Video

REPORTING FROM ACTRIMS FORUM 2018

SAN DIEGO – Although clinical tools to assess ambulatory function among people with multiple sclerosis exist, some measure it as part of a comprehensive assessment while others require the patient to answer many questions and then clinicians to calculate a score.

To devise a more targeted, simpler instrument, Emily Evans, MD, and her colleagues developed the PDAS or Patient Derived Ambulation Scale. They evaluated the correlation of this single-item scale to assess ambulation – an important measure of patient function – and evaluated how the results correlated with existing tools such as the Patient Determined Disease Steps and 12-item MS Walking Scale. Dr. Evans presented preliminary findings at the ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

“We feel this is a quick test that can be readily implemented into clinical practice,” Dr. Evans, a neurologist at the John L. Trotter MS Center at Washington University in St. Louis, said in a video interview.

REPORTING FROM ACTRIMS FORUM 2018

SAN DIEGO – Although clinical tools to assess ambulatory function among people with multiple sclerosis exist, some measure it as part of a comprehensive assessment while others require the patient to answer many questions and then clinicians to calculate a score.

To devise a more targeted, simpler instrument, Emily Evans, MD, and her colleagues developed the PDAS or Patient Derived Ambulation Scale. They evaluated the correlation of this single-item scale to assess ambulation – an important measure of patient function – and evaluated how the results correlated with existing tools such as the Patient Determined Disease Steps and 12-item MS Walking Scale. Dr. Evans presented preliminary findings at the ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

“We feel this is a quick test that can be readily implemented into clinical practice,” Dr. Evans, a neurologist at the John L. Trotter MS Center at Washington University in St. Louis, said in a video interview.

REPORTING FROM ACTRIMS FORUM 2018

SAN DIEGO – Although clinical tools to assess ambulatory function among people with multiple sclerosis exist, some measure it as part of a comprehensive assessment while others require the patient to answer many questions and then clinicians to calculate a score.

To devise a more targeted, simpler instrument, Emily Evans, MD, and her colleagues developed the PDAS or Patient Derived Ambulation Scale. They evaluated the correlation of this single-item scale to assess ambulation – an important measure of patient function – and evaluated how the results correlated with existing tools such as the Patient Determined Disease Steps and 12-item MS Walking Scale. Dr. Evans presented preliminary findings at the ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

“We feel this is a quick test that can be readily implemented into clinical practice,” Dr. Evans, a neurologist at the John L. Trotter MS Center at Washington University in St. Louis, said in a video interview.

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

SAN DIEGO – Compelling findings in a genetically engineered mouse model of multiple sclerosis identify mechanisms of how adolescence and gut dysbiosis contribute to the risk of MS. In addition, disparities in gut microbiome species could explain why some people are at higher risk for developing multiple sclerosis, while others seem to enjoy a protective effect against development of this and other autoimmune diseases.

The hope is that these findings could pave the way for clinicians to potentially prevent development of multiple sclerosis in people at higher risk, perhaps through altering the gut flora and probiotic therapy, Suhayl Dhib-Jalbut, MD, said in a video interview at ACTRIMS Forum 2018, held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Dr. Dhib-Jalbut and his team discovered these findings using humanized transgenic mice – in other words, mice containing risk genes for triggering disease transferred from a patient with multiple sclerosis. The mice were more likely to develop MS-like disease at certain ages and in the presence of an altered gut microbiome or gut dysbiosis (Proc Natl Acad Sci U S A. 2017 Oct 31;114[44]:E9318-27).

Dr. Dhib-Jalbut is past president of ACTRIMS and is professor and chairman of the departments of neurology at Rutgers–Robert Wood Johnson Medical School, New Brunswick, N.J., and New Jersey Medical School, Newark. He has received research grants from Biogen and Teva, and is a consultant for Genzyme, Teva, Celgene, and, Mallinckrodt.

Adults with cystic fibrosis (CF) should undergo screening colonoscopy for colorectal cancer every 5 years beginning at age 40 years, unless they have had a solid organ transplant – in which case, screening should begin at age 30 years. For both groups, screening intervals should be shortened to 3 years if any adenomatous polyps are recovered.

The new screening recommendation is 1 of 10 set forth by the Cystic Fibrosis Foundation, in conjunction with the American Gastroenterological Association. The document reflects the significantly increased risk of colorectal cancer among adults with the chronic lung disorder, Denis Hadjiliadis, MD, and his colleagues wrote in the February issue of Gastroenterology. CF patients face up to a 10-fold risk of colorectal cancer, compared with the general population; the risk approaches a 30-fold increase among CF patients who have undergone a lung transplant.

SOURCE: American Gastroenterological Association

In addition to making recommendations on screening intervals and protocols, the document asks clinicians to reframe their thinking of CF as a respiratory-only disease.

“Physicians should recognize that CF is a colon cancer syndrome,” wrote Dr. Hadjiliadis, director of the Adult Cystic Fibrosis Program at the University of Pennsylvania, Philadelphia, and his coauthors.

The increased colorectal cancer risk has become increasingly evident as CF patients live longer, Dr. Hadjiliadis and the panel wrote.

“The current median predicted survival is 41 years, and persons born in 2015 have an estimated average life expectancy of 45 years. The increasing longevity of adults with CF puts them at risk for other diseases, such as gastrointestinal cancer.”

In addition to the normal age-related risk, however, CF patients seem to have an elevated risk profile unique to the disease. The underlying causes have not been fully elucidated but may have to do with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), which are responsible for the excess thickened mucosal secretions that characterize CF. CFTR also is a tumor-suppressor gene in the intestinal tract of mice, and is important in gastrointestinal epithelial homeostasis. “Absence of CFTR is associated with dysregulation of the immune response, intestinal stem cells, and growth signaling regulators,” the authors noted.

In response to this observed increased risk of colorectal cancers among CF patients, the Cystic Fibrosis Foundation convened an 18-member task force to review the extant literature and compile colorectal cancer screening recommendations for CF patients who show no signs of such malignancies. The team reviewed 1,159 articles and based its findings on the 50 most relevant. The papers comprised observational studies, case-control studies, and case reports; there are no randomized clinical trials of screening for this population.

The American Gastroenterological Association reviewed and approved all of the recommendations:

• Screening decisions should be a collaborative process between the CF patient and clinician, taking into account comorbidities, safety, and quality of life. This should include a discussion of expected lifespan; patients with limited lifespan won’t benefit from screening for a slow-growing cancer. Patients should also consider that the colonoscopy prep for CF patients is somewhat more complex than for non-CF patients. “Given these complexities, the task force agreed that individuals with CF and their providers should … carefully assess the risks and benefits of CRC screening and its impact on the health and quality of life for the adult with CF.”
• The decision team should include an endoscopist. An endoscopist with CF training is preferred, but the panel noted these specialists are rare.
• Colonoscopy is the preferred method of screening for CF patients, since it can both detect and remove polyps. “This is one of the main reasons why colonoscopy is the screening procedure of choice for other high-risk groups,” the panel noted.
• There is insufficient evidence to recommend alternate screening methods in CF patients, including CT scanning, colonography, stool-based tests, or flexible sigmoidoscopy.
• In CF patients without signs of CRC, screening should commence at age 40 years and be repeated every 5 years as long as the results are negative.
• Any CF patient who has had adenomatous polyps on a screening colonoscopy should have a repeat colonoscopy within 3 years, unless clinical findings support more frequent screening.
• For any adult CF patient older than age 30 years who has undergone a solid organ transplant, screening colonoscopy should commence within 2 years of transplantation. “Although the absolute risk of CRC in individuals with CF is extremely low for patients younger than 30 years, the risk … greatly increases after lung transplantation,” to 25-30 times the age-adjusted baseline, the panel wrote. “Increased posttransplantation survival means that many transplant patients will enter older age groups where there is an increased risk of cancer.” Screening should be performed after recovery and within 2 years, unless there was a negative colonoscopy in the 5 years before transplant.
• Thereafter, patients who have had a solid organ transplant should undergo colonoscopy every 5 years, based on their life expectancy. “In cases where the expected survival time is limited (less than 10 years), screening should not be performed. For adults appropriately selected, lung transplantation usually increases survival probability. Therefore, a lung transplantation candidate with a short life expectancy is likely to become a screening candidate before and after transplantation at the appropriate ages described here, because the potential survival increases to approximately 10 years.”
• Colonoscopy should be repeated every 3 years on CF patients with transplants with a history of adenomatous polyps. This interval may be as short as 1 year for patients with high-risk, large, or multiple polyps.
• CF patients should undergo more intense bowel prep for colonoscopy, with three-four washes of a minimum of one liter of purgative per wash; the last wash should occur 4-6 hours before the procedure. Split-prep regimens (several smaller-volume washes) are better than a single larger-volume wash. The panel suggested a sample CF-specific regimen available from the Minnesota Cystic Fibrosis Center.

The new document reflects expert consensus on the currently available data, the panel said. As more data emerge, the recommendations might change.

“It is possible that different subpopulations will need more or less frequent schedules for rescreening and surveillance. Our recommendations are making an effort to balance the risk of missing advanced colorectal cancer and minimizing the burden and risk of too frequent examinations.”

None of the panel members had any financial disclosures.

[email protected]

SOURCE: Hadjiliadis D et al. Gastroenterology. 2017 Dec 28. doi. org/10.1053/j.gastro.2017.12.012

Adults with cystic fibrosis (CF) should undergo screening colonoscopy for colorectal cancer every 5 years beginning at age 40 years, unless they have had a solid organ transplant – in which case, screening should begin at age 30 years. For both groups, screening intervals should be shortened to 3 years if any adenomatous polyps are recovered.

The new screening recommendation is 1 of 10 set forth by the Cystic Fibrosis Foundation, in conjunction with the American Gastroenterological Association. The document reflects the significantly increased risk of colorectal cancer among adults with the chronic lung disorder, Denis Hadjiliadis, MD, and his colleagues wrote in the February issue of Gastroenterology. CF patients face up to a 10-fold risk of colorectal cancer, compared with the general population; the risk approaches a 30-fold increase among CF patients who have undergone a lung transplant.

SOURCE: American Gastroenterological Association

In addition to making recommendations on screening intervals and protocols, the document asks clinicians to reframe their thinking of CF as a respiratory-only disease.

“Physicians should recognize that CF is a colon cancer syndrome,” wrote Dr. Hadjiliadis, director of the Adult Cystic Fibrosis Program at the University of Pennsylvania, Philadelphia, and his coauthors.

The increased colorectal cancer risk has become increasingly evident as CF patients live longer, Dr. Hadjiliadis and the panel wrote.

“The current median predicted survival is 41 years, and persons born in 2015 have an estimated average life expectancy of 45 years. The increasing longevity of adults with CF puts them at risk for other diseases, such as gastrointestinal cancer.”

In addition to the normal age-related risk, however, CF patients seem to have an elevated risk profile unique to the disease. The underlying causes have not been fully elucidated but may have to do with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), which are responsible for the excess thickened mucosal secretions that characterize CF. CFTR also is a tumor-suppressor gene in the intestinal tract of mice, and is important in gastrointestinal epithelial homeostasis. “Absence of CFTR is associated with dysregulation of the immune response, intestinal stem cells, and growth signaling regulators,” the authors noted.

In response to this observed increased risk of colorectal cancers among CF patients, the Cystic Fibrosis Foundation convened an 18-member task force to review the extant literature and compile colorectal cancer screening recommendations for CF patients who show no signs of such malignancies. The team reviewed 1,159 articles and based its findings on the 50 most relevant. The papers comprised observational studies, case-control studies, and case reports; there are no randomized clinical trials of screening for this population.

The American Gastroenterological Association reviewed and approved all of the recommendations:

• Screening decisions should be a collaborative process between the CF patient and clinician, taking into account comorbidities, safety, and quality of life. This should include a discussion of expected lifespan; patients with limited lifespan won’t benefit from screening for a slow-growing cancer. Patients should also consider that the colonoscopy prep for CF patients is somewhat more complex than for non-CF patients. “Given these complexities, the task force agreed that individuals with CF and their providers should … carefully assess the risks and benefits of CRC screening and its impact on the health and quality of life for the adult with CF.”
• The decision team should include an endoscopist. An endoscopist with CF training is preferred, but the panel noted these specialists are rare.
• Colonoscopy is the preferred method of screening for CF patients, since it can both detect and remove polyps. “This is one of the main reasons why colonoscopy is the screening procedure of choice for other high-risk groups,” the panel noted.
• There is insufficient evidence to recommend alternate screening methods in CF patients, including CT scanning, colonography, stool-based tests, or flexible sigmoidoscopy.
• In CF patients without signs of CRC, screening should commence at age 40 years and be repeated every 5 years as long as the results are negative.
• Any CF patient who has had adenomatous polyps on a screening colonoscopy should have a repeat colonoscopy within 3 years, unless clinical findings support more frequent screening.
• For any adult CF patient older than age 30 years who has undergone a solid organ transplant, screening colonoscopy should commence within 2 years of transplantation. “Although the absolute risk of CRC in individuals with CF is extremely low for patients younger than 30 years, the risk … greatly increases after lung transplantation,” to 25-30 times the age-adjusted baseline, the panel wrote. “Increased posttransplantation survival means that many transplant patients will enter older age groups where there is an increased risk of cancer.” Screening should be performed after recovery and within 2 years, unless there was a negative colonoscopy in the 5 years before transplant.
• Thereafter, patients who have had a solid organ transplant should undergo colonoscopy every 5 years, based on their life expectancy. “In cases where the expected survival time is limited (less than 10 years), screening should not be performed. For adults appropriately selected, lung transplantation usually increases survival probability. Therefore, a lung transplantation candidate with a short life expectancy is likely to become a screening candidate before and after transplantation at the appropriate ages described here, because the potential survival increases to approximately 10 years.”
• Colonoscopy should be repeated every 3 years on CF patients with transplants with a history of adenomatous polyps. This interval may be as short as 1 year for patients with high-risk, large, or multiple polyps.
• CF patients should undergo more intense bowel prep for colonoscopy, with three-four washes of a minimum of one liter of purgative per wash; the last wash should occur 4-6 hours before the procedure. Split-prep regimens (several smaller-volume washes) are better than a single larger-volume wash. The panel suggested a sample CF-specific regimen available from the Minnesota Cystic Fibrosis Center.

The new document reflects expert consensus on the currently available data, the panel said. As more data emerge, the recommendations might change.

“It is possible that different subpopulations will need more or less frequent schedules for rescreening and surveillance. Our recommendations are making an effort to balance the risk of missing advanced colorectal cancer and minimizing the burden and risk of too frequent examinations.”

None of the panel members had any financial disclosures.

[email protected]

SOURCE: Hadjiliadis D et al. Gastroenterology. 2017 Dec 28. doi. org/10.1053/j.gastro.2017.12.012

Adults with cystic fibrosis (CF) should undergo screening colonoscopy for colorectal cancer every 5 years beginning at age 40 years, unless they have had a solid organ transplant – in which case, screening should begin at age 30 years. For both groups, screening intervals should be shortened to 3 years if any adenomatous polyps are recovered.

The new screening recommendation is 1 of 10 set forth by the Cystic Fibrosis Foundation, in conjunction with the American Gastroenterological Association. The document reflects the significantly increased risk of colorectal cancer among adults with the chronic lung disorder, Denis Hadjiliadis, MD, and his colleagues wrote in the February issue of Gastroenterology. CF patients face up to a 10-fold risk of colorectal cancer, compared with the general population; the risk approaches a 30-fold increase among CF patients who have undergone a lung transplant.

SOURCE: American Gastroenterological Association

In addition to making recommendations on screening intervals and protocols, the document asks clinicians to reframe their thinking of CF as a respiratory-only disease.

“Physicians should recognize that CF is a colon cancer syndrome,” wrote Dr. Hadjiliadis, director of the Adult Cystic Fibrosis Program at the University of Pennsylvania, Philadelphia, and his coauthors.

The increased colorectal cancer risk has become increasingly evident as CF patients live longer, Dr. Hadjiliadis and the panel wrote.

“The current median predicted survival is 41 years, and persons born in 2015 have an estimated average life expectancy of 45 years. The increasing longevity of adults with CF puts them at risk for other diseases, such as gastrointestinal cancer.”

In addition to the normal age-related risk, however, CF patients seem to have an elevated risk profile unique to the disease. The underlying causes have not been fully elucidated but may have to do with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), which are responsible for the excess thickened mucosal secretions that characterize CF. CFTR also is a tumor-suppressor gene in the intestinal tract of mice, and is important in gastrointestinal epithelial homeostasis. “Absence of CFTR is associated with dysregulation of the immune response, intestinal stem cells, and growth signaling regulators,” the authors noted.

In response to this observed increased risk of colorectal cancers among CF patients, the Cystic Fibrosis Foundation convened an 18-member task force to review the extant literature and compile colorectal cancer screening recommendations for CF patients who show no signs of such malignancies. The team reviewed 1,159 articles and based its findings on the 50 most relevant. The papers comprised observational studies, case-control studies, and case reports; there are no randomized clinical trials of screening for this population.

The American Gastroenterological Association reviewed and approved all of the recommendations:

• Screening decisions should be a collaborative process between the CF patient and clinician, taking into account comorbidities, safety, and quality of life. This should include a discussion of expected lifespan; patients with limited lifespan won’t benefit from screening for a slow-growing cancer. Patients should also consider that the colonoscopy prep for CF patients is somewhat more complex than for non-CF patients. “Given these complexities, the task force agreed that individuals with CF and their providers should … carefully assess the risks and benefits of CRC screening and its impact on the health and quality of life for the adult with CF.”
• The decision team should include an endoscopist. An endoscopist with CF training is preferred, but the panel noted these specialists are rare.
• Colonoscopy is the preferred method of screening for CF patients, since it can both detect and remove polyps. “This is one of the main reasons why colonoscopy is the screening procedure of choice for other high-risk groups,” the panel noted.
• There is insufficient evidence to recommend alternate screening methods in CF patients, including CT scanning, colonography, stool-based tests, or flexible sigmoidoscopy.
• In CF patients without signs of CRC, screening should commence at age 40 years and be repeated every 5 years as long as the results are negative.
• Any CF patient who has had adenomatous polyps on a screening colonoscopy should have a repeat colonoscopy within 3 years, unless clinical findings support more frequent screening.
• For any adult CF patient older than age 30 years who has undergone a solid organ transplant, screening colonoscopy should commence within 2 years of transplantation. “Although the absolute risk of CRC in individuals with CF is extremely low for patients younger than 30 years, the risk … greatly increases after lung transplantation,” to 25-30 times the age-adjusted baseline, the panel wrote. “Increased posttransplantation survival means that many transplant patients will enter older age groups where there is an increased risk of cancer.” Screening should be performed after recovery and within 2 years, unless there was a negative colonoscopy in the 5 years before transplant.
• Thereafter, patients who have had a solid organ transplant should undergo colonoscopy every 5 years, based on their life expectancy. “In cases where the expected survival time is limited (less than 10 years), screening should not be performed. For adults appropriately selected, lung transplantation usually increases survival probability. Therefore, a lung transplantation candidate with a short life expectancy is likely to become a screening candidate before and after transplantation at the appropriate ages described here, because the potential survival increases to approximately 10 years.”
• Colonoscopy should be repeated every 3 years on CF patients with transplants with a history of adenomatous polyps. This interval may be as short as 1 year for patients with high-risk, large, or multiple polyps.
• CF patients should undergo more intense bowel prep for colonoscopy, with three-four washes of a minimum of one liter of purgative per wash; the last wash should occur 4-6 hours before the procedure. Split-prep regimens (several smaller-volume washes) are better than a single larger-volume wash. The panel suggested a sample CF-specific regimen available from the Minnesota Cystic Fibrosis Center.

The new document reflects expert consensus on the currently available data, the panel said. As more data emerge, the recommendations might change.

“It is possible that different subpopulations will need more or less frequent schedules for rescreening and surveillance. Our recommendations are making an effort to balance the risk of missing advanced colorectal cancer and minimizing the burden and risk of too frequent examinations.”

None of the panel members had any financial disclosures.

[email protected]

SOURCE: Hadjiliadis D et al. Gastroenterology. 2017 Dec 28. doi. org/10.1053/j.gastro.2017.12.012

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?

Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.

Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.

The venetoclax/rituximab combination will “probably emerge as a new standard therapy” for refractory CLL based on the data presented, Dr. Brodsky said.

Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.

In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.

[email protected]

ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?

Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.

Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.

The venetoclax/rituximab combination will “probably emerge as a new standard therapy” for refractory CLL based on the data presented, Dr. Brodsky said.

Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.

In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.

[email protected]

ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?

Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.

Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.

The venetoclax/rituximab combination will “probably emerge as a new standard therapy” for refractory CLL based on the data presented, Dr. Brodsky said.

Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.

In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.

[email protected]

LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.

“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).

Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.

The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.

“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).

Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.

The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.

“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).

Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.

The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.

[email protected]

Eradicating chronic hepatitis C virus (HCV) infection led to significant decreases in liver stiffness in a systematic review and meta-analysis of nearly 3,000 patients.

Mean liver stiffness fell by 4.1 kPa (kilopascals) (95% confidence interval, 3.3-4.9 kPa) 12 or more months after patients achieved sustained virologic response to treatment, but did not significantly change in patients who did not achieve SVR, reported Siddharth Singh, MD, of the University of San Diego, La Jolla, Calif., and his associates in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.038). The results were especially striking among patients who received direct-acting antiviral agents (DAAs) or who had high baseline levels of inflammation, the investigators added.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Based on these findings, about 47% of patients with advanced fibrosis or cirrhosis at baseline will drop below 9.5 kPa after achieving SVR, they reported. “With this decline in liver stiffness, it is conceivable that risk of liver-related complications would decrease, particularly in patients without cirrhosis,” they added. “Future research is warranted on the impact of magnitude and kinetics of decline in liver stiffness on improvement in liver-related outcomes.”

Eradicating HCV infection was known to decrease liver stiffness, but the magnitude of decline was not well understood. Therefore, the reviewers searched the literature through October 2016 for studies of HCV-infected adults who underwent liver stiffness measurement by vibration-controlled transient elastography before and at least once after completing HCV treatment. All studies also included data on median liver stiffness among patients who did and did not achieve SVR. The search identified 23 observational studies and one post hoc analysis of a randomized controlled trial, for a total of 2,934 patients, of whom 2,214 achieved SVR.

Among patients who achieved SVR, mean liver stiffness dropped by 2.4 kPa at the end of treatment (95% CI, 1.7-3.0 kPa), by 3.1 kPa 1-6 months later (95% CI, 1.6-4.7 kPa), and by 3.2 kPa 6-12 months after completing treatment (90% CI, 2.6-3.9 kPa). A year or more after finishing treatment, patients who achieved SVR had a 28% median decrease in liver stiffness (interquartile range, 22%-35%). However, liver stiffness did not significantly change among patients who did not achieve SVR, the reviewers reported.

Mean liver stiffness declined significantly more among patients who received DAAs (4.5 kPa) than among recipients of interferon-based regimens (2.6 kPa; P = .03). However, studies of DAAs included patients with greater liver stiffness at baseline, which could at least partially explain this discrepancy, the investigators said. Baseline cirrhosis also was associated with a greater decline in liver stiffness (mean, 5.1 kPa, vs. 2.8 kPa in patients without cirrhosis; P = .02), as was high baseline alanine aminotransferase level (P less than .01). Among patients whose baseline liver stiffness measurement exceeded 9.5 kPa, 47% had their liver stiffness drop to less than 9.5 kPa after achieving SVR.

Coinfection with HIV did not significantly alter the magnitude of decline in liver stiffness 6-12 months after treatment in patients who achieved SVR, the reviewers noted. “[Follow-up] assessment after SVR was relatively short; hence, long-term evolution of liver stiffness after antiviral therapy and impact of decline in liver stiffness on patient clinical outcomes could not be ascertained,” they wrote. The studies also did not consistently assess potential confounders such as nonalcoholic fatty liver disease, diabetes, and alcohol consumption.

One reviewer disclosed funding from the National Institutes of Health/National Library of Medicine. None had conflicts of interest.

Eradicating chronic hepatitis C virus (HCV) infection led to significant decreases in liver stiffness in a systematic review and meta-analysis of nearly 3,000 patients.

Mean liver stiffness fell by 4.1 kPa (kilopascals) (95% confidence interval, 3.3-4.9 kPa) 12 or more months after patients achieved sustained virologic response to treatment, but did not significantly change in patients who did not achieve SVR, reported Siddharth Singh, MD, of the University of San Diego, La Jolla, Calif., and his associates in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.038). The results were especially striking among patients who received direct-acting antiviral agents (DAAs) or who had high baseline levels of inflammation, the investigators added.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Based on these findings, about 47% of patients with advanced fibrosis or cirrhosis at baseline will drop below 9.5 kPa after achieving SVR, they reported. “With this decline in liver stiffness, it is conceivable that risk of liver-related complications would decrease, particularly in patients without cirrhosis,” they added. “Future research is warranted on the impact of magnitude and kinetics of decline in liver stiffness on improvement in liver-related outcomes.”

Eradicating HCV infection was known to decrease liver stiffness, but the magnitude of decline was not well understood. Therefore, the reviewers searched the literature through October 2016 for studies of HCV-infected adults who underwent liver stiffness measurement by vibration-controlled transient elastography before and at least once after completing HCV treatment. All studies also included data on median liver stiffness among patients who did and did not achieve SVR. The search identified 23 observational studies and one post hoc analysis of a randomized controlled trial, for a total of 2,934 patients, of whom 2,214 achieved SVR.

Among patients who achieved SVR, mean liver stiffness dropped by 2.4 kPa at the end of treatment (95% CI, 1.7-3.0 kPa), by 3.1 kPa 1-6 months later (95% CI, 1.6-4.7 kPa), and by 3.2 kPa 6-12 months after completing treatment (90% CI, 2.6-3.9 kPa). A year or more after finishing treatment, patients who achieved SVR had a 28% median decrease in liver stiffness (interquartile range, 22%-35%). However, liver stiffness did not significantly change among patients who did not achieve SVR, the reviewers reported.

Mean liver stiffness declined significantly more among patients who received DAAs (4.5 kPa) than among recipients of interferon-based regimens (2.6 kPa; P = .03). However, studies of DAAs included patients with greater liver stiffness at baseline, which could at least partially explain this discrepancy, the investigators said. Baseline cirrhosis also was associated with a greater decline in liver stiffness (mean, 5.1 kPa, vs. 2.8 kPa in patients without cirrhosis; P = .02), as was high baseline alanine aminotransferase level (P less than .01). Among patients whose baseline liver stiffness measurement exceeded 9.5 kPa, 47% had their liver stiffness drop to less than 9.5 kPa after achieving SVR.

Coinfection with HIV did not significantly alter the magnitude of decline in liver stiffness 6-12 months after treatment in patients who achieved SVR, the reviewers noted. “[Follow-up] assessment after SVR was relatively short; hence, long-term evolution of liver stiffness after antiviral therapy and impact of decline in liver stiffness on patient clinical outcomes could not be ascertained,” they wrote. The studies also did not consistently assess potential confounders such as nonalcoholic fatty liver disease, diabetes, and alcohol consumption.

One reviewer disclosed funding from the National Institutes of Health/National Library of Medicine. None had conflicts of interest.

Eradicating chronic hepatitis C virus (HCV) infection led to significant decreases in liver stiffness in a systematic review and meta-analysis of nearly 3,000 patients.

Mean liver stiffness fell by 4.1 kPa (kilopascals) (95% confidence interval, 3.3-4.9 kPa) 12 or more months after patients achieved sustained virologic response to treatment, but did not significantly change in patients who did not achieve SVR, reported Siddharth Singh, MD, of the University of San Diego, La Jolla, Calif., and his associates in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2017.04.038). The results were especially striking among patients who received direct-acting antiviral agents (DAAs) or who had high baseline levels of inflammation, the investigators added.

SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

Based on these findings, about 47% of patients with advanced fibrosis or cirrhosis at baseline will drop below 9.5 kPa after achieving SVR, they reported. “With this decline in liver stiffness, it is conceivable that risk of liver-related complications would decrease, particularly in patients without cirrhosis,” they added. “Future research is warranted on the impact of magnitude and kinetics of decline in liver stiffness on improvement in liver-related outcomes.”

Eradicating HCV infection was known to decrease liver stiffness, but the magnitude of decline was not well understood. Therefore, the reviewers searched the literature through October 2016 for studies of HCV-infected adults who underwent liver stiffness measurement by vibration-controlled transient elastography before and at least once after completing HCV treatment. All studies also included data on median liver stiffness among patients who did and did not achieve SVR. The search identified 23 observational studies and one post hoc analysis of a randomized controlled trial, for a total of 2,934 patients, of whom 2,214 achieved SVR.

Among patients who achieved SVR, mean liver stiffness dropped by 2.4 kPa at the end of treatment (95% CI, 1.7-3.0 kPa), by 3.1 kPa 1-6 months later (95% CI, 1.6-4.7 kPa), and by 3.2 kPa 6-12 months after completing treatment (90% CI, 2.6-3.9 kPa). A year or more after finishing treatment, patients who achieved SVR had a 28% median decrease in liver stiffness (interquartile range, 22%-35%). However, liver stiffness did not significantly change among patients who did not achieve SVR, the reviewers reported.

Mean liver stiffness declined significantly more among patients who received DAAs (4.5 kPa) than among recipients of interferon-based regimens (2.6 kPa; P = .03). However, studies of DAAs included patients with greater liver stiffness at baseline, which could at least partially explain this discrepancy, the investigators said. Baseline cirrhosis also was associated with a greater decline in liver stiffness (mean, 5.1 kPa, vs. 2.8 kPa in patients without cirrhosis; P = .02), as was high baseline alanine aminotransferase level (P less than .01). Among patients whose baseline liver stiffness measurement exceeded 9.5 kPa, 47% had their liver stiffness drop to less than 9.5 kPa after achieving SVR.

Coinfection with HIV did not significantly alter the magnitude of decline in liver stiffness 6-12 months after treatment in patients who achieved SVR, the reviewers noted. “[Follow-up] assessment after SVR was relatively short; hence, long-term evolution of liver stiffness after antiviral therapy and impact of decline in liver stiffness on patient clinical outcomes could not be ascertained,” they wrote. The studies also did not consistently assess potential confounders such as nonalcoholic fatty liver disease, diabetes, and alcohol consumption.

One reviewer disclosed funding from the National Institutes of Health/National Library of Medicine. None had conflicts of interest.

ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.

When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.

Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.

For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).

Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.

Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.

[email protected]

On Twitter @mitchelzoler
 

ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.

When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.

Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.

For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).

Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.

Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.

[email protected]

On Twitter @mitchelzoler
 

ORLANDO – A high fraction of U.S. patients with atrial fibrillation receive an inappropriately low dosage of an anticoagulant for stroke prevention, often in a misguided attempt to avoid potential bleeding complications.

When physicians “reduce the dose to prevent a bleed they increase the risk for an ischemic stroke,” Elaine M. Hylek, MD, said in a video interview during the annual International AF Symposium.

Recent data on actual anticoagulant dosages prescribed to U.S. patients with atrial fibrillation show that “an unexpectedly high proportion of prescriptions for apixaban (Eliquis), dabigatran (Pradaxa), and rivaroxaban (Xarelto) are given at lower doses,” Dr. Hylek noted at the meeting. The lower-dose formulations with U.S. marketing are only appropriate for patients on apixaban with at least two of the following: serum creatinine 1.5 mg/dL or higher, age 80 years or older, and weight 60 kg or less; patients on dabigatran with moderate renal impairment or treated with dronedarone or systemic ketoconazole; or patients on rivaroxaban with a creatinine clearance of 15-50 mL/min.

For example, in the pivotal trial for apixaban only 5% of atrial fibrillation patients qualified for the lower dosage, yet recent data have shown that, in actual U.S. practice roughly a quarter of patients were on this lower dosage, said Dr. Hylek, professor of medicine at Boston University and director of the thrombosis and anticoagulation service at Boston Medical Center (Curr Med Res Opin. 2016 July;32[7]:1277-79). A second recent report showed that among U.S. patients with atrial fibrillation hospitalized for an ischemic stroke 84% had received inadequate anticoagulation with either subtherapeutic dosages of anticoagulant or no anticoagulant at all (JAMA. 2017 Mar 14;317[10]:1057-67).

Another manifestation of the underprescribing problem are patients with atrial fibrillation treated with aspirin only, an approach proven ineffective for preventing ischemic strokes in these patients, Dr. Hylek said.

Dr. Hylek has been an advisor to or has received honoraria from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Doasense, Janssen, Medtronic, Pfizer, and Portola, and she has received research funding from Boehringer Ingelheim, Bristol-Myers Squibb, and Janssen.

[email protected]

On Twitter @mitchelzoler