in demographic and phenotypic disease presentation in Otago, New Zealand. METHODS: This study was conducted at Dunedin Hospital and the study period was 1996-2013. Otago residents diagnosed with IBD were identified retrospectively from hospital lists using ICD-10 codes. Diagnosis, and place and date of diagnosis, were confirmed using medical notes and histology reports. Demographic, clinical and diagnostic data were recorded. Age-standardised incidence rates were estimated and trends over time assessed. Multinomial logistic regression was used to assess evidence for any changes in the distribution of disease location for Crohn's disease (CD) cases. RESULTS: The diagnosis of IBD was confirmed in 224 males and 218 females, and most were New Zealand European. Of the total number of confirmed IBD cases, 40.0% were ulcerative colitis (UC), 52.1% were CD and 7.9% were IBD unclassified. The age distribution illustrated bimodal peaks at 20-24 years and 65-69 years. Incidence rates varied from year to year, but there was no statistically significant change over the 18-year study period. The estimated age-standardised IBD incidence varied between 5.8/100,000 in 2006 and 29.8/100,000 in 2012. The incidence rates for UC and CD were 2.8/100,000 and 1.8/100,000, respectively, in 2006 and 6.3/100,000 and 21.8/100,000, respectively, in 2012. There were no significant phenotypic changes in CD patients over the study period. CONCLUSIONS: The IBD incidence in Otago, New Zealand, is high compared to many other countries. Annual age-standardised incidence rates vary, highlighting the limitations of single-year incidence data.

Effects of inhaled bronchodilators on lung function and cycling performance in female athletes with and without exercise-induced bronchoconstriction.

OBJECTIVES: Inhaled ß2-agonists may cause differential effects on lung function and athletic performance in female compared to male athletes. The objective of this study was to compare the effects of inhaled ß2-agonists on lung function and cycling performance between female athletes with and without exercise-induced bronchoconstriction and with previously published data on men. DESIGN: Double-blind crossover randomized controlled trial. METHODS: Twenty-one female athletes (6 with exercise-induced bronchoconstriction and 15 without exercise-induced bronchoconstriction) performed a simulated 10-km time-trial on a cycle ergometer 60 min after the inhalation of either 400 µg of salbutamol or placebo. Forced expiratory volume in 1s, was measured immediately before and 30 min after inhalation. Performance was measured by mean power output over the duration of the time trial. RESULTS: After salbutamol inhalation, Forced expiratory volume in 1s improved significantly in athletes with exercise-induced bronchoconstriction (M (SD) = 6.1% (47.6)) and athletes without exercise-induced bronchoconstriction (4.0% (3.1); p ≤ 0.02). Mean power output was significantly decreased after salbutamol use (204 W (21)) compared to placebo (208 W (17); p = 0.047), regardless of airway hyperresponsiveness. Relative to placebo, salbutamol significantly increased mean oxygen consumption (46.9 mL kg(-1)min(-1) (5.9) vs. 44.8 mL kg(-1)min(-1) (4.0); p = 0.049) and significantly decreased cycling economy (72.8 W L(-1)min(-1) (6.8) vs. 76.4 W L(-1)min(-1) (4.3); p = 0.01). CONCLUSIONS: The inhalation of salbutamol induced a significant increase in lung function in female athletes, but this increased lung function did not translate to improved exercise performance.