BACKGROUND AND AIMS: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure for obesity, a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, its impact on cardiovascular risk remains underexplored. This study evaluates ESG's effects on ASCVD risk and obesity-related comorbidities. METHODS: In this cohort study, 168 adults with obesity (aged 30-79 years; body mass index, >30 kg/ m2 or >27 kg/m2; with comorbidities) underwent ESG at a single tertiary care facility from 2013 to 2024. Patients were evaluated at baseline and 12 months after procedure using the Pooled Cohort Equations (PCEs) for patients aged 40-79 years and the Predicting Risk of Cardiovascular Disease Events (PRE-VENT) equations for those aged 30-79 years. Changes in body weight, glycemic control, blood pressure, lipid profile (total cholesterol, low-and high-density lipoprotein cholesterol, triglycerides), and liver enzymes (alanine aminotransferase) were also analyzed. RESULTS: Of the 168 patients (median age, 48 years; 74% female; body mass index, 36.0 kg/m2), 129 and 159 met inclusion criteria for PCEs and PREVENT equations, respectively. At 12 months, median PCEs ASCVD risk score decreased from 3.3% to 3.0% (21% reduction, P < 0.001), while the PREVENT 10-year cardiovascular disease risk score declined from 3.1% to 2.4% (20% reduction; P < 0.001), with similar reductions in 30-year risk scores and greater improvements in high/intermediate-risk patients and those aged >50 years. Patients achieved a median total body weight loss of 13.5% (IQR, 8.1%-18.6%), with significant metabolic improvements, and >80% experienced diabetes resolution. There was 1 (0.6%) moderate adverse event. CONCLUSION: Adults who underwent ESG showed significant improvements in ASCVD risk and obesity-related comorbidities at 12 months after procedure. These findings suggest that ESG may be an effective intervention for managing obesity and mitigating cardiovascular risk in patients with obesity. ClincialTrials.gov identifier: NCT04494048.

Introduction: The serum-based endoscopic healing index (EHI) test identifies endoscopic Crohn’s disease (CD) activity. Data are lacking on the relationship between EHI with other endpoints. We assessed the relationship between EHI and the simplified Magnetic Resonance Index of Activity. Materials and Methods: Data were prospectively collected on patients with CD with either an EHI or fecal calprotectin (FCAL) within 90 days of magnetic resonance enterography (MRE). Diagnostic accuracy was assessed using area under the receiver operator characteristics. Proportions with any, severe, and terminal ileum MR inflammation were compared above/below identified thresholds for both EHI and FCAL. Results: A total of 241 MREs paired to either EHI or FCAL from 155 patients were included. Both EHI and FCAL had similar accuracy to diagnose inflammation (area under the receiver operator characteristics: EHI: 0.635 to 0.651, FCAL: 0.680 to 0.708). Optimal EHI values were 42 and 26 for inflammation on MRE and endoscopy, respectively. Patients with EHI ≥42 (100% vs. 63%, P =0.002), FCAL >50 µg/g (87% vs. 64%, P <0.001) and FCAL >250 µg/g (90% vs. 75%, P =0.02) had higher rates of simplified Magnetic Resonance Index of Activity ≥1 compared with lower values. EHI differentiated ileitis numerically more than FCAL (delta: 24% to 25% vs. 11% to 21%). Patients with FCAL ≥50 µg/g had higher rates of severe inflammation compared with FCAL <50 µg/g (75% vs. 47%, P <0.001), whereas smaller differentiation existed for EHI threshold of 42 (63% vs. 49%, P =0.35). Conclusion: Both EHI and FCAL were specific in their confirmation of inflammation and disease activity on MRE in patients with CD. However, MRE-detected inflammation was frequently present in the presence of low EHI and FCAL in similar proportions.

Introduction: The Merit-Based Incentive Payment System (MIPS) is a mandatory pay-for-performance program created by the Centers for Medicare & Medicaid Services, which enrolls over 300,000 physicians. Participating clinicians are assigned a final score (FS) based on four categories, which is used to determine financial incentives/penalties (payment adjustment (PA): -7% to + 1.79%). Gastroenterologists’ performance in the MIPS program has not been reported. Methods: MIPS data was obtained from 2019 Quality Payment Program Experience. Clinicians can report to MIPS as Individual, part of a group, or part of an alternative payment model (APM) (e.g. Medicare Shared Savings Program). Univariate was performed with t-test and Pearson, multivariate was performed with multiple regression analysis. Results: Of 12,872 gastroenterologists who participated in MIPS in 2019, 1,724 (13.4%) were practicing as individuals, 6,150 (47.8%) were part of a group, and 4,998 (38.8%) were part of an APM. The average FS for gastroenterologist was 85.4 (IQR 82.8-95.9), compared to that of all physicians (80.5, IQR 67.4-93.7). The average years in practice was 11 (IQR 9-14), and is negatively associated with FS (P< 0.01) and PA (P< 0.01). Individuals had lower FS (66.0) compared to those in a group (83.1, P< 0.01) and those in an APM (94.9, P< 0.01). Similarly, individuals had lower PA (0.6%) compared to those in a group (0.8%, P< 0.001) and those in a APM (1.5%, P< 0.01). Practice size is positively associated with FS (P< 0.01) and PA (P< 0.01). However, there is no statistical difference in practicing in a rural (FS 84.6; PA 1.0%) vs nonrural setting (FS 85.5, P=0.09; PA 1.0%, P=0.52). In terms of multivariable analysis, participation type (P< 0.001) and practice size (P< 0.001) remained statistically significant for both FS and PA; however, year in medicine did not remain statistically significant (FS: P=0.32, PA: P=0.55). Conclusion: Gastroenterologists have a higher FS compared to all physician participants in the MIPS program. Participation in APM and being a part of a larger practice are associated with higher FS and PA. MIPS was developed as a pay-for-performance program to continue to drive high-quality, high-value care in the US. However, there are concerns about its ability to assess quality given the more developed infrastructure for data processing and reporting in larger practices. Further studies are needed to improve MIPS to reflect best clinical practices rather than processing and reporting processes.

Ying, Xiaohan1; Mathis, Walter S.2; Kahn, Peter A.3; Jesudian, Arun B.4; Fortune, Brett E.5; Brown, Robert S. Jr.4 Author Information

Higher ustekinumab concentrations were associated with improved radiologic (Simplified Magnetic Resonance Index of Activity for Crohn's Disease) and stringent biomarker (calprotectin) outcomes. The high concentration needed for these novel endpoints validates previous studies using the same assay.

Chronic hepatitis B (CHB) is a major cause of liver-related morbidity and mortality globally, and there are an estimated 1.6 million people in the United States living with CHB. 1 Lim J.K. et al. Am J Gastroenterol. 2020; 115: 1429-1438 Crossref PubMed Scopus (77) Google Scholar Because there is currently no cure for CHB, affected patients often require lifelong antiviral treatment to achieve viral suppression, which is cost-prohibitive for many. Medicare Part D Spending for Hepatitis B Virus Drugs: Completing the Picture and Extending the DatasetGastroenterologyVol. 166Issue 2PreviewWe read with interest the recent research letter from Ying et al1 analyzing spending for oral drugs used to treat hepatitis B in Medicare Part D between 2013 and 2020. The analysis included the originator and generic forms for tenofovir disoproxil fumarate (TDF), entecavir, and tenofovir alafenamide (TAF). This study showed a significantly higher number of beneficiaries over time of these antiviral therapies despite an overall decreasing trend in spending. This work is important in understanding the impact of chronic hepatitis B, which is estimated to affect 1.5 million Americans. Full-Text PDF

Introduction: Protein losing enteropathy (PLE) can be classified into erosive, non-erosive, and increased interstitial pressure PLE. Presenting signs are often chronic non-bloody diarrhea, anasarca, abdominal pain, and weight loss. We present a complex case of a PLE presentation with a novel diagnosis. Case Description/Methods: A 30-year-old woman with a history of migraines presented with severe abdominal pain and chronic diarrhea. She was on long-term combined estrogen-progestin oral contraceptive pills (OCP) and chronic high dose non-steroidal anti-inflammatory (NSAID) medications. She was exposed to mycoplasma pneumoniae one month prior to presentation, without other infectious exposures. Laboratory tests were notable for hemoglobin 6 g/dL, albumin 0.5 g/dL, stool pathogen PCR negative, and fecal calprotectin >3000µg/g. Extensive infectious work up only revealed Mycoplasma IgM+. Inflammatory markers and alpha-1 anti-trypsin clearance were elevated, and she was found to have warm autoimmune hemolytic anemia. CT angiography excluded ischemia and vasculitis (autoimmune serologies were negative), revealing diffuse enterocolitis, confirmed on magnetic resonance enterography with ileal ulcers. Endoscopic evaluation revealed diffuse superficial ulcerations terminal ileum and colon with diffuse mucosal sloughing. Histopathology revealed diffusely injured crypts with crypt drop-out and minimal inflammation, without any findings to suggest infection, inflammatory bowel disease (IBD) or autoimmune enteritis (Figure). Normal B-cell switching studies excluded common variable immunodeficiency (CVID). Due to profound anasarca and inability to tolerate oral intake, albumin infusions and total parenteral nutrition were started. There was minimal response to systemic or topical steroids. Diarrhea was mildly improved with albumin repletion, and she was empirically started on vedolizumab. Discussion: Given the absence of classic IBD findings, negative infectious and immunological testing, we present the first case of autoimmune cryptolytic enterocolitis, a histopathologic diagnosis of unclear etiology and pathogenesis. The patient has responded to vedolizumab infusions as an empiric treatment for an IBD-like entity. Nevertheless, supporting the autoimmune component of this entity, is a possible concomitant potential pathway of molecular mimicry in the setting of post-mycoplasma infection along with chronic high dose NSAID and OCP exposure.Figure 1.: Terminal Ileum and Sigmoid Colon with Diffuse Crypt Dropout.

Background and study aim COVID-19 patients are at increased risk for venous thromboembolism (VTE) requiring the use of anticoagulation. Gastrointestinal bleeding (GIB) is increasingly being reported, complicating the decision to initiate or resume anticoagulation as providers balance the risk of thrombotic disease with the risk of bleeding. Our study aimed to assess rebleeding rates in COVID-19 patients with GIB and determine whether endoscopy reduces these rebleeding events. We also report 30-day VTE and mortality rates. Methods This was a retrospective study evaluating 56 COVID-19 patients with GIB for the following outcomes: 30-day rebleeding rate, 30-day VTE rate, effects of endoscopic intervention on the rate of rebleeding, and 30-day mortality. Results The overall rates of VTE and rebleeding events were 27 % and 41 %, respectively. Rebleeding rates in patients managed conservatively was 42 % compared with 40 % in the endoscopy group. Overall, 87 % of those who underwent invasive intervention resumed anticoagulation vs. 55 % of those managed medically (P = 0.02). The all-cause 30-day mortality and GIB-related deaths were 32 % and 9 %, respectively. Mortality rates between the endoscopic and conservative management groups were not statistically different (25 % vs. 39 %; P = 0.30). Conclusions Although rebleeding rates were similar between the endoscopic and conservative management groups, patients who underwent intervention were more likely to restart anticoagulation. While endoscopy appeared to limit the duration that anticoagulation was withheld, larger studies are needed to further characterize its direct effect on mortality outcomes in these complex patients.