Towards Noninvasive Detection of Oesophageal Varices

Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Non-invasive assessment and prediction of clinically significant portal hypertension

Hepatic venous pressure gradient (HVPG) predicts variceal development, bleeding, clinical decompensation and death. Measurement is invasive, time-consuming and performed in few centres. Reduction of HVPG to ≥12 mm Hg or by >20% significantly reduces bleeding risk and mortality. Detection of non-responders requires repeated HVPG measurement as conventional non-invasive assessment is not accurate in predicting haemodynamic response. Cirrhotics have a hyperdynamic circulation and impaired baroreceptor sensitivity (BRS). The authors assessed whether non-invasive measurement of systemic haemodynamics and BRS detected clinically significant portal hypertension (CSPH, HVPG ≥12 mm Hg).N/

Automonic dysfunction measured by baroreflex sensitivity is markedly abnormal in stable cirrhosis despite minimal systemic haemodynamic changes

Baroreceptor sensitivity (BRS) is well recognised as a composite marker of the overall integrity of the autonomic nervous system, maintaining cardiovascular status both at rest and during physiological stress. Autonomic dysfunction occurs in 43–80% of cases of cirrhosis, affecting both sympathetic and parasympathetic branches. BRS impairment occurs independently of aetiology and correlates with disease severity and the hyperdynamic circulation. BRS has been studied extensively in advanced disease, especially pre-transplantation but less so in more compensated disease. Impaired BRS is associated with a 5-fold increase in mortality, independent of cirrhosis stage, yet can be improved by drugs and liver transplantation.N/

P24 Presence of impaired baroreceptor sensitivity is a poor prognostic marker in cirrhosis

Autonomic function is essential for blood pressure control and baroreceptor sensitivity (BRS) acts as a composite marker of overall function. Both sympathetic and parasympathetic function is impaired in cirrhosis. Impaired BRS predicts death in cardiovascular diseases and chronic kidney disease.N/

P16 Non-invasive detection of oesophageal varices: comparison of non-invasive assessment of systemic haemodynamics with laboratory parameters and predictive scores

Endoscopic screening for varices (OV) is advised in cirrhosis, repeated every 1–3 years, with primary prophylaxis given to large OV. This is costly to endoscopy units, unpleasant for patients and multiple procedures may affect compliance. Cirrhosis is characterised by a hyperdynamic circulation; novel tools make non-invasive assessment possible.N/

PTU-066 Non-invasive assessment of systemic haemodynamics to determine variceal bleeding risk in cirrhotic patients: Abstract PTU-066

Variceal bleeding is one of the most severe complications of portal hypertension. Universal endoscopic variceal screening is recommended and primary prophylaxis given based on oesophageal variceal size. Risk of bleeding also relates to other factors such as portal pressure, liver disease severity, and red wale markings at endoscopy. Currently there is no non-invasive way of measuring portal pressure or bleeding risk. The aim of this study was to evaluate whether non-invasive assessment of systemic haemodynamics in cirrhosis can identify bleeding risk in portal hypertension.N/

Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes

Little is known about the assessment and treatment of self-stigma in substance abusing populations. This article describes the development of an acceptance based treatment (Acceptance and Commitment Therapy-ACT) for self-stigma in individuals in treatment for substance use disorder. We report initial outcomes from a study with 88 participants in a residential treatment program. The treatment involves 6 h of a group workshop focused on mindfulness, acceptance, and values work in relation to self-stigma. Preliminary outcomes showed medium to large effects across a number of variables at post-treatment. Results were as expected with one potential process of change, experiential avoidance, but results with other potential mediators were mixed