Sustained and cumulative impact of an electronic medical record-based alert on a hepatitis C birth cohort screening programme.

The study aimed to assess the effect of an electronic medical record-embedded best practice alert (BPA) on HCV age cohort screening in primary care clinics. HCV testing by primary care physicians was monitored prior and subsequent to the implantation of the BPA. Four intervals of 9 months duration were analysed in detail, including a pre-BPA baseline analysis and three annual post-BPA assessments. Pre- and post-BPA orders consistently followed a power law distribution, characterized by small groups of physicians placing the majority of test orders. Significant correlations were present between the numbers of tests orders by each physician, suggesting that 'high' and 'low' screening performances tended to be physician-specific. Testing rates increased markedly in response to the BPA, resulting in completion of screening in 56.8% (50,468 of 88,914%) of the entire age cohort within less than 3 years. In conclusion, HCV age cohort testing by primary care physicians follows a power-law distribution, with high-performing physicians contributing disproportionately to the overall effort. A simple BPA resulted in a sufficient increase in testing to allow testing of the entire target population within a reasonable time frame.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis.

BACKGROUND: Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges. AIM: To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events. METHODS: We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI). RESULTS: We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95). CONCLUSION: Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Effect of a Best Practice Alert on Birth-Cohort Screening for Hepatitis C Virus.

INTRODUCTION: We assessed the influence of a best practice alert (BPA) embedded within the electronic medical record on improving hepatitis C virus (HCV) birth-cohort screening by primary care physicians (PCPs). METHODS: Screening by 155 PCPs was monitored during 2 consecutive 9-month periods before and after implementation of the BPA. All tests were reviewed to differentiate true screening from other testing indications. RESULTS: Of 155 PCPs, 131 placed screening orders before and after BPA. Twenty-two PCPs started testing after BPA (P = 0.02). The number of tests placed and screening rates per PCP increased from 16 to 84 and from 3.3% to 13.2%, respectively (P < 0.0001). Before BPA, most PCPs rarely ordered screening HCV tests, whereas a small group of physicians generated most tests, indicative of an underlying power-law distribution. After the BPA, a new group of high-performing PCPs emerged, whose screening patterns were again characterized by a power-law distribution. However, pre-BPA test rates of individual PCPs were not predictive of their post-BPA rates. Overall, the introduction of the BPA narrowed the gap between low- and high-performing testers, indicating that modest increases in testing by a large number of low-performing PCPs could drive substantial improvement in program implementation. DISCUSSION: HCV birth-cohort screening by PCPs was shaped by an underlying power-law distribution. This distribution was preserved after the implementation of a BPA, although pre-BPA test rates were not predictive of post-BPA rates. Increases in test rates by high- and low-performing PCPs both contributed to the overall success of the BPA.

Ketogenic, Hypocaloric Diet Improves Nonalcoholic Steatohepatitis.

BACKGROUND AND OBJECTIVES: Nonalcoholic steatohepatitis (NASH) is strongly associated with obesity. A weight loss of ≥10% is necessary to improve NASH severity, but this goal has rarely been achieved in published studies using different diet protocols. The effect of a ketogenic, hypocaloric, commercial diet ("Ideal Protein," IP) on body weight, metabolic markers, and liver tests in a group of NASH patients is evaluated in this study. Daily calorie intake was tailored to achieve a weight loss of ≥10%. METHODS: We analyzed 38 patients with NASH who were placed on the IP diet between 2014 and 2018 and compared their outcomes with 6 control patients who declined the diet. All patients were evaluated by a trained health coach in weekly intervals throughout the study period. Clinical and laboratory data obtained before and at 6.5 months after intervention were compared using paired t-testing. RESULTS: The patients on the IP diet experienced a significant weight reduction (217 ± 8 lb vs. 194 ± 7 lb; mean ± S.E.M.), corresponding to an average weight loss of 9.7% ± 1.6%. Significant changes in systolic blood pressure (133 ± 3 mmHg vs. 123 ± 3 mmHg), triglycerides (200 ± 21 mmol/L vs. 132 ± 11 mmol/L), hemoglobin A1c (6.71% ± 0.29% vs. 5.74% ± 0.19%), SGPT (97.3 ± 11.1 IU/L vs. 44.2 ± 5.9 IU/L), SGOT (82.4 ± 10.5 IU/L vs. 32.8 ± 5.2 IU/L), and Fib-4 scores (2.25 ± 0.23 vs. 1.40 ± 0.13) were also observed (P<0.05 in all cases). In the IP group, 50.5% of patients lost ≥10% body weight. In contrast, no significant changes were observed in the control group. The IP diet was well tolerated, and no safety signals were noticed. CONCLUSIONS: A ketogenic, hypocaloric resulted in striking weight loss and significant improvements in metabolic parameters and liver tests, suggesting that this approach carries promise for the dietary management of patients with NASH.

A Case of Severe, Nilotinib-Induced Liver Injury.

Idiosyncratic hepatotoxicity is a leading reason for the discontinuation or dose modification of Food and Drug Administration (FDA)-approved medications in the United States. We report the case of a 53-year-old woman with chronic myeloid leukemia who developed acute cholestatic hepatitis in response to the tyrosine kinase inhibitor nilotinib. Nilotinib was discontinued, and the patient's liver function tests normalized over the next 3 months. We conclude that nilotinib may cause life-threatening hepatotoxicity and recommend that patients on the medication undergo regular monitoring of their liver tests.