Continuing Medical Education Questions: August 2021.

Article Title: A microsimulation model to determine the cost-effectiveness of treat to target strategies for Crohn's disease.

Continuing Medical Education Questions: April 2019.

To receive CME/MOC credit for this activity, please go to: http://acgjournalcme.gi.org/Article Title: Diagnosis and Treatment of Rumination Syndrome: A Critical Review.

Continuing Medical Education Questions: September 2019.

Article Title: Inflammatory Bowel Disease: A Practical Path to Transitioning from Pediatric to Adult Care.

Hepatitis B Virus Screening and Reactivation in a National VA Cohort of Patients with Inflammatory Bowel Disease Treated with Tumor Necrosis Factor Antagonists.

BACKGROUND: Practice guidelines recommend screening for hepatitis B virus (HBV) infection prior to initiating treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor (anti-TNF) therapy. However, the adherence to these screening guidelines and the clinical outcomes of HBV reactivation following anti-TNF use are not well known. METHODS: This is a retrospective cohort study using the Veterans Health Administration datasets for IBD patients with filled prescriptions for anti-TNFs from 2003 to 2011. Laboratory testing was used to define HBV screening status in the 12 months preceding anti-TNF initiation. Logistic regression models were used to identify predictors of HBV screening. Cases of potential HBV reactivation were identified using ICD-9 codes for HBV infection or acute liver failure or by medications used for HBV infection treatment, and manually reviewed for verification. RESULTS: We identified 3357 IBD patients with filled prescriptions for anti-TNF medications. The HBV testing prior to anti-TNF initiation was 8.1% in 2003 and increased to 43.2% by 2011, with an overall rate of 23.7%. In multivariate analysis, African-American race, facilities with a higher volume of IBD patients, and facilities with an academic affiliation were associated with a higher probability of HBV screening. We did not identify a single case of confirmed clinically relevant HBV reactivation after anti-TNF initiation during 7210 patient-years of medication use. CONCLUSIONS: HBV screening rates prior to anti-TNF initiation are low among IBD patients, but have increased over time. Despite low rates of screening, clinically significant HBV reactivation after anti-TNF initiation in this US cohort was nonexistent.

Expanded use of aggressive therapies improves survival in early and intermediate hepatocellular carcinoma.

BACKGROUND: Despite the increasing annual incidence of hepatocellular carcinoma (HCC) in the USA, now estimated at 2.7 cases per 100 000 population, only a small proportion of patients receive treatment and 5-year survival rates range from 9% to 17%. OBJECTIVES: The present study examines the effects of multimodal treatment on survival in a mixed-stage HCC cohort, focusing on the impact of radical therapy in patients with Barcelona Clinic Liver Cancer (BCLC) stage B disease. METHODS: A retrospective review of the medical records of 254 patients considered for HCC treatment between 2003 and 2011 at a large tertiary referral centre was conducted. RESULTS: A total of 195 (76.8%) patients were treated with a median of two liver-directed interventions. Median survival time was 16 months. In proportional hazards analysis, radiofrequency ablation (RFA) and resection were associated with significantly improved 1- and 5-year survival among patients with BCLC stage 0-A disease. In patients with BCLC stage B disease, RFA conferred a survival benefit at 1 year and resection was associated with significantly improved survival at 5 years. CONCLUSIONS: As one of few studies to track the complete course of sequential HCC therapies, the findings of the present study suggest that HCC patients with intermediate-stage (BCLC stage B) disease may benefit from aggressive interventions not currently included in societal guidelines.

Ulcerative Colitis: What is the Optimal Treatment Goal and How Do We Achieve It?

OPINION STATEMENT: The treatment paradigms and therapeutic options for ulcerative colitis (UC) have rapidly evolved during the past decade. Traditionally, the treatment target has focused on achieving successful induction and maintenance of steroid-free clinical remission. This has been shown to provide a better quality of life and a reduction in complications, hospitalizations, and surgery. Recent studies, however, suggest that achieving "mucosal healing" or endoscopic remission may be the optimal treatment endpoint. In this review, we will examine the treatment goals for UC and the efficacy of each therapy to reach these targets. We will also review the therapeutic options available for UC: mesalamines, steroids, immunomodulators, and biologics, including the first anti-integrin inhibitor, approved in May 2014, for the treatment of UC. Therapeutic drug monitoring, which measures serum drug level and anti-drug antibody concentrations, is emerging as an important clinical decision tool in patients on tumor necrosis factor (TNF)-antagonists. These evolving treatment strategies allow gastroenterologists to optimize control of the disease and offer patients a better quality of life.

Preemptive adefovir versus lamivudine for prevention of hepatitis B reactivation in chronic hepatitis B patients undergoing chemotherapy.

BACKGROUND: This proof-of-concept study compared lamivudine (LAM) with a newer antiviral agent, adefovir dipivoxil (ADF), in preventing hepatitis B virus (HBV) reactivation in chronic HBV patients undergoing chemotherapy. METHODS: Hepatitis B surface antigen (HBsAg) positive patients intended to undergo chemotherapy were randomized to receive either LAM 100 mg daily or ADF 10 mg daily. Anti-viral therapy was started 1 week prior to chemotherapy and until 6 months after completing chemotherapy. The primary outcome was HBV reactivation rate. All patients with viral breakthrough were screened for resistance mutations by direct sequencing. RESULTS: Seventy treatment-naïve patients were consecutively randomized 1:1 to LAM or ADF. The median baseline HBV DNA levels were similar (LAM 3.36 vs. ADF 3.17 log10 copies/mL, p = 0.860). The median duration was 8.3 months on LAM and 10.6 months on ADF (p = 0.220). HBV reactivation was observed in 13/35 (37.1%) on LAM compared with 10/35 (28.6%) on ADF (p = 0.611). The median time to HBV reactivation was 4.6 and 8.1 months, on LAM and ADF respectively. Among these 13 patients, 8/13 (61.5%) on LAM had developed drug resistance mutations but none on ADF had developed drug resistance mutations to ADF (p = 0.003). Both drugs were well tolerated and no severe drug-related toxicities were reported. CONCLUSION: In this randomized clinical study, adefovir and lamivudine demonstrated similar efficacy in preventing hepatitis B reactivation in HBsAg-positive patients undergoing chemotherapy. In patients whose hepatitis B reactivated, adefovir was associated with a lower resistance profile.

Estimating DNA repair by sequential evaluation of head and neck tumor radiation sensitivity using the comet assay.

BACKGROUND: The alkaline comet assay is a microelectrophoretic technique for detecting single-strand DNA breaks, and may be used as an indirect measure of hypoxia by determining the radiation sensitivity of individual cells. OBJECTIVE: To assess the ability of the comet assay to estimate the rate of DNA repair after irradiation in patients with head and neck cancer. METHODS: The comet assay was used to evaluate DNA damage in fine-needle aspirates of lymph nodes containing metastatic squamous cell carcinoma in patients with head and neck cancer 1, 2, and 3 minutes after treatment with 500 rad (5 Gy) of irradiation. The amount of DNA damage (measured as the "tail moment" of the comet) is proportional to the number of DNA single-strand breaks after irradiation, which in turn depends on the oxygen concentration in each cell. RESULTS: The mean +/- SD of the median tail moment of the 1-minute postirradiation comets was 29.4 +/- 14.2 (n = 27). After 2 minutes, the mean median tail moment decreased to 25.4 +/- 13.6 (n = 25), representing a mean decrease of 11.9% in those patients with both 1- and 2-minute comet assays. Assuming a linear rate of repair, this decrease in DNA damage corresponds to a repair half-life of 4.2 minutes. A 3-minute assay was also performed on samples from a smaller number of patients (n = 9), with a mean value not significantly different from that of the 2-minute assay of the samples from this group. CONCLUSIONS: The comet assay is a promising tool for evaluating radiation sensitivity in individual cells. The rate of DNA repair early after irradiation is consistent with data in the literature.

Functional abdominal pain causing Scurvy, Pellagra, and Hypovitaminosis A.

Severe vitamin deficiency disease is rarely seen in developed countries. We present an atypical case of a young man with scurvy, pellagra, and hypovitaminosis A, caused by longstanding functional abdominal pain that severely limited his ability to eat.

A 13 year-old boy with post-transplantation lymphoproliferative disorder presenting with obscure gastrointestinal bleeding: a case report.

One well recognized and potentially serious complication of chronic immunosuppression in organ transplant recipients is post-transplantation lymphoproliferative disorders (PTLD). This accounts for 20% of all malignancies in transplant recipients, which is four times higher than the general population (1,2). The diagnosis of PTLD is often difficult, due to various manifestations resulting in late diagnosis. We report an unusual presentation of PTLD in a pediatric patient where the diagnosis was achieved only after extensive investigation.