https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2003.50346

A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C

The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.

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Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration.

Review of recent research on hepatitis C therapy for 54th annual meeting of the American association for the study of liver diseases

BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

Purpose Empathy is a key element of patient– physician communication; it is relevant to and positively influences patients’ health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency. Method The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size 30 were excluded. Results Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline.

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Empathy decline and its reasons: a systematic review of studies with medical students and residents.

Background and Aim There is no standardized guideline to screen, image, or refer patients with non-alcoholic fatty liver disease (NAFLD) to a specialist. In this study, we used transient elastography (TE) to examine the fibrosis stages at which patients are first diagnosed with NAFLD. Subsequently, we analyzed metabolic markers to establish cut-offs beyond which noninvasive imaging should be considered to confirm NAFLD/non-alcoholic steatohepatitis fibrosis in patients. Methods Charts spanning July 2015-April 2018 for 116 NAFLD patients who had TE performed were reviewed. Univariate and multivariate analysis of metabolic markers was conducted. Results At the first hepatology visit, TE showed 73% F0-F2 and 27% F3-F4. Univariate analysis showed that high-density lipoproteins (HDL), hemoglobin A1c (A1c), aspartate transaminase (AST), and alanine transaminase (ALT) were significantly different between the F0-F2 and F3-F4 groups. Multivariate analysis showed that AST (P = 0.01) and A1c (P = 0.05) were significantly different. Optimal cut-offs for these markers to detect liver fibrosis on TE were AST >43 U/L and A1c >6.6%. The logistic regression function combining these two variables to reflect the probability (P) of the patient having advanced fibrosis (F3-F4) on TE yielded the formula: P = eR /(1 + eR ), where R = -8.56 + 0.052 * AST + 0.89 * A1c. Conclusions Our study suggested that >25% of patients presenting to a specialist for NAFLD may have advanced fibrosis (F3-F4). Diabetes (A1c >6.6%) and AST >43 U/L were the most predictive in identifying NAFLD patients with advanced fibrosis on imaging. We proposed a formula that may be used to prioritize NAFLD patients at higher risk of having advanced fibrosis for specialist referral and imaging follow-up.

Timely diagnosis and staging of non-alcoholic fatty liver disease using transient elastography and clinical parameters.

The national burden of chronic liver disease is steadily increasing and is only expected to worsen with the ongoing obesity and opioid epidemics fueling growth in the prevalence of nonalcoholic fatty liver disease and a resurgence of new hepatitis C infections. Our letter highlights the disparity between the rising prevalence of chronic liver disease and the proportion of medical students who receive exposure to patients with liver disease as part of their medical education. A more comprehensive survey of clerkship directors is needed to further corroborate this data, which may lead to reforms in medical school curricula to better address the expanding burden of chronic liver disease.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep4.1338

The Time Is Now for Mandatory Liver-Focused Clinical Experiences in Medical School

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Development of a Competency-Based Transplant Hepatology Fellowship

RBV (1.29 × 10 9 /L) arms (P 105 kg BW arm had neut 105 kg. Five patients in Peg2a/RBV had plts <25 × 10 9 /L. Regressions for moving averages plots by arm for rates of decreased blood counts vs baseline BW demonstrated: 1) grade 3-4 neutropenia for the 3 arms diverging at <100 kg BW, with the steepest slope for the Peg2a/RBV arm; 2) for grades 2-4 anemia, both PEG/RBV arms showed a slight increase in anemia with decreasing BW, whereas there was a steep increase in anemia for the Peg2a/RBV arm below BW <90 kg, with a divergence from the other 2 arms for those with a BW of <70 kg; 3) grades 2-4 thrombocytopenia decreased with lower BW for both PEG2b/RBV arms but increased with lower BW in the Peg2a/RBV arm. Conclusions: Treatment with Peg2a/RBV causes significantly more neutropenia and thrombocytopenia than either PEG/ RBV regimen, particularly with lower BW. This may reflect the increased bone marrow exposure to interferon on a BW basis in the Peg2a/RBV regimen as well as possible inherent differences between the different peginterferon molecules. Note: Abstract has been updated since submission.

http://hivandhepatitis.com/2008icr/aasld/posters/SCI08-0888-03Safety_FNL.pdf

Hematologic Safety Data From the IDEAL Trial: Neutropenia, Anemia, and Thrombocytopenia Profiles of Peginterferon alfa/Ribavirin

As the hepatitis C epidemic enters its third decade, several trends have become evident: incidence has decreased, prevalence is leveling off, therapy is becoming more individualized, and developments in pharmacotherapy and pharmacogenomics promise to improve treatment outcomes. It is frustrating in this setting that although intravenous drug use continues to be the primary mode of transmission of hepatitis C virus (HCV) in the United States and Europe, nosocomial outbreaks of HCV infection continue to be reported [1–3]. Such outbreaks are not new, having been extensively reported and analyzed in the setting of hemodialysis and poor infection control when using multidose saline vials, heparin solutions, and pain remediation treatments [4–7]. Such outbreaks, while preventable and disconcerting, offer the opportunity to study the natural history of acute hepatitis C. As all chronic cases of HCV infection were at one time acute, we can imply the modes of transmission, spontaneous clearance rates, natural history and treatment responsiveness, but lack the ability afforded by analysis of acute cases to determine such information prospectively. Although most cases of acute HCV infection are thought to be asymptomatic, studies of acute hepatitis C have generally enrolled symptomatic patients. In this cohort, spontaneous clearance seems higher than in case series of chronic hepatitis C [8]. Generalization of the natural history of HCV infection from both acute cohorts is problematic, as variations of mode of transmission, age at transmission, gender, race, and presence of medical comorbidities affect outcome and treatment response [9]. Management of acute HCV infection remains unsettled, but guidelines based on available studies do exist. Initiation of treatment is recommended in order to prevent treatment of patients with high likelihood of spontaneous viral clearance. Reports of such spontaneous resolution of infection vary from 0 to 80% with a mean of 26%, depending on both viral and host factors [8, 10–13]. Conversely, too lengthy a delay in therapy adversely affects treatment response. The optimal time of initiation of treatment remains a topic of debate, but most studies recommend waiting no longer than 8–16 weeks from transmission [14, 15]. Pharmacologic therapy for acute HCV infection has not been standardized regarding medication or duration, but has been demonstrated to be cost-effective in two metaanalyses [14, 16]. Interferon monotherapy, both unmodified and PEGylated, has been the mainstay of clinical trials and has been rewarded with very high rates of sustained virologic response (SVR). As with chronic HCV infections, patients with genotype 2 and 3 have a higher SVR than those with genotype 1, but response rates in excess of 90% are commonly reported. Duration of therapy may be as short as 12 weeks in those patients demonstrating clearance of virus at 4 weeks of therapy (early virologic response, EVR) and as long as 48 weeks in those with genotype 1 and 4 disease and no EVR. The addition of ribavirin has not demonstrably increased SVR rates in the treatment of acute hepatitis C [17–20]. In this issue of Digestive Diseases and Sciences, Fazili and co-investigators make a significant contribution to our C. Santos Department of Internal Medicine, Thomas Jefferson University, 833 Chestnut Street, Suite 220, Philadelphia, PA 19107, USA e-mail: carmi.santos@jeffersonhospital.org

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Steven K. Herrine

Papers

Timely diagnosis and staging of non-alcoholic fatty liver disease using transient elastography and clinical parameters.

The Time Is Now for Mandatory Liver-Focused Clinical Experiences in Medical School

Development of a Competency-Based Transplant Hepatology Fellowship

Hematologic Safety Data From the IDEAL Trial: Neutropenia, Anemia, and Thrombocytopenia Profiles of Peginterferon alfa/Ribavirin

Making the Best of a Bad Situation: Early Chronic Nosocomial HCV infection