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Wong YJ, Chen Z, Li J, Liu C, Qi X, Chan YH. Reply: CHESS-ALARM score: Is it a 5-year prediction score? J Gastroenterol Hepatol 2022; 37:1405. [PMID: 35514323 DOI: 10.1111/jgh.15885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/02/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Y J Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore
| | - Z Chen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - J Li
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - C Liu
- CHESS Center Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - X Qi
- CHESS Center Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Y H Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Wong YJ, Nguyen MH. Is it safe to treat chronic hepatitis C patients with decompensated cirrhosis with PI-based DAAs? J Hepatol 2022; 77:257-258. [PMID: 35074472 DOI: 10.1016/j.jhep.2021.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, California, USA; Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA.
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Wong YJ, Kumar R. Follow-Up Paracentesis in Spontaneous Bacterial Peritonitis: Prognostic, but May Not Improve Survival. Clin Gastroenterol Hepatol 2022; 20:1615-1616. [PMID: 34371164 DOI: 10.1016/j.cgh.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-National University of Singapore Academic Medical Centre, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-National University of Singapore Academic Medical Centre, Singapore
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Wong YJ, Li J, Liu C, Chen Z, Chan YH, Putera M, Teh KB, Ang TL, Zhao L, Yan Z, Kumar R, Li X, Qi X. CHESS-ALARM score to stratify decompensation risk in compensated advanced chronic liver disease patients: An international multicenter study. J Gastroenterol Hepatol 2022; 37:1043-1051. [PMID: 35253271 DOI: 10.1111/jgh.15819] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM A combination of platelet and elastography (PE criteria) was proposed to identify compensated advanced chronic liver disease (cACLD) patients at risk of liver decompensation. We aim to validate and refine PE criteria by developing a new predictive score to predict decompensation in Asian cACLD patients. METHODS An international cohort of 633 cACLD patients with liver stiffness measurement (LSM) and esophagogastroduodenoscopy performed were included. We validated PE criteria to predict first liver decompensation using competing risk analysis, with death and hepatocellular carcinoma as competing events. We developed a predictive model using proportional subdistribution hazard regression. Prognostic accuracy was compared with the model of end-stage liver disease (MELD), albumin-bilirubin (ALBI), and ALBI-FIB-4 score using time-dependent area under operative characteristic curve (tAUC). RESULTS Sixty patients developed decompensation over the median follow-up of 39 months. Favorable Baveno VI status ruled out cACLD patients at risk of liver decompensation. LSM > 25 kPa was suboptimal to predict cACLD patients who will develop liver decompensation. We developed CHESS-ALARM score by incorporating age, platelet, and gender into LSM. CHESS-ALARM score (tAUC = 0.86, 95% confidence interval [CI]: 0.79-0.94) has significantly higher accuracy than MELD (tAUC: 0.61), ALBI (tAUC: 0.62), ALBI-FIB-4 (tAUC: 0.70), and LSM > 25 kPa (tAUC: 0.54) to predict liver decompensation at 5 years (P < 0.05 for all). Patients with CHESS-ALARM score ≥ -0.37 had an 11-fold higher risk of decompensation (subdistribution hazard ratio = 11.2, 95% CI: 5.1-24.5). CONCLUSION CHESS-ALARM score can be readily incorporated into clinical practice of cACLD patients to estimate individual risk of liver decompensation; however, more data are required in morbidly obese cACLD patients of nonviral etiology.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jia Li
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Zhaojin Chen
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Yiong Huak Chan
- Biostatistic Unit, Yong Loo Lin School of Medicine, Singapore
| | - Martin Putera
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kok Ban Teh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lili Zhao
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Zhongfang Yan
- Department of Radiology, Tianjin Second People's Hospital, Tianjin, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore
| | - Xin Li
- Department of Clinical Nutrition, Tianjin Second People's Hospital, Tianjin, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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Wong YJ, Li J, Chen Z, Liu C, Qi X. Reply: CHESS-ALARM score: Can it raise the alarm accurately? J Gastroenterol Hepatol 2022; 37:1169. [PMID: 35434833 DOI: 10.1111/jgh.15863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Y J Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Program, SingHealth, Singapore
| | - J Li
- Department of Gastroenterology and Hepatology, Tianjin Second People's Hospital, Tianjin, China
| | - Z Chen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - C Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - X Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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Wong YJ, Nguyen MH. Is it safe to treat chronic hepatitis C patients with decompensated cirrhosis with protease inhibitors-based direct-acting antivirals? Liver Int 2022; 42:1207-1208. [PMID: 35220647 DOI: 10.1111/liv.15214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, California, USA.,Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA
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Lee ZY, Suah BH, Teo YH, Teo YN, Syn NLX, Yeo TC, Wong RCC, Chai P, Wong YJ, Ho JSY, Leow AS, Yeo LLL, Tan BYQ, Sia CH. Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation and Concomitant Liver Cirrhosis: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2022; 22:157-65. [PMID: 34008145 DOI: 10.1007/s40256-021-00482-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) have a higher risk of developing thromboembolic events. Current guidelines recommend the use of oral anticoagulants for stroke prevention in these patients. Several clinical trials demonstrated that direct oral anticoagulants (DOACs) have similar efficacy and are safer alternatives to traditional oral anticoagulants. However, patients with concomitant liver cirrhosis were excluded from these trials. OBJECTIVE We aimed to systematically identify and review published clinical studies on the use of DOACs in patients with AF and liver cirrhosis and assess the efficacy and safety of DOACs in these patients. METHODS A systematic review of clinical trials and retrospective studies was conducted by searching the PubMed, Cochrane Library, Embase, SCOPUS, and Web of Science databases up to September 2020. RESULTS Three retrospective studies were included, involving 4011 patients with AF and liver cirrhosis. The use of DOACs was associated with a significant reduction in ischemic stroke (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.42-0.90; p = 0.01), major bleeding events (HR 0.64; 95% CI 0.57-0.72; p < 0.001), and intracranial hemorrhage (HR 0.49; 95% CI 0.40-0.59; p < 0.001). CONCLUSIONS Compared with warfarin in patients with AF and liver cirrhosis, DOACs appear to be associated with improved efficacy and safety outcomes. Randomized controlled trials are warranted to confirm these findings.
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Hussain I, Wong YJ, Lohan R, Lin S, Kumar R. Does preemptive transjugular intrahepatic portosystemic shunt improve survival after acute variceal bleeding? Systematic review, meta-analysis, and trial sequential analysis of randomized trials. J Gastroenterol Hepatol 2022; 37:455-463. [PMID: 34665473 DOI: 10.1111/jgh.15714] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/20/2021] [Accepted: 10/12/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM A preemptive transjugular intrahepatic portosystemic shunt (p-TIPSS) after acute variceal bleeding (AVB) is advocated. However, when compared with the current standard of care, the survival benefit of p-TIPSS is questionable. We performed a systematic review, meta-analysis, and trial sequential analysis of randomized control trials (RCTs) to assess the survival benefit of p-TIPSS in patients with cirrhosis and AVB. METHODS Comprehensive literature search of three bibliographic databases (MEDLINE, Embase, and Cochrane) was conducted from inception till May 2021. All study types evaluating the survival benefit of p-TIPSS in AVB were considered for inclusion. The relative risk (RR) of mortality and rebleeding at 6 weeks and mortality at 1 year with a random-effects model was computed. Trial sequential analysis was performed for the primary outcome of 6-week mortality. RESULTS A total of nine studies (four RCTs and five cohort studies) comprising 2861 patients with AVB were included. The overall pooled risks of mortality at 6 weeks and 1 year were 17.9% (95% confidence interval [CI]: 16.5-19.3%) and 26.7% (95% CI: 25.0-28.3%), respectively. Although p-TIPSS was associated with lower 6-week rebleeding risk (RR = 0.20; 95% CI = 0.13-0.29, I2 = 0%), data from pooled RCTs showed no significant difference in mortality at 6 weeks (RR = 0.33; 95% CI = 0.08-1.36, I2 = 63%) or at 1 year (RR = 0.76; 95% CI = 0.51-1.14, I2 = 30%). Using trial sequential analysis, required sample size to detect a 20% relative risk reduction in mortality at 6 weeks with p-TIPSS was estimated to be 6317, which is beyond the total number of patients available for analysis. CONCLUSIONS This meta-analysis found that the available data from RCTs are insufficient to confer 6-week mortality benefit with p-TIPSS compared with standard of care; thus, adequately powered RCTs are required.
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Affiliation(s)
- Ikram Hussain
- Division of Gastroenterology, Department of Medicine, Woodlands Health Campus, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Centre, CGH Campus, Singapore.,Duke-NUS Medicine ACP, Singapore
| | - Rahul Lohan
- Department of Diagnostics Radiology, Khoo Teck Puat Hospital, Singapore
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Academic Medical Centre, CGH Campus, Singapore
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Koh JH, Liew ZH, Ng GK, Liu HT, Tam YC, De Gottardi A, Wong YJ. Efficacy and safety of direct oral anticoagulants versus vitamin K antagonist for portal vein thrombosis in cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:56-62. [PMID: 34393072 DOI: 10.1016/j.dld.2021.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIM Portal vein thrombosis (PVT) is associated with a higher risk of liver-related complications. Recent guidelines recommend direct-acting anticoagulants (DOAC) in patients with cirrhosis and non-tumoral PVT. However, data on the efficacy and safety of DOAC in these patients remain limited. We aim to investigate the efficacy and safety of DOAC compared to vitamin K antagonists (VKA) to treat non-tumoral PVT in patients with cirrhosis. METHODS We performed a systematic search of six electronic databases using MeSH term and free text. We selected all studies comparing the use of DOACs with vitamin K antagonist to treat PVT in cirrhosis. The primary outcome was PVT recanalization. Secondary outcomes were and PVT progression, major bleeding, variceal bleeding and death. RESULTS From 944 citations, we included 552 subjects from a total of 11 studies (10 observational and 1 randomized trial) that fulfilled the inclusion criteria. We found that DOAC were associated with a higher pooled rate of PVT recanalization (RR = 1.67, 95%CI: 1.02, 2.74, I2 = 79%) and lower pooled risk of PVT progression (RR = 0.14, 95%CI: 0.03-0.57, I2 = 0%). The pooled risk of major bleeding (RR = 0.29, 95%CI: 0.08-1.01, I2 = 0%), variceal bleeding (RR = 1.29, 95%CI: 0.64-2.59, I2 = 0%) and death (RR = 0.31, 95%CI: 0.01-9.578, I2 = 80%) was similar between DOAC and VKA. CONCLUSION For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOAC and VKA. However, DOAC were associated with a higher pooled rate of PVT recanalization. Dedicated randomized studies are needed to confirm these findings.
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10
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Li JW, Chia T, Fock KM, Chong KDW, Wong YJ, Ang TL. Artificial intelligence and polyp detection in colonoscopy: Use of a single neural network to achieve rapid polyp localization for clinical use. J Gastroenterol Hepatol 2021; 36:3298-3307. [PMID: 34327729 DOI: 10.1111/jgh.15642] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 05/11/2021] [Accepted: 07/22/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Artificial intelligence has been extensively studied to assist clinicians in polyp detection, but such systems usually require expansive processing power, making them prohibitively expensive and hindering wide adaption. The current study used a fast object detection algorithm, known as the YOLOv3 algorithm, to achieve real-time polyp detection on a laptop. In addition, we evaluated and classified the causes of false detections to further improve accuracy. METHODS The YOLOv3 algorithm was trained and validated with 6038 and 2571 polyp images, respectively. Videos from live colonoscopies in a tertiary center and those obtained from public databases were used for the training and validation sets. The algorithm was tested on 10 unseen videos from the CVC-Video ClinicDB dataset. Only bounding boxes with an intersection over union area of > 0.3 were considered positive predictions. RESULTS Polyp detection rate in our study was 100%, with the algorithm able to detect every polyp in each video. Sensitivity, specificity, and F1 score were 74.1%, 85.1%, and 83.3, respectively. The algorithm achieved a speed of 61.2 frames per second (fps) on a desktop RTX2070 GPU and 27.2 fps on a laptop GTX2060 GPU. Nearly a quarter of false negatives happened when the polyps were at the corner of an image. Image blurriness accounted for approximately 3% and 9% of false positive and false negative detections, respectively. CONCLUSION The YOLOv3 algorithm can achieve real-time poly detection with high accuracy and speed on a desktop GPU, making it low cost and accessible to most endoscopy centers worldwide.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
| | | | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
| | | | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
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11
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Wong YJ, Kumar R, Tan J, Thurairajah PH. Authors’ reply: Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites. Singapore Med J 2021; 62:666. [PMID: 35092303 DOI: 10.11622/smedj.2021237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Medicine Programme, SingHealth, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Medicine Programme, SingHealth, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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12
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Wong YJ, Kew GS, Tan PS, Chen Z, Putera M, Yip WA, Ang TL, Fock KM, Lee GH, Hsiang J, Huang DQ, Kwek A, Muthiah MD, Kumar R, Tan M, Tan J, Thurairajah PH, Teo EK, Tai BC, Lim SG. Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study. Clin Res Hepatol Gastroenterol 2021; 45:101598. [PMID: 33780835 DOI: 10.1016/j.clinre.2020.101598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients. METHODS Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort. RESULTS Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs. CONCLUSION We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.
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13
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Tan CK, Wong YJ, Wang LM, Ang TL, Kumar R. Autoimmune hepatitis following COVID-19 vaccination: True causality or mere association? J Hepatol 2021; 75:1250-1252. [PMID: 34153398 PMCID: PMC8404983 DOI: 10.1016/j.jhep.2021.06.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Chin Kimg Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Lai Mun Wang
- Section of Pathology, Department of Laboratory Medicine, Changi General Hospital, Singapore,Pathology Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore.
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Abstract
INTRODUCTION H. pylori eradication reduces the risk of gastric malignancies and peptic ulcer disease. First-line therapies include 14-day PAC (proton pump inhibitor [PPI], amoxicillin, clarithromycin) and PBMT (PPI, bismuth, metronidazole, tetracycline). Second-line therapies include 14-day PBMT and PAL (PPI, amoxicillin, levofloxacin). This clinical audit examined current treatment outcomes in Singapore. METHODS Clinical data of H. pylori-positive patients who underwent empirical first- and second-line eradication therapies from 1 January 2017 to 31 December 2018 were reviewed. Treatment success was determined by 13C urea breath test performed at least 4 weeks after treatment and 2 weeks off PPI. RESULTS A total of 963 patients (862 PAC, 36 PMC [PPI, metronidazole, clarithromycin], 18 PBMT, 13 PBAC [PAC with bismuth], 34 others) and 98 patients (62 PMBT, 15 PAL, 21 others) received first- and second-line therapies respectively. A 14-day treatment duration was appropriately prescribed for first- and second-line therapies in 65.2% and 82.7% of patients, respectively. First-line treatment success rates were noted for PAC (seven-day: 76.9%, ten-day: 88.3%, 14-day: 92.0%), PMC (seven-day: 0, ten-day: 75.0%, 14-day: 69.8%), PBMT (ten-day: 100%, 14-day: 87.5%) and PBAC (14-day: 100%). 14-day treatment was superior to seven-day treatment (90.8% vs. 71.4%; p = 0.028). PAC was superior to PMC (p < 0.001) but similar to PBMT (p = 0.518) and PBAC (p = 0.288) in 14-day therapies. 14-day second-line PAL and PBMT had similar efficacy (90.9% vs. 82.4%; p = 0.674). CONCLUSION First-line empirical treatment using PAC, PBMT and PBAC for 14 days had similar efficacy. Success rates for second-line PBMT and PAL were similar.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Digestive Disease Centre, Changi General Hospital, Singapore
| | - Kim Wei Lim
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Digestive Disease Centre, Changi General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Digestive Disease Centre, Changi General Hospital, Singapore
| | - Malcolm Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Digestive Disease Centre, Changi General Hospital, Singapore
| | - Andrew Siang Yih Wong
- Digestive Disease Centre, Changi General Hospital, Singapore.,Department of Surgery, Changi General Hospital, Singapore
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15
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
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16
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Wong YJ, Qiu TY, Ng GK, Zheng Q, Teo EK. Efficacy and Safety of Statin for Hepatocellular Carcinoma Prevention Among Chronic Liver Disease Patients: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2021; 55:615-623. [PMID: 33606427 DOI: 10.1097/mcg.0000000000001478] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/29/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND AIM Hepatocellular carcinoma (HCC) is a deadly complication among patients with chronic liver disease (CLD). Controversies on the efficacy and safety of statin to prevent HCC among patients with CLD remain despite the growing evidences. We aim to investigate the efficacy and safety of using statin for HCC prevention among adult with CLD. METHODS We performed a systematic search of 4 electronic databases (PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrial.gov) up to April 15, 2020. We selected all types of studies evaluating the statin use and the risk of HCC among CLD patients, regardless of language, region, publication date, or status. The primary endpoint was the pooled risk of HCC. The secondary endpoint was the risk of statin-associated myopathy. RESULT From 583 citations, we included a total of 13 studies (1,742,260 subjects, 7 types of statins), fulfilling the inclusion criteria, evaluating efficacy and safety of statin in CLD patients for HCC prevention. All studies were observational (2 nested case-control studies, 11 cohort studies), and no randomised trial was identified. We found that statin user has a lower pooled risk of HCC development (hazard ratio=0.57, 95% confidence interval: 0.52-0.62, I2=42%). HCC reduction was consistent among statin users in cirrhosis, hepatitis B virus, and hepatitis C virus infections. The risk of statin-associated myopathy was similar between statin user and nonuser (hazard ratio=1.07, 95% confidence interval=0.91-1.27). CONCLUSION Statin use was safe and associated with a lower pooled risk of HCC development among adults with CLD. Given the bias with observation studies, prospective randomised trial is needed to confirm this finding.
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Affiliation(s)
- Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Tian-Yu Qiu
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | | | | | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital
- Yong Loo Lin School of Medicine, National University of Singapore
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17
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Putera M, Tan CK, Wong YJ, Kumar R. Higher mortality in acute variceal haemorrhage: Is fresh frozen plasma alone to be blamed? Liver Int 2021; 41:1977-1978. [PMID: 34021960 DOI: 10.1111/liv.14968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Martin Putera
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Chin Kimg Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke- NUS Academic Medical Centre, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke- NUS Academic Medical Centre, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke- NUS Academic Medical Centre, Singapore
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18
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Putera M, Teh KB, Kumar R, Wong YJ. Small esophageal varices in compensated cirrhosis patients: to treat or not to treat? J Hepatol 2021; 75:491-492. [PMID: 33716090 DOI: 10.1016/j.jhep.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Martin Putera
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore Health Service, Singapore
| | - Kok Ban Teh
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore Health Service, Singapore
| | - Rahul Kumar
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore Health Service, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore Health Service, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore.
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19
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Teh KB, Loo JH, Tam YC, Wong YJ. Efficacy and safety of albumin infusion for overt hepatic encephalopathy: A systematic review and meta-analysis. Dig Liver Dis 2021; 53:817-823. [PMID: 34011479 DOI: 10.1016/j.dld.2021.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The efficacy and safety of albumin infusion for treatment and prevention of overt hepatic encephalopathy (OHE) among cirrhosis patients remained controversial. We performed a systematic review and meta-analysis to evaluate the benefit of albumin infusion for the treatment and prevention of OHE. METHODS We performed a systematic search of 4 electronic databases up to 31st January 2021. The primary outcome was the resolution of OHE. Secondary outcomes were inpatient mortality and albumin-associated adverse events. We assessed the pooled odds' risk, pooled mean differences, 95% confidence interval and heterogeneity using Review Manager Version 5.3. RESULTS A total of 12 studies (2,087 subjects) were identified. Among cirrhosis patients with OHE, albumin infusion was associated with a lower pooled risk of OHE (OR=0.43, 95%CI: 0.27, 0.68; I2=0%). Among patients without baseline OHE, albumin infusion was associated with a lower pooled risk of developing OHE (OR=0.53, 95%CI: 0.32, 0.86; I2=62%). Albumin infusion was associated with a lower pooled risk of inpatient mortality (OR=0.36, 95%CI: 0.21, 0.60; I2=0%). CONCLUSION Well-powered randomized trials are required to confirm the benefits of albumin infusion for the prevention and treatment of overt hepatic encephalopathy among decompensated cirrhosis patients.
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Affiliation(s)
- Kok Ban Teh
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yew Chong Tam
- Department of Medicine, Singapore General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Duke-NUS Academic Medicine Programme, Singhealth, Singapore.
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20
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Huang C, Seah JJ, Tan CK, Kam JW, Tan J, Teo EK, Kwek A, Wong YJ, Tan M, Ang TL, Kumar R. Modified AST to platelet ratio index improves APRI and better predicts advanced fibrosis and liver cirrhosis in patients with non-alcoholic fatty liver disease. Clin Res Hepatol Gastroenterol 2021; 45:101528. [PMID: 33268036 DOI: 10.1016/j.clinre.2020.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/13/2020] [Accepted: 08/24/2020] [Indexed: 02/08/2023]
Abstract
AIMS Advanced fibrosis (AF) and liver cirrhosis (LC) are important milestones in non-alcoholic fatty liver disease (NAFLD). FIB-4, NFS and BARD are validated scores with good accuracy in detecting AF and LC. APRI does not have similar predictive accuracy. While a modification (m-APRI) improves its use in viral hepatitis, this has yet to be evaluated in NAFLD. This study compares diagnostic performance of aforementioned scores in predicting AF and LC in NAFLD. METHODS Consecutive NAFLD patients undergoing Transient Elastography (TE) using Echosens® Fibroscan® for fibrosis staging were included. Cut-off liver stiffness measurements for AF and LC were 7.9 kPa and 11.5 kPa respectively. Anthropometric and laboratory tests done within 3 months were used. Diagnostic performances of scores were analyzed by standard statistical tests. RESULTS 161 patients qualified for the study. Mean age was 60.2 ± 14 years, BMI 26.8 ± 4.6 kg/m2. M-probe was used in 113, XL in 48. Optimal cut-offs of m-APRI for AF and LC were 5.84 and 9 respectively. Area under receiver operator characteristic curves (AUROC) for prediction of AF at optimal cut-off points were m-APRI 0.84, APRI 0.80, FIB-4: 0.77, NFS 0.77 and BARD 0.65. For prediction of LC, AUROC were m-APRI: 0.83, APRI: 0.76, FIB-4: 0.81, NFS: 0.77 and BARD: 0.66. m-APRI was significantly superior to all scores compared in detecting AF (p < 0.05 for all) and superior to APRI (p = 0.008) and BARD (p = 0.007) in predicting LC. There was no significant difference between m-APRI and FIB-4 or NFS in prediction of LC. CONCLUSIONS For prediction of AF in NAFLD, m-APRI outperforms BARD, APRI, NFS and FIB-4, while for the prediction of cirrhosis, m-APRI is superior to APRI and BARD but comparable to NFS and FIB-4.
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Affiliation(s)
- Cheryl Huang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; NUS Yong Loo Lin School of Medicine, Singapore
| | - Jun Jie Seah
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; NUS Yong Loo Lin School of Medicine, Singapore
| | - Chin Kimg Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jia Wen Kam
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Malcolm Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.
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21
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Wong YJ, Thurairajah PH, Kumar R, Tan J, Fock KM, Law NM, Li W, Kwek A, Tan YB, Koh J, Lee ZC, Kumar LS, Teo EK, Ang TL. Efficacy and safety of sofosbuvir/velpatasvir in a real-world chronic hepatitis C genotype 3 cohort. J Gastroenterol Hepatol 2021; 36:1300-1308. [PMID: 33217040 DOI: 10.1111/jgh.15324] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Real-world data on sofosbuvir/velpatasvir with and without ribavirin (SOF/VEL ± RBV), particularly among patients with genotype 3 (GT3) decompensated cirrhosis, prior treatment, coinfection, and hepatocellular carcinoma (HCC), are scarce. We aimed to assess the efficacy and safety of SOF/VEL ± RBV in a real-world setting that included both community and incarcerated GT3 hepatitis C virus (HCV) patients. METHODS We included all GT3 HCV patients treated with SOF/VEL ± RBV in our institution. The primary outcome measure was the overall sustained virological response 12 weeks after treatment (SVR12), reported in both intention-to-treat (ITT) and per-protocol analyses. The secondary outcome measures were SVR12 stratified by the presence of decompensated cirrhosis, prior treatment, HCC, and HIV/hepatitis C virus coinfection and the occurrence rate of serious adverse events requiring treatment cessation or hospitalization. RESULTS A total of 779 HCV patients were treated with 12 weeks of SOF/VEL ± RBV, of which 85% were treated during incarceration. Among the 530 GT3 HCV patients, 31% had liver cirrhosis, and 6% were treatment-experienced. The overall SVR12 for GT3 was 98.7% (95% confidence interval: 97.3%, 99.5%) and 99.2% (95% confidence interval: 98.1%, 99.8%) in ITT and per-protocol analyses, respectively. High SVR12 was also seen in ITT analysis among GT3 HCV patients with decompensated cirrhosis (88%), prior treatment (100%), HCC (100%), and HIV/hepatitis B virus coinfection (100%). Apart from one patient who developed myositis, no other serious adverse events were observed. CONCLUSION The SOF/VEL ± RBV is a safe and efficacious treatment option for GT3 HCV patients in a real-world setting. SOF/VEL with RBV may be considered for decompensated GT3 HCV patients.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Prem Harichander Thurairajah
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University of Singapore, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Yu Bin Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jingyun Koh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Zheng Cong Lee
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiing-Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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22
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Tan YY, Tay GSK, Wong YJ, Li JW, Kwek ABE, Ang TL, Wang LM, Tan MTK. Clinical Features and Predictors of Dysplasia in Proximal Sessile Serrated Lesions. Clin Endosc 2021; 54:578-588. [PMID: 33915614 PMCID: PMC8357591 DOI: 10.5946/ce.2020.198] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/11/2020] [Indexed: 02/05/2023] Open
Abstract
Background/Aims Proximal colorectal cancers (CRCs) account for up to half of CRCs. Sessile serrated lesions (SSLs) are precursors to CRC. Proximal location and presence of dysplasia in SSLs predict higher risks of progression to cancer. The prevalence of dysplasia in proximal SSLs (pSSLs) and clinical characteristics of dysplastic pSSLs are not well studied.
Methods Endoscopically resected colonic polyps at our center between January 2016 and December 2017 were screened for pSSLs. Data of patients with at least one pSSL were retrieved and clinicopathological features of pSSLs were analysed. pSSLs with and without dysplasia were compared for associations.
Results Ninety pSSLs were identified, 45 of which had dysplasia giving a prevalence of 50.0%. Older age (65.9 years vs. 60.1 years, p=0.034) was associated with the presence of dysplasia. Twelve pSSLs were 10 mm or larger. After adjusting for age, pSSLs ≥10 mm had an adjusted odds ratio of 5.98 (95% confidence interval, 1.21–29.6) of having dysplasia compared with smaller pSSLs.
Conclusions In our cohort of pSSLs, the prevalence of dysplasia is high at 50.0% and is associated with lesion size ≥10 mm. Endoscopic resection for all proximal serrated lesions should be en bloc to facilitate accurate histopathological examination for dysplasia as its presence warrants shorter surveillance intervals.
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Affiliation(s)
- Yi Yuan Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Gary Sei Kiat Tay
- Department of Pathology, Changi General Hospital, Singapore, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lai Mun Wang
- Department of Pathology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Pathology Academic Clinical Programme, SingHealth Duke-NUS Medical School, Singapore, Singapore
| | - Malcolm Teck Kiang Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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23
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Wong YJ, Kumar R, Chua YJJ, Ang TL. Long-term albumin infusion in decompensated cirrhosis: A review of current literature. World J Hepatol 2021; 13:421-432. [PMID: 33959225 PMCID: PMC8080546 DOI: 10.4254/wjh.v13.i4.421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
Decompensated cirrhosis is characterized by chronic inflammation and severe portal hypertension leading to systemic circulatory dysfunction. Albumin infusion has been widely used in decompensated cirrhosis in patients with spontaneous bacterial peritonitis, large-volume paracentesis and hepatorenal syndrome. Emerging data suggest long-term albumin infusion has both oncotic and non-oncotic properties which may improve the clinical outcomes in decompensated cirrhosis patients. We review the current literature on both the established and potential role of albumin, and specifically address the controversies of long-term albumin infusion in decompensated cirrhosis patients.
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Affiliation(s)
- Yu Jun Wong
- Department ofGastroenterology and Hepatology, Changi General Hospital, Singapore 529889, Singapore
| | - Rahul Kumar
- Department ofGastroenterology and Hepatology, Changi General Hospital, Singapore 529889, Singapore
| | - Yu Jing Jonathan Chua
- Department of Internal Medicine, Yong Loo Lin School of Medicine, Singapore 117597, Singapore
| | - Tiing Leong Ang
- Department ofGastroenterology and Hepatology, Changi General Hospital, Singapore 529889, Singapore
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24
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Wong YJ, Lum HM, Tan PT, Teo EK, Tan J, Kumar R, Thurairajah PH. Clinical implications of prompt ascitic drain removal among cirrhosis with refractory ascites. Singapore Med J 2021; 62:659-664. [PMID: 33866716 DOI: 10.11622/smedj.2021049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Large-volume paracentesis (LVP) is the first-line treatment for decompensated cirrhosis with refractory ascites. While ascitic drain removal (ADR) within 72 hours was once considered safe, it was uncertain if ADR within 24 hours could further reduce the risk of ascitic drain-related bacterial peritonitis (AdBP). This study aimed to investigate the association between the timing of ADR and the presence of AdBP. METHODS All cirrhotics with refractory ascites who underwent LVP in our institution from 2014 to 2017 were studied. AdBP was diagnosed based on ascitic fluid neutrophil count ≥ 250 cells/mm3 or positive ascitic fluid culture following recent paracentesis within two weeks. RESULTS A total of 131 patients who underwent LVP were followed up for 1,806 patient-months. Their mean age was 68.3 ± 11.6 years, and 65.6% were male. Their mean Model for End-Stage Liver Disease (MELD) score was 15.2. The overall incidence of AdBP was 5.3%. ADR beyond 24 hours was significantly associated with longer median length of stay (five days vs. three days, p < 0.001), higher risk of AdBP (0% vs. 8.9%, p = 0.042) and AKI following LVP (odds ratio 20.0, 95% confidence interval 2.4-164.2, p = 0.021). Overall survival was similar in patients with ADR within and beyond 24 hours. CONCLUSION ADR within 24 hours is associated with reduced risk of AdBP and AKI. As AdBP is associated with resistant organism and AKI, we recommend prompt ADR within 24 hours, especially among patients who have Child-Pugh C with alcoholic cirrhosis.
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Affiliation(s)
- Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Singapore
| | - Huey-Ming Lum
- Department of Gastroenterology and Hepatology, Singapore
| | - Pei-Ting Tan
- Clinical Trial & Research Unit, Changi General Hospital, Singapore
| | - Eng-Kiong Teo
- Department of Gastroenterology and Hepatology, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Singapore
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25
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Chang PE, Tan CK, Cheah CC, Li W, Chow WC, Wong YJ. Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease. Dig Dis Sci 2021; 66:1343-1348. [PMID: 32440746 DOI: 10.1007/s10620-020-06334-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The expanded Baveno-VI criteria may further reduce the need for screening gastroscopy compared to Baveno-VI criteria. AIM We sought to validate the performance of these criteria in a cohort of compensated advanced chronic liver disease (cACLD) patients with predominantly hepatitis B infection. METHODS Consecutive cACLD patients from 2006 to 2012 with paired liver stiffness measurements and screening gastroscopy within 1 year were included. The expanded Baveno-VI criteria were applied to evaluate the sensitivity (SS), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) for the presence of high-risk varices (HRV). RESULTS Among 165 cACLD patients included, 17 (10.3%) had HRV. The commonest etiology of cACLD was chronic hepatitis B (36.4%) followed by NAFLD (20.0%). Application of expanded Baveno-VI criteria avoided more screening gastroscopy (43.6%) as compared to the original Baveno-VI criteria (18.8%) without missing more HRV (1 with both criteria). The overall SS, SP, PPV and NPV of the expanded Baveno-VI criteria in predicting HRV were 94.1%, 48.0%, 17.2% and 98.6%, respectively. CONCLUSION Application of the expanded Baveno-VI criteria can safely avoid screening gastroscopy in 43.6% of cACLD patients with an excellent ability to exclude HRV.
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Affiliation(s)
- Pik-Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chang-Chuen Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.
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26
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Marjot T, Moon AM, Cook JA, Abd-Elsalam S, Aloman C, Armstrong MJ, Pose E, Brenner EJ, Cargill T, Catana MA, Dhanasekaran R, Eshraghian A, García-Juárez I, Gill US, Jones PD, Kennedy J, Marshall A, Matthews C, Mells G, Mercer C, Perumalswami PV, Avitabile E, Qi X, Su F, Ufere NN, Wong YJ, Zheng MH, Barnes E, Barritt AS, Webb GJ. Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: An international registry study. J Hepatol 2021; 74:567-577. [PMID: 33035628 PMCID: PMC7536538 DOI: 10.1016/j.jhep.2020.09.024] [Citation(s) in RCA: 330] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease (CLD) and cirrhosis are associated with immune dysregulation, leading to concerns that affected patients may be at risk of adverse outcomes following SARS-CoV-2 infection. We aimed to determine the impact of COVID-19 on patients with pre-existing liver disease, which currently remains ill-defined. METHODS Between 25th March and 8th July 2020, data on 745 patients with CLD and SARS-CoV-2 (including 386 with and 359 without cirrhosis) were collected by 2 international registries and compared to data on non-CLD patients with SARS-CoV-2 from a UK hospital network. RESULTS Mortality was 32% in patients with cirrhosis compared to 8% in those without (p <0.001). Mortality in patients with cirrhosis increased according to Child-Pugh class (A [19%], B [35%], C [51%]) and the main cause of death was from respiratory failure (71%). After adjusting for baseline characteristics, factors associated with death in the total CLD cohort were age (odds ratio [OR] 1.02; 1.01-1.04), Child-Pugh A (OR 1.90; 1.03-3.52), B (OR 4.14; 2.4-7.65), or C (OR 9.32; 4.80-18.08) cirrhosis and alcohol-related liver disease (OR 1.79; 1.03-3.13). Compared to patients without CLD (n = 620), propensity-score-matched analysis revealed significant increases in mortality in those with Child-Pugh B (+20.0% [8.8%-31.3%]) and C (+38.1% [27.1%-49.2%]) cirrhosis. Acute hepatic decompensation occurred in 46% of patients with cirrhosis, of whom 21% had no respiratory symptoms. Half of those with hepatic decompensation had acute-on-chronic liver failure. CONCLUSIONS In the largest such cohort to date, we demonstrate that baseline liver disease stage and alcohol-related liver disease are independent risk factors for death from COVID-19. These data have important implications for the risk stratification of patients with CLD across the globe during the COVID-19 pandemic. LAY SUMMARY This international registry study demonstrates that patients with cirrhosis are at increased risk of death from COVID-19. Mortality from COVID-19 was particularly high among patients with more advanced cirrhosis and those with alcohol-related liver disease.
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Affiliation(s)
- Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Jonathan A Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious diseases Department, Tanta University, Tanta, Egypt
| | - Costica Aloman
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Elisa Pose
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Erica J Brenner
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Maria-Andreea Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ahad Eshraghian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz, Iran
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Upkar S Gill
- Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, QMUL, London, UK
| | - Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James Kennedy
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Charmaine Matthews
- Department of Gastroenterology and Hepatology, Royal Liverpool Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - George Mells
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Carolyn Mercer
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain
| | - Xialong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Feng Su
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease, Zhejiang Province, Wenzhou, Zhejiang, China
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gwilym J Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK; Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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Wong YJ, Thurairajah PH, Kumar R, Fock KM, Law NM, Chong SY, Manejero FG, Ang TL, Teo EK, Tan J. The impact of unrestricted access to direct-acting antiviral among incarcerated hepatitis C virus-infected patients. Clin Mol Hepatol 2021; 27:474-485. [PMID: 33601868 PMCID: PMC8273645 DOI: 10.3350/cmh.2021.0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Despite the disproportionally high prevalence rates of hepatitis C virus (HCV) amongst the incarcerated population, eradication remains challenging due to logistic and financial barriers. Although treatment prioritization based on disease severity is commonly practiced, the efficacy of such approach remained uncertain. We aimed to compare the impact of unrestricted access to direct-acting antiviral (DAA) among incarcerated HCV-infected patients in Singapore. Methods In this retrospective study, we reviewed all incarcerated HCV-infected patients treated in our hospital during the restricted DAA era (2013–2018) and unrestricted DAA access era (2019). Study outcomes included the rate of sustained virological response (SVR), treatment completion and treatment default. Subgroup analysis was performed based on the presence of liver cirrhosis, HCV genotype and HCV treatment types. Results A total of 1,001 HCV patients was followed-up for 1,489 person-year. They were predominantly male (93%) with genotype-3 HCV infection (71%), and 38% were cirrhotic. The overall SVR during the restricted DAA access era and unrestricted DAA access era were 92.1% and 99.1%, respectively. Unrestricted access to DAA exponentially improved the treatment access among HCV-infected patients by 460%, resulting in a higher SVR rate (99% vs. 92%, P=0.003), higher treatment completion rate (99% vs. 93%, P<0.001) and lower treatment default rate (1% vs. 9%, P<0.001).Conclusion: In this large cohort of incarcerated HCV-infected patients, we demonstrated that unrestricted access to DAA is an impactful strategy to allow rapid treatment up-scale in HCV micro-elimination.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | | | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sin-Yoong Chong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Tiing-Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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28
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Qiu TY, See JJH, Shi H, Wong YJ. Acute liver failure and seizure: a case report of an unusual presentation of acute painless aortic dissection. Eur Heart J Case Rep 2020; 5:ytaa429. [PMID: 33644640 PMCID: PMC7898567 DOI: 10.1093/ehjcr/ytaa429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/07/2020] [Accepted: 09/26/2020] [Indexed: 02/05/2023]
Abstract
Background Painless aortic dissection presenting with seizure and acute liver failure is uncommon. We described a case of early recognition leading to successful treatment of painless aortic dissection with atypical presentation. Case summary A young lady presented with generalized tonic-clonic seizures coupled with hepatitic pattern of deranged liver function test. Examination revealed blood pressure of 99/75 mmHg and hepatic flap. Electrocardiography showed sinus tachycardia. Urgent bedside echocardiography showed preserved cardiac function without significant valvular pathology, but noted a moderate pericardial effusion. Abdominal Ultrasound excluded liver cirrhosis or biliary obstructions. Viral hepatitis serologies and anti-liver panel were negative. She was progressively hypotensive with concurrent acute liver failure and oliguric acute kidney injury. Despite no chest pain, her rising serum troponin and widened mediastinum prompted an urgent computed-tomography aortogram, which showed a 4.3 cm dilatation of ascending thoracic aorta with acute haemopericardium and cardiac tamponade. She was diagnosed with malperfusion syndrome from Stanford type A aortic dissection. She underwent emergent ascending aorta and aortic arch repair and dialysis. She experienced complete recovery in her kidney, liver, and neurological function post-operatively. Discussion Painless aortic dissection masquerade as acute liver failure is uncommon. We describe a successful early recognition of malperfusion syndrome from painless aortic dissection, thus providing window for timely, life-saving intervention. Clinical challenges in this case include: (i) atypical presentation of aortic dissection, (ii) worsening acute liver failure which could lead to unnecessary liver transplantation, and (iii) risk of contrast-induced nephropathy in the setting of acute renal failure.
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Affiliation(s)
- Tian-Yu Qiu
- Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore
| | - Jason Jia-Hao See
- Department of Cardiology, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore
| | - Haiyuan Shi
- Department of Diagnostic Radiology, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore
| | - Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore
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29
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Wong YJ, Qiu TY, Tam YC, Mohan BP, Gallegos-Orozco JF, Adler DG. Efficacy and Safety of IV albumin for non-spontaneous bacterial peritonitis infection among patients with cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2020; 52:1137-1142. [PMID: 32586766 DOI: 10.1016/j.dld.2020.05.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
UNLABELLED Efficacy and Safety of intravenous albumin for non-spontaneous bacterial peritonitis infection among patients with cirrhosis: A systematic review and meta-analysis of randomized controlled trials INTRODUCTION: Bacterial infection is a common cause of acute-on-chronic liver failure (ACLF) and death among cirrhosis. The benefit of intravenous (IV) albumin among cirrhosis with non-SBP infection remains unclear as individual studies are underpowered to detect the survival benefit of IV albumin. AIM We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of intravenous albumin for non-SBP infection among cirrhosis patients. METHODS We performed a systematic search of electronic databases (Pubmed, MEDLINE and Clinicalkey) up to 1st December 2019. Studies evaluating IV albumin for non-SBP infection were selected. Using random effect model, the pooled odds ratio (OR), 95% confidence interval (95%CI) and heterogeneity were assessed. RESULTS A total of 3 RCTs (406 subjects) fulfilling the inclusion criteria among 218 citations were identified. There was no significant heterogeneity across included studies. In this meta-analysis, we found that the pooled risk of renal impairment (RI) (OR=0.58, 95%CI: 0.28-1.23, I2=0%), mortality at 30 days (OR=1.61, 95%CI: 0.87-3.00, I2=0%) as well as mortality at 90 days (OR=1.30, 95%CI: 0.81-2.07, I2=0%) were similar between albumin and control group. Pooled event of pulmonary edema occurred more commonly in albumin group (OR 5.17, 95%CI 1.62-16.47, I2=0%). More subjects achieved resolution of ACLF in IV albumin group as compared to control group (OR=0.11, 95%CI: 0.02-0.69, p=0.02). CONCLUSION Albumin did not reduce the risk of RI and mortality, yet increases the risk of pulmonary edema. Albumin may promote recovery of ACLF, however, more data is required to validate this benefit.
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Affiliation(s)
- Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | - Tian-Yu Qiu
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | - Yew-Chong Tam
- Education Resource Centre, Singapore General Hospital, Department of Medicine
| | - Babu P Mohan
- University of Arizona, Tucson, USA; Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Juan-F Gallegos-Orozco
- Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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30
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Decallonne B, Martens PJ, Van den Bruel A, Vanhole C, Kahaly GJ. Graves Disease With Thyroid-Stimulating Hormone Receptor-Blocking Autoantibodies During Pregnancy. Ann Intern Med 2020; 172:767-769. [PMID: 32203974 DOI: 10.7326/l19-0818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
| | | | | | | | - George J Kahaly
- Johannes Gutenberg University Medical Center, Mainz, Germany (G.J.K.)
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31
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Affiliation(s)
- Kangqi Ng
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Beng Hoong Poon
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Troy Hai Kiat Puar
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jessica Li Shan Quah
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Wann Jia Loh
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Yu Jun Wong
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Thean Yen Tan
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jagadesan Raghuram
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
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Teh KKJ, Tay SW, Chen K, Koh SJ, Wong YJ, Kwek ABE, Li JW, Fock KM, Teo EK, Ang TL, Tan MTK. Impact of enhanced personal protective equipment on colonoscopy performance during the COVID-19 pandemic. Endosc Int Open 2020; 8:E809-E814. [PMID: 32523979 PMCID: PMC7274840 DOI: 10.1055/a-1167-1703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Using personal protective equipment (PPE) can reduce risk of disease transmission. During the COVID-19 pandemic, enhanced PPE (EPPE) is recommended when performing endoscopy. We aimed to evaluate the impact of EPPE on colonoscopy performance when compared to standard PPE (SPPE). Patients and methods A review of electronic medical records and endoscopy reports of consecutive patients who underwent colonoscopy during two similar one-month time periods (in 2019 and during the COVID-19 pandemic in 2020) was performed. SPPE was used in 2019 and EPPE was used in 2020. Patient clinical data and procedure-related information were captured and analyzed. The primary outcomes were time to cecum (TTC) and total procedure time. Secondary outcomes were adenoma detection rate (ADR), polyp detection rate (PDR) and cecal intubation rate (CIR). Statistical analysis was performed using STATA v16.1. Results Two hundred and forty-seven colonoscopy procedures were analyzed. Baseline demographics and indications for colonoscopy of patients in both groups were similar. There were no significant differences in median TTC (10.0 vs 10.0 min, P = 0.524) or total procedure time (22.5 vs 23.0 min, P = 0.946) between colonoscopy performed in SPPE and EPPE. The ADR, PDR and CIR were also similar. Conclusion Our findings suggest that use of EPPE does not affect colonoscopy performance.
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Affiliation(s)
- Kevin Kim Jun Teh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Shu Wen Tay
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kaina Chen
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Samantha Jingyun Koh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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33
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Chang JPE, Wong YJ, Yang WL, Lim KBL, Tan PS, Ho GH, Yip BCH, Li JW, Chong CH, Ong DEH, Chua TS, Vu CKF, Gwee KA, Ang TL, Tan CK. Chapter of Gastroenterologists professional guidance for management of patients with liver disease in Singapore during the COVID-19 pandemic. Singapore Med J 2020; 61:619-623. [PMID: 32349198 DOI: 10.11622/smedj.2020069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.
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Affiliation(s)
- Jason Pik Eu Chang
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Wei Lyn Yang
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore
| | - Kieron Boon Leng Lim
- Mount Elizabeth Medical Centre, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Poh Seng Tan
- PS Tan Digestive and Liver Centre, Mount Elizabeth Hospital, Singapore
| | - Gim Hin Ho
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Division of Gastroenterology, Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Benjamin Cherng Hann Yip
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Division of Gastroenterology, Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - James Weiquan Li
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Chern Hao Chong
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Gutcare Digestive Liver Endoscopy Associates, Singapore
| | - David Eng Hui Ong
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Tju Siang Chua
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,AliveoMedical, Mount Alvernia and Mount Elizabeth Hospitals, Singapore
| | - Charles Kien Fong Vu
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore
| | - Kok Ann Gwee
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Gleneagles Hospital, Singapore
| | - Tiing Leong Ang
- Chapter of Gastroenterologists, Academy of Medicine, Singapore.,Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Chee Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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Wong YJ, Tan M, Zheng Q, Li JW, Kumar R, Fock KM, Teo EK, Ang TL. A systematic review and meta-analysis of the COVID-19 associated liver injury. Ann Hepatol 2020; 19:627-634. [PMID: 32882393 PMCID: PMC7458067 DOI: 10.1016/j.aohep.2020.08.064] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES The novel coronavirus disease 2019 (COVID-19) has affected more than 5 million people globally. Data on the prevalence and degree of COVID-19 associated liver injury among patients with COVID-19 remain limited. We conducted a systematic review and meta-analysis to assess the prevalence and degree of liver injury between patients with severe and non-severe COVID-19. METHODS We performed a systematic search of three electronic databases (PubMed/MEDLINE, EMBASE and Cochrane Library), from inception to 24th April 2020. We included all adult human studies (>20 subjects) regardless of language, region or publication date or status. We assessed the pooled odds ratio (OR), mean difference (MD) and 95% confidence interval (95%CI) using the random-effects model. RESULTS Among 1543 citations, there were 24 studies (5961 subjects) which fulfilled our inclusion criteria. The pooled odds ratio for elevated ALT (OR = 2.5, 95%CI: 1.6-3.7, I2 = 57%), AST (OR = 3.4, 95%CI: 2.3-5.0, I2 = 56%), hyperbilirubinemia (OR = 1.7, 95%CI: 1.2-2.5, I2 = 0%) and hypoalbuminemia (OR = 7.1, 95%CI: 2.1-24.1, I2 = 71%) were higher subjects in critical COVID-19. CONCLUSION COVID-19 associated liver injury is more common in severe COVID-19 than non-severe COVID-19. Physicians should be aware of possible progression to severe disease in subjects with COVID-19-associated liver injury.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital; Yong Loo Lin School of Medicine, National University of Singapore.
| | - Malcolm Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital,Yong Loo Lin School of Medicine, National University of Singapore
| | - Qishi Zheng
- Singapore Clinical Research Institute,Cochrane Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital,Yong Loo Lin School of Medicine, National University of Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital,Yong Loo Lin School of Medicine, National University of Singapore,Cochrane Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital,Yong Loo Lin School of Medicine, National University of Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital,Yong Loo Lin School of Medicine, National University of Singapore
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35
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Wong YJ, Teh JGX, Khor C, Tan DMY. Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting for combined malignant biliary and duodenal obstruction. Endoscopy 2019; 51:E394-E395. [PMID: 31340391 DOI: 10.1055/a-0929-4927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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36
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Wong YJ, Lum HM, Fook-Chong S, Lim ST, Salazar E. Do total parenteral nutrition and bowel rest reduce the risk for perforation in patients with gastrointestinal tract lymphoma receiving chemotherapy? Nutrition 2019; 67-68:110515. [PMID: 31476571 DOI: 10.1016/j.nut.2019.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/21/2019] [Accepted: 03/01/2019] [Indexed: 02/08/2023]
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37
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Wong YJ, Kalki RC, Lin KW, Kumar R, Tan J, Teo EK, Li JW, Ang TL. Short- and long-term predictors of spontaneous bacterial peritonitis in Singapore. Singapore Med J 2019; 61:419-425. [PMID: 31363784 DOI: 10.11622/smedj.2019085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is the commonest complication of liver cirrhosis. Timely and appropriate treatment of SBP is crucial, particularly with the rising worldwide prevalence of multidrug-resistant organisms (MDROs). We aimed to investigate the clinical outcomes of SBP in Singapore. METHODS All cirrhotic patients with SBP diagnosed between January 2014 and December 2017 were included. Nosocomial SBP (N-SBP) was defined as SBP diagnosed more than 48 hours after hospitalisation. Clinical outcomes were analysed as categorical outcomes using univariate and multivariate analysis. RESULTS There were 33 patients with 39 episodes of SBP. Their mean age was 64.5 years and 69.7% were male. The commonest aetiology of cirrhosis was hepatitis B (27.3%). The Median Model for End-stage Liver Disease (MELD) score was 17; 33.3% had acute-on-chronic liver failure and 60.6% had septic shock at presentation. N-SBP occurred in 25.6% of SBP cases. N-SBP was more commonly associated with MDROs, previous antibiotic use in the past three months (p = 0.014) and longer length of stay (p = 0.011). The 30-day and 90-day mortality among SBP patients was 30.8% and 51.3%, respectively. MELD score > 20 was a predictor for 30-day mortality. N-SBP and MELD score > 20 were predictors for 90-day mortality. CONCLUSION N-SBP was significantly associated with recent antibiotic use, longer hospitalisation, more resistant organisms and poorer survival among patients with SBP. N-SBP and MELD score predict higher mortality in SBP. Judicious use of antibiotics may reduce N-SBP and improve survival among cirrhotic patients.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kenneth Weicong Lin
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Wong Y, Cheen MHH, Hsiang JC, Kumar R, Tan J, Teo EK, Thurairajah PH. Economic evaluation of direct-acting antivirals for the treatment of genotype 3 hepatitis C infection in Singapore. JGH Open 2019; 3:210-216. [PMID: 31276038 PMCID: PMC6586564 DOI: 10.1002/jgh3.12139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM The prohibitively high cost of direct-acting antivirals (DAA) for hepatitis C virus (HCV) infection remains a barrier to treatment access in Singapore. We aimed to evaluate whether DAA as first-line therapy would be cost-effective for genotype 3 (GT3) HCV patients compared with pegylated interferon and ribavirin (PR). METHODS A decision tree analysis was used to compare the costs and outcomes of DAA and PR as first-line therapy. Treatment effectiveness, defined as sustained virological response, was assessed using a retrospective cohort of treated GT3 HCV patients. Direct medical costs were estimated from the payer's perspective using billing information. We obtained health utilities from published literature. We performed extensive one-way sensitivity analyses and probabilistic sensitivity analyses to account for uncertainties regarding the model parameters. RESULTS In base case analysis, first-line therapy with DAA and PR yielded quality-adjusted life years (QALYs) of 0.69 and 0.62 at a cost of USD 54 634 and USD 23 857, respectively. The resultant incremental cost-effectiveness ratio (ICER) (USD 449 232/QALY) exceeded the willingness-to-pay threshold (USD 53 302/QALY). The ICER was robust for uncertainties regarding the model parameters. The cost of DAA is the key factor influencing the cost-effectiveness of HCV treatment. At current price, DAA as first-line therapy is not cost-effective compared with PR, with or without consideration of retreatment. Threshold analysis suggested that DAA can be cost-effective if it costs less than USD 17 002 for a 12-week treatment course. CONCLUSION At current price, DAA as first-line therapy is not cost-effective compared with PR in GT3 HCV patients in Singapore.
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Affiliation(s)
- Yu‐Jun Wong
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - McVin HH Cheen
- Department of PharmacySingapore General HospitalSingapore
| | - John C Hsiang
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Rahul Kumar
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Jessica Tan
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Eng K Teo
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Prem H Thurairajah
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
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Wong YJ, Loh JT, Tan D. Gastrointestinal: An uncommon case of severe esophagitis. J Gastroenterol Hepatol 2019; 34:7. [PMID: 30079615 DOI: 10.1111/jgh.14379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/09/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Y J Wong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - J T Loh
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Dmy Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Wong YJ, Chew SY, Hsiang JC, Thurairajah PH, Kumar R, Teo EK, Gokhale RS, Noor IBM, Tan J. VIEKIRA PAK associated drug-induced interstitial lung disease: Case series with systematic review of literature. Clin Mol Hepatol 2018; 25:218-222. [PMID: 30184617 PMCID: PMC6589856 DOI: 10.3350/cmh.2018.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 07/13/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Si Yuan Chew
- Department of Respiratory Medicine and Critical Care, Changi General Hospital, Singapore, Singapore
| | - John Chen Hsiang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Respiratory Medicine and Critical Care, Changi General Hospital, Singapore, Singapore
| | - Imran Bin Mohamed Noor
- Department of Respiratory Medicine and Critical Care, Changi General Hospital, Singapore, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Wong YJ, Irani FG, Tan M, Teo M. Massive upper gastrointestinal bleeding post-Whipple's surgery from anastomotic varices due to mesenteric hypertension. Endoscopy 2018; 50:E159-E162. [PMID: 29742774 DOI: 10.1055/a-0595-7507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Farah Gillian Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Malcolm Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Melissa Teo
- Division of Surgical Oncology, Singapore General Hospital, Singapore.,National Cancer Center, Singapore
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Wong YJ, Choo KJL, Soh JXJ, Tan CK. Author's reply: Cytomegalovirus (CMV) hepatitis: an uncommon complication of CMV reactivation in drug reaction with eosinophilia and systemic symptoms. Singapore Med J 2018; 59:289-290. [PMID: 29796687 PMCID: PMC5966645 DOI: 10.11622/smedj.2018060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Jade Xiao Jue Soh
- Department of Infectious Disease, Singapore General Hospital, Singapore
| | - Chee Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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Wong YJ, Choo KJL, Soh JXJ, Tan CK. Cytomegalovirus (CMV) hepatitis: an uncommon complication of CMV reactivation in drug reaction with eosinophilia and systemic symptoms. Singapore Med J 2018; 59:112-113. [PMID: 29568844 DOI: 10.11622/smedj.2018016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Jade Xiao Jue Soh
- Department of Infectious Disease, Singapore General Hospital, Singapore
| | - Chee Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Abstract
Paraduodenal hernia (PDH), though uncommon, is a surgical emergency associated with high risk of strangulation and incarceration. Diagnosis of PDH remains challenging due to its non-specific presentation. We report the presentation and management of PDH in our hospital. All PDHs diagnosed from 2003 to 2014 were identified from a hospital database. Diagnosis of PDH was based on either radiological imaging or intraoperative surgical findings. Eight PDHs were identified during the study period. Median age was 48.5 (24–63) years and five occurred in females. All were left-sided PDHs. Six patients experienced recurrent symptoms prior to presentation. The commonest presenting symptoms were recurrent abdominal pain (four patients) and intestinal obstruction (four patients). Five patients were treated conservatively either because they had no obstructive symptoms or they declined surgery. All of them remained well up to a median of 27 (16–45) months’ follow-up. In contrast, three patients with obstructive symptoms underwent surgical repair (laparotomy, hernia repair and adhesiolysis). One patient had sub-acute intestinal obstruction after surgical repair and required re-exploratory surgery. All three PDH patients with obstructive symptoms remained well on follow-up (median 61 (range: 27–114) months) after surgery. In conclusion, PDH is an uncommon cause of intestinal obstruction. A high index of suspicion is required to diagnose PDH.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Narayan Lath
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Alvin Kim Hock Eng
- Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore
| | - Vikneswaran Navasivayam
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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Wong YJ, Tan BH, Leow WQ, Mesenas SJ. Cytomegalovirus infection masquerading as gastric carcinoma in an immune-compromised host. Proceedings of Singapore Healthcare 2017. [DOI: 10.1177/2010105817731797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
A 63-year-old man post-renal transplantation on immunosuppressants presented with reflux symptoms for one month. Significant medical history included a history of upper gastrointestinal bleeding, insulin-dependent diabetes mellitus and ischemic heart disease. Barium meal showed a large plaque-like lesion along greater curvature suspicious of malignancy. Gastroscopy revealed a large polyploidal gastric mass which was biopsied. Histological result showed numerous cytomegalovirus (CMV) viral inclusions within hyperplastic gastric mucosa without dysplasia or neoplasm. The findings were consistent with CMV gastric polyp. Following treatment with antiviral therapy and reduction in immunosuppressants, the CMV gastric polyp became smaller. This highlights the importance of considering CMV as a differential of gastric mass in an immunosuppressed host as treatment options varied between surgery and antiviral therapy.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Ban Hock Tan
- Department of Infectious Disease, Singapore General Hospital, Singapore
| | - Wei Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Steven Joseph Mesenas
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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Alhamid SM, Lee DXY, Wong HM, Chuah MB, Wong YJ, Narasimhalu K, Tan TT, Low SY. Implementing electronic handover: interventions to improve efficiency, safety and sustainability. Int J Qual Health Care 2016; 28:608-614. [PMID: 27512129 DOI: 10.1093/intqhc/mzw082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 06/12/2016] [Accepted: 06/15/2016] [Indexed: 02/05/2023] Open
Abstract
PROBLEM Effective handovers are critical for patient care and safety. Electronic handover tools are increasingly used today to provide an effective and standardized platform for information exchange. The implementation of an electronic handover system in tertiary hospitals can be a major challenge. Previous efforts in implementing an electronic handover tool failed due to poor compliance and buy-in from end-users. A new electronic handover tool was developed and incorporated into the existing electronic medical records (EMRs) for medical patients in Singapore General Hospital (SGH). INITIAL ASSESSMENT There was poor compliance by on-call doctors in acknowledging electronic handovers, and lack of adherence to safety rules, raising concerns about the safety and efficiency of the electronic handover tool. Urgent measures were needed to ensure its safe and sustained use. SOLUTION A quality improvement group comprising stakeholders, including end-users, developed multi-faceted interventions using rapid PDSA (P-Plan, D-Do, S-Study, A-Act ) cycles to address these issues. IMPLEMENTATION Innovative solutions using media and online software provided cost-efficient measures to improve compliance. EVALUATION The percentage of unacknowledged handovers per day was used as the main outcome measure throughout all PDSA cycles. Doctors were also assessed for improvement in their knowledge of safety rules and their perception of the electronic handover tool. LESSONS LEARNT An electronic handover tool complementing daily clinical practice can be successfully implemented using solutions devised through close collaboration with end-users supported by the senior leadership. A combined 'bottom-up' and 'top-down' approach with regular process evaluations is crucial for its long-term sustainability.
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Affiliation(s)
- Sharifah Munirah Alhamid
- Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Desmond Xue-Yuan Lee
- Clinical Services and Improvement, Division of Medicine, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Hei Man Wong
- Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Matthew Bingfeng Chuah
- Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Yu Jun Wong
- Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Kaavya Narasimhalu
- Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Thuan Tong Tan
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Su Ying Low
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, 169608, Singapore
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