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The article presents the discussion on weight loss target needed to reverse liver fibrosis or decreasing the risk of myocardial infarction. Topics include weight loss reducing the risk of obesity-associated diseases such as diabetes and nonalcoholic fatty liver disease; and medical bariatrician, psychologist, dietitian, exercise physiologist, and surgeon being essential for improved outcomes.

Background: While bidirectional endoscopy is recognized as the standard approach for investigating iron deficiency anemia (IDA) in men older than 45 and postmenopausal women, evidence supporting the application of this approach in younger men and premenopausal women is scarce in the absence of symptoms. Our primary aim is to identify the diagnostic yield of bidirectional endoscopy in men younger than 45 and premenopausal women, and describe the clinical characteristics of those with significant endoscopic and pathology-proven findings. Methods: We performed a retrospective chart review including patients younger than age 45 with IDA who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy at the Brooklyn VA Hospital between 2009 and 2023. Demographic, clinical, and endoscopic patient data was all collected, stratified, analyzed, and interpreted. Results: In 143 patients younger than age 45 with IDA, 28.6% were found to have positive upper gastrointestinal (GI) findings, of which 70.3% were pathology-proven H. pylori cases. 57.9% of patients reported upper GI symptoms, while 42.9% of patients were asymptomatic. In total, 18.2% of symptomatic patients were found to have clinically significant findings on EGD as compared with 42.9% of asymptomatic patients. Additionally, 9.1% of symptomatic patients were found to have biopsy proven H. pylori-associated gastritis or duodenitis as compared with 33.9% of asymptomatic patients. Of the patients who underwent colonoscopy, 8.3% were found to have lower GI lesions. Conclusions: We found the diagnostic yield of EGD to be significantly higher than that of colonoscopy in younger IDA patients. Our findings suggest current guidelines are clinically relevant to the young patient cohort. Our study also found asymptomatic IDA patients below age 45 to have a significantly higher diagnostic yield of EGD as compared to symptomatic IDA patients within the same age cohort. The differences in diagnostic yields may be a result of symptomatic patients being more likely to have been prescribed proton pump inhibitors or histamine receptor antagonists prior to endoscopy. [ABSTRACT FROM AUTHOR]

A continuing medical education (CME) examination from the American College of Gastroenterology (ACG) on topics like hepatocellular carcinoma surveillance of chronic hepatitis B is presented.

Hepatitis C and type 2 diabetes mellitus (DM) are two rising epidemics with significant impact on each other. Hepatitis C-infected patients have a higher incidence of type 2 diabetes, and diabetic patients have a high prevalence of hepatitis C. There is mounting evidence that glucose abnormalities have a negative impact on the disease progression as well as antiviral therapy outcomes. Utilization of oral glucose tolerance testing has the potential to uncover previously undetected DM as well as impaired glucose tolerance or prediabetes in patients with chronic hepatitis C (CHC). Early detection of diabetes and prediabetes with oral glucose tolerance testing in CHC patients can lead to interventions, with significant positive impact on disease progression and antiviral therapy outcomes. [ABSTRACT FROM AUTHOR]

An abstract of the article "Interstitial Pneumonitis: A Rare But Potentially Fatal Complication of Combination Therapy" by Ayse Aytaman, Deepak Vadhan, Fidelina Desoto-Lapaix, Michael Cutaia, Ronny Awaida, JoAnn Comas, Lawrence Riccio, and Gerald Fruchter is presented.

Simple Summary: In this perspective piece we will summarize our path to implement local, regional and integrated service network tumor boards and our use of technology to facilitate this process and provide guidance for other institutions outside of Veterans Affairs system to implement this unique model. We offer a road map to establish regional multidisciplinary liver tumor boards. In this perspective piece, we summarize the development and implementation of multidisciplinary liver tumor boards across the Veterans Affairs health care system dating back to 2010. Referral to multidisciplinary tumor boards (MDLTB) has been demonstrated to decrease the number of unnecessary invasive procedures, reduce health care costs and maximize patient outcomes. Although the VA is the largest single care provider in the US, there is significant heterogeneity in healthcare delivery. We have shown that receiving care at VA centers with MDLTB is associated with higher odds of receiving active therapy and a 13% reduction in mortality. Access to expert hepatology care appears to be one of the critical benefits of MDLTB resulting in 30% reduction in mortality. Integrated health care systems such as the VA have the unique capability of implementing virtual tumor boards that can easily overcome geographic barriers and standardize care across multiple facilities regardless of their access to hepatology or other disciplines. Significant barriers remain requiring implementation plans. This document serves as a roadmap to establish multidisciplinary tumor boards, including standardization of imaging reports, identifying stake holders who need to be present at tumor board, institution buy-in, and specifics for local, regional and integrated service network tumor boards. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic hepatitis C virus (HCV) infection has the highest prevalence in "baby boomers" born in 1945 through 1965. New York State mandates that all persons born during this period be screened at least once for hepatitis C. Local problem: Military veteran HCV screening is often missed during primary care visits. Methods: After baseline screening, provider education with and without an HCV education dashboard of information in the Electronic Medical Record system was used to determine if screening proportions could be improved. The Chisquare and Z-test for independent proportions compared after with before education screening. The odds ratio compared after versus before screening odds. Interventions: Two interventions were tested. One was provider education with a 30-minute lecture. The second was the lecture with addition of an HCV education computer dashboard. Results: The Chi-square test and Z-test comparing the month immediately after provider education was significant for increased screening (p < .01) compared with baseline. There was a 2.04-fold (95% confidence interval, 1.31-3.20) greater odds of screening in the month after education. If two or more months went by after education, the effect of education no longer improved screening proportions. Provider education plus the use of HCV education dashboard did not improve screening from baseline to the month immediately after screening (p = .95). Conclusion: Provider education significantly improved HCV screening the month immediately after education, then regressed toward baseline. Adding an HCV education dashboard to education did not improve screening. To maintain elevated screening proportions, provider screening educationmust be reinforced on a frequent basis for sustained effect. [ABSTRACT FROM AUTHOR]

Background: The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated.Objective: The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival.Design: Retrospective observational study.Data Source: Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology.Results: Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival.Conclusion: We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Background: As the era of interferon-alpha (IFN)-based therapy for hepatitis C ends, long-term treatment outcomes are now being evaluated.Aim: To more fully understand the natural history of hepatitis C infection by following a multisite cohort of patients.Methods: Patients with chronic HCV were prospectively enrolled in 1999-2000 from 11 VA medical centers and followed through retrospective medical record review.Results: A total of 2211 patients were followed for an average of 8.5 years after enrollment. Thirty-one percent of patients received HCV antiviral therapy, 15 % with standard IFN/ribavirin only, 16 % with pegylated IFN/ribavirin, and 26.7 % of treated patients achieved sustained virologic response (SVR). Cirrhosis developed in 25.8 % of patients. Treatment nonresponders had a greater than twofold increase in the hazard of cirrhosis and hepatocellular carcinoma, compared to untreated patients, whereas SVR patients were only marginally protected from cirrhosis. Nearly 6 % developed hepatocellular carcinoma, and 27.1 % died during the follow-up period. Treated patients, regardless of response, had a significant survival benefit compared to untreated patients (HR 0.58, CI 0.46-0.72). Improved survival was also associated with college education, younger age, lower levels of alcohol consumption, and longer duration of medical service follow-up-factors typically associated with treatment eligibility.Conclusions: As more hepatitis C patients are now being assessed for all-oral combination therapy, these results highlight that patient compliance and limiting harmful behaviors contribute a significant proportion of the survival benefit in treated patients and that the long-term clinical benefits of SVR may be less profound than previously reported. [ABSTRACT FROM AUTHOR]

Background/Aims: HIV-infected patients now live longer and often have complications of liver disease, especially with hepatitis B or C virus coinfection. Limited data are available on those with hepatocellular carcinoma (HCC). Methods: A retrospective analysis from 1992 to 2005 in 6 centers identified 63 HIV-infected HCC patients. Controls were 226 consecutive HIV-negative HCC patients from four sites. Results: HIV-positive patients were younger than controls (52 vs. 64years, p <0.001), more commonly had chronic hepatitis B or C (97% vs. 73%, p <0.001), were more frequently symptomatic (51% vs. 38%, p =0.048), had a higher median alfa-fetoprotein level (227 vs. 51 ng/ml, p =0.005), but a similar mean Child–Turcotte–Pugh score (7.0 vs. 7.5, p =0.05) and HCC staging score (Barcelona-Clínic-Liver-Cancer stages C+D in 50% vs. 58%, p =0.24). HCC developed faster in HIV/HCV-coinfected than in HCV-monoinfected patients (mean, 26 vs. 34years after HCV infection, p =0.002). HIV-positive patients received proven therapy more often (48% vs. 31%, p =0.017), but median survival was similar (6.9 vs. 7.5 months, p =0.44). Independent factors predicting survival were symptomatic presentation (hazard ratio [HR], 0.437; p <0.001), any proven therapy (HR, 2.19; p <0.001), diagnosis after 01-Jan-2002 (HR, 1.52; p =0.010), Barcelona-Clínic-Liver-Cancer stages C+D (HR, 0.491; p <0.001), AST/ALT⩾2.00 (HR, 0.597; p =0.001), AFP⩾400 ng/mL (HR, 0.55, p =0.003), and platelets⩾100,000/mm3 (HR, 0.651; p =0.012), but not HIV-serostatus (p =0.19). In HIV-infected patients without HCC therapy (n =33), median survival was longer with undetectable HIV RNA (<400copies/mL) than with HIV viremia (6.5 vs. 2.6 months, p =0.013). Conclusions: HIV-positive HCC patients are younger and more frequently symptomatic and infected with HCV or HBV than HIV-negative patients. Tumor staging and survival are similar. In untreated patients, undetectable HIV RNA independently predicts better survival. [Copyright &y& Elsevier]

OBJECTIVES: The efficacy of combination therapy with pegylated interferon (PEG IFN) α plus ribavirin (RBV) in the retreatment of chronic hepatitis C (CHC) in patients who previously failed combination standard IFN plus RBV or IFN monotherapy has not been well established. METHODS: Three hundred and twenty-one CHC patients including virologic nonresponders to combination IFN plus RBV (n = 219) or IFN monotherapy (n = 47), and relapsers to combination therapy (n = 55) were randomized to receive PEG IFN α-2b 1.5 μg/kg per wk plus RBV 800 mg per day (Regimen A, n = 160) or PEG IFN α-2b 1.0 μg/kg per wk plus RBV 1,000–1,200 mg per day (Regimen B, n = 161) for 48 wks. RESULTS: Sustained virologic response (SVR) occurred in 16% of the overall study population (Regimen A vs B, 18% vs 13%, p= 0.21), in 8% of the combination therapy nonresponders (10% vs 6%, p= 0.35), in 21% of the IFN monotherapy nonresponders (16% vs 27%, p= 0.35), and in 42% of the combination therapy relapsers (50% vs 32%, p= 0.18). In nonresponders to prior combination therapy, HCV ribonucleic acid levels <100,000 copies/mL at the end of the prior treatment course were associated with an increased SVR compared with levels ≥100,000 copies/mL (21% vs 5%, p= 0.002). In the overall study population, genotype 1 patients had lower SVR rates than others (14% vs 33%, p= 0.01), and African Americans had lower SVR than Caucasians (4% vs 18%, p= 0.01). CONCLUSION: Combination therapy with PEG IFN α-2b plus RBV is more effective in patients who relapsed after combination standard IFN plus RBV than in nonresponders to either combination therapy or IFN monotherapy. There was no significant effect of dosing regimen. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many veterans may not be candidates for hepatitis C virus (HCV) treatment due to contraindications to therapy. The aims of this study were to determine the proportion of HCV-infected veterans who were eligible for interferon alfa and ribavirin therapy and to evaluate barriers to HCV treatment. METHODS: We prospectively enrolled 4,084 veterans who were referred for HCV treatment over a 1-yr period at 24 Veterans Affairs (VA) Medical Centers. Treatment candidacy was assessed using standardized criteria and the opinion of the treating clinician. RESULTS: Overall, 32.2% (95% CI, 30.8–33.7%) were candidates for HCV treatment according to standardized criteria, whereas 40.7% (95% CI, 39.2–42.3%) were candidates in the opinion of the treating clinician. Multivariable analysis identified ongoing substance abuse (OR = 17.68; 95% CI, 12.24–25.53), comorbid medical disease (OR = 9.62; 95% CI, 6.85–13.50), psychiatric disease (OR = 9.45; 95% CI, 6.70–13.32), and advanced liver disease (OR = 8.43; 95% CI, 4.42–16.06) as the strongest predictors of not being a treatment candidate. Among patients who were considered treatment candidates, 76.2% (95% CI, 74.0–78.3%) agreed to be treated and multivariable analysis showed that persons ≥50 yr of age (OR = 1.37; 95% CI, 1.07–1.76) and those with >50 lifetime sexual partners (OR = 1.44; 95% CI, 1.08–1.93) were more likely to decline treatment. CONCLUSIONS: The majority of veteran patients are not suitable candidates for HCV treatment because of substance abuse, psychiatric disease, and comorbid medical disease, and many who are candidates decline therapy. Multidisciplinary collaboration is needed to overcome barriers to HCV therapy in this population. (Am J Gastroenterol 2005;100:1–8) [ABSTRACT FROM AUTHOR]

OBJECTIVES:The aims of this study were to determine the prevalence of hepatitis C virus (HCV) infection and its risk factors, as well as the prevalence of coinfection with HIV and its risk factors, among patients with confirmed HCV infection.METHODS:In a 1-day cross-sectional HCV survey at six Veterans Affairs Medical Centers in the New York City metropolitan area, all 1943 patients undergoing phlebotomy for any reason were asked to be tested for HCV antibody by enzyme immumoassay (EIA). A total of 1098 patients (57%) agreed to HCV testing, 1016 of whom also completed a questionnaire on demographics and HCV risk factors. All HCV EIA(+) samples were confirmed by HCV RNA and HCV recombinant immunoblot assay (RIBA) antibody testing and were also tested for HCV viral load, HCV genotype, and antibodies to HIV in a blinded fashion.RESULTS:The prevalence of confirmed HCV infection was 10.6% (95% CI = 8.7–12.4%), and the prevalence of HCV viremia was 8.2% (95% CI = 6.6–9.8%). The rate of HCV viremia among anti-HCV(+) patients was 77.6%, and HCV genotype 1 was present in 87.5% of viremic patients. Independent risk factors for HCV infection were injection drug use (OR = 35.6, 95% CI = 16.9–75.2), blood exposure during combat (OR = 2.6, 95% CI = 1.2–5.7), alcohol abuse (OR = 2.4; 95% CI = 1.2–4.8), and service in the Vietnam era (OR = 2.1; 95% CI = 1.0–4.5). Coinfection with HIV was present in 24.8% of anti-HCV(+) patients. The only independent risk factor for coinfection was age <50 yr (OR = 3.7, 95% CI = 1.1–12.1).CONCLUSIONS:U.S. veterans who are receiving medical care at VA medical centers in the New York City metropolitan area have a much higher rate of chronic hepatitis C than the general population, with a high frequency of genotype 1. Coinfection with HIV is very common in patients with confirmed HCV infection, and these patients should routinely be offered HIV testing. [Copyright &y& Elsevier]

The development of decompensation in cirrhosis demarcates a marked change in the natural history of chronic liver disease. HMG-CoA reductase inhibitors (statins) exert pleiotropic effects that reduce inflammation and fibrosis as well as improve vascular reactivity. Retrospective studies uniformly have associated statin utilization with improved outcomes for patients with cirrhosis. Prospective human studies have shown that statins reduce portal hypertension and reduce death in patients with decompensated cirrhosis after variceal hemorrhage when added to standard therapy with an acceptable safety profile. This proposal aims to extend these findings to demonstrate that simvastatin reduces incident hepatic decompensation events among cirrhotic patients at high risk for hepatic decompensation. We will perform the SACRED Trial (NCT03654053), a phase III, prospective, multi-center, double-blind, randomized clinical trial at 11 VA Medical Centers. Patients with compensated cirrhosis with clinically significant portal hypertension will be stratified based upon the concomitant use of nonselective beta-blockers and randomized to simvastatin 40 mg/day versus placebo for up to 24 months. Patients will be observed for the development of hepatic decompensation (variceal hemorrhage, ascites, encephalopathy), hepatocellular carcinoma, liver-related death, death from any cause, and/or complications of statin therapy. Ancillary studies will evaluate patient-reported outcomes and pharmacogenetic corollaries of safety and/or efficacy. Statins have a long track-record of safety and tolerability. This class of medications is generic and inexpensive, and thus, if the hypothesis is proven, there will be few barriers to widespread acceptance of the role of statins to prevent decompensation in patients with compensated cirrhosis. ClinicalTrials.gov Identifier: NCT03654053 [ABSTRACT FROM AUTHOR]

An abstract of the article "Gastric Necrosis: A Complication of Gastric Banding" by Gerald Fruchter, Vlado Simko, Hatem Shoukeir, Hueldine Webb, and Ayse Aytaman is presented.