Global prevalence, cascade of care, and prophylaxis coverage of hepatitis B in 2022: a modelling study

BACKGROUND

The 2016 World Health Assembly endorsed the elimination of hepatitis B virus (HBV) infection as a public health threat by 2030; existing therapies and prophylaxis measures make such elimination feasible, even in the absence of a virological cure. We aimed to estimate the national, regional, and global prevalence of HBV in the general population and among children aged 5 years and younger, as well as the rates of diagnosis, treatment, prophylaxis, and the future burden globally.

METHODS

In this modelling study, we used a Delphi process with data from literature reviews and interviews with country experts to quantify the prevalence, diagnosis, treatment, and prevention measures for HBV infection. The PRoGReSs Model, a dynamic Markov model, was used to estimate the country, regional, and global prevalence of HBV infection in 2022, and the effects of treatment and prevention on disease burden. The future incidence of morbidity and mortality in the absence of additional interventions was also estimated at the global level.

FINDINGS

We developed models for 170 countries which resulted in an estimated global prevalence of HBV infection in 2022 of 3·2% (95% uncertainty interval 2·7-4·0), corresponding to 257·5 million (216·6-316·4) individuals positive for HBsAg. Of these individuals, 36·0 million were diagnosed, and only 6·8 million of the estimated 83·3 million eligible for treatment were on treatment. The prevalence among children aged 5 years or younger was estimated to be 0·7% (0·6-1·0), corresponding to 5·6 million (4·5-7·8) children with HBV infection. Based on the most recent data, 85% of infants received three-dose HBV vaccination before 1 year of age, 46% had received a timely birth dose of vaccine, and 14% received hepatitis B immunoglobulin along with the full vaccination regimen. 3% of mothers with a high HBV viral load received antiviral treatment to reduce mother-to-child transmission.

INTERPRETATION

As 2030 approaches, the elimination targets remain out of reach for many countries under the current frameworks. Although prevention measures have had the most success, there is a need to increase these efforts and to increase diagnosis and treatment to work towards the elimination goals.

FUNDING

John C Martin Foundation, Gilead Sciences, and EndHep2030.

Development and Validation of a Novel 1-year Mortality Risk Score That Includes the Use of Antithrombotic in Patients With Overt Gastrointestinal Bleeding

GOALS AND BACKGROUND

We aimed to develop a novel 1-year mortality risk-scoring system that includes use of antithrombotic (AT) drugs and to validate it against other scoring systems in patients with acute gastrointestinal bleeding (GIB).

STUDY

We developed a risk-scoring system from prospectively collected data on patients admitted with GIB between January 2013 and August 2020, who had at least 1- year of follow-up. Independent predictors of 1-year mortality were determined after adjusting for the following confounders: the age-adjusted Charlson Comorbidity Index (CCI) (divided into 4 groups: CCI-0=0, CCI-1=1 to 3, CCI-2=4 to 6, CCI-3 ≥7), need for blood transfusion, GIB severity, need for endoscopic therapy, and type of AT. The risk score was based on independent predictors.

RESULTS

Five hundred seventy-six patients were included and 123 (21%) died at 1-year follow-up. Our risk -score was based on the following: CCI-2 (2 points), CCI-3 (4 points), need for blood transfusion (1 point), and no use of aspirin (1 point), as aspirin use was protective (maximum score=6). Patients with higher risk scores had higher mortality. The model had a better predictive accuracy [AUC=0.82, 95% confidence interval (0.78-0.86), P <0.0001] than the Rockall score for upper GIB (Area Under the Curve (AUC)=0.68, P <<0.0001), the Oakland score for lower GIB (AUC=0.69, p =0.004), or the Shock Index for all (AUC=0.54, P <0.0001).

CONCLUSION

A simple and novel score that includes use of AT upon admission accurately predicts 1-year mortality in patients with GIB. This scoring system may help guide follow-up decisions and inform the prognosis of patients with GIB.

Hepatitis delta virus infection prevalence, diagnosis and treatment in the Middle East: A scoping review

Hepatitis D virus (HDV) infection is a global public health concern, especially because of its unique existence in the presence of hepatitis B virus infection. HDV infection is estimated to affect 12 million people globally. Having a clearer understanding of its prevalence in all regions of the world is essential for helping direct preventive and early interventional treatment. This mini-review assessed the literature over the last 10 years to determine the prevalence, diagnostic means and treatment guidelines available for HDV in the Middle East. The search found limited data available in 21 articles, of which 18 were studies focused on Iran. Prevalence rates ranged dramatically among the countries, and none of the 12 countries included in the search had specific HDV guidelines. This review highlights the urgent need for more precise data for the Middle East region to help establish early diagnosis and treatment options for HDV.

Smoking Is Not an Independent Risk Factor for Surgery in Patients with Crohn's Disease on Biologic Therapy

Introduction

The development and course of inflammatory bowel disease appear to be influenced by environmental factors. Particularly, smoking has been shown to assume a harmful role in Crohn's disease (CD) and a protective role in ulcerative colitis. This study aims to examine the effect of smoking on need for surgery in patients with moderate to severe CD receiving biologic therapy.

Methods

This was a retrospective study of adult patients with CD at a University Medical Center over a 20-year period.

Results

A total of 251 patients were included (mean age 36.0 ± 15.0; 70.1% males; current, former, and nonsmokers: 44.2%, 11.6%, and 43.8%, respectively). Mean duration on biologics was 5.0 ± 3.1 years (>2/3 received anti-TNFs, followed by ustekinumab in 25.9%) and a third of patients (29.5%) received more than one biologic. Disease-related surgeries (abdominal, perianal, or both) occurred in 97 patients (38.6%): 50 patients had surgeries prior to starting biologics only, 41 had some surgeries after, and 6 had insufficient information. There was no significant difference in surgeries between ever-smokers (current or previous) versus nonsmokers in the overall study group. On logistic regression, the odds of having any CD surgery were higher in patients with longer disease duration (OR = 1.05, 95% CI = 1.01, 1.09) and in those receiving more than one biologic (OR = 2.31, 95% CI = 1.16, 4.59). However, among patients who had surgery prior to biologic therapy, smokers were more likely to have perianal surgery compared to nonsmokers (OR = 10.6, 95% CI = 2.0, 57.4; p = 0.006).

Conclusion

In biologic-naive CD patients requiring surgery, smoking is an independent predictor of perianal surgery. Smoking, however, is not an independent risk factor for surgery in this cohort after starting biologics. The risk of surgery in those patients is primarily associated with disease duration and the use of more than one biologic.

Predictors of Sustained Response With Tofacitinib Therapy in Patients With Ulcerative Colitis

BACKGROUND

Tofacitinib is an oral, small molecule JAK inhibitor for the treatment of ulcerative colitis. We evaluate baseline characteristics as predictors of sustained response and remission in patients with ulcerative colitis receiving tofacitinib maintenance therapy.

METHODS

Patients with clinical response following OCTAVE Induction 1 and 2 entered OCTAVE Sustain and were rerandomized to receive tofacitinib 5 or 10 mg twice daily or placebo. Baseline characteristics were stratified by week 52 efficacy endpoints (remission, sustained remission, clinical response, sustained clinical response). Associations between baseline characteristics and efficacy endpoints were evaluated using logistic regression analyses.

RESULTS

Overall, 170 of 487 (34.9%) patients were in remission at week 52. In multivariable modeling, endoscopic subscore at baseline of OCTAVE Induction 1 and 2 (2 vs 3; odds ratio [OR], 1.60; 95% confidence interval [CI], 1.06-2.44]), partial Mayo score (<2 vs ≥2; OR, 1.92; 95% CI, 1.27-2.90), and age (per 10-years; OR, 1.19; 95% CI, 1.02-1.39) at baseline of OCTAVE Sustain (following 8 weeks' tofacitinib induction therapy) were associated with higher odds of remission at week 52. Oral corticosteroid use (OR, 0.63; 95% CI, 0.42-0.96) and C-reactive protein (per unit; OR, 0.94; 95% CI, 0.89-0.99) at baseline of OCTAVE Sustain were associated with reduced likelihood of remission at week 52. In general, opposite associations were observed for time to loss of response.

CONCLUSION

Patients with greater clinical improvement after 8 weeks of tofacitinib induction therapy are more likely to maintain response or remission with tofacitinib regardless of dose received during maintenance, highlighting the importance of a robust response to induction therapy.

Impact of sedation type on adenoma detection rate by colonoscopy

BACKGROUND & AIMS

Endoscopic detection of polyps and adenomas decreases the incidence and mortality of colorectal cancer. The available data concerning the relationship between the sedation type and adenoma detection rate (ADR) or polyp detection rate (PDR) is inconclusive. The aim of our study was to evaluate the impact of conscious vs. deep (propofol) sedation on the ADR/PDR in diagnostic and screening colonoscopies.

METHODS

This was a retrospective cohort study. Patients aged 50-75 years old presenting for a first screening or diagnostic colonoscopy were included. Baseline demographic characteristics were collected, as well as PDR and ADR. Endoscopic withdrawal time and quality of bowel preparation rated in a binary fashion were also collected. Two multivariate logistic regression models were used to evaluate the independent predictors of endoscopic detection of polyps and adenomas.

RESULTS

574 patients met our inclusion criteria. Mean age was 59.26 ± 7.21 with 52.4% females and an average BMI of 28.08 ± 4.89. 374 patients (65.2%) underwent screening colonoscopies, and deep sedation was performed in 200 patients (34.8%). Only 4.7% had bad bowel preparation. PDR was 70% and ADR was 52%. On bivariate analysis, no significant difference was shown in PDR and ADR between conscious and deep sedation groups (0.70, 0.71; p = 0.712 and 0.50, 0.54; p = 0.394, respectively). On multivariate analysis for PDR, age and withdrawal time were independent predictors. For ADR, age, female sex, and withdrawal time were independent predictors. Sedation type and the indication did not reach statistical significance in both models.

CONCLUSION

The use of deep sedation didn't influence the ADR/PDR quality metrics in our mixed cohort of screening and diagnostic colonoscopies.

Management of acute diarrhea in the emergency department of a tertiary care university medical center

Objectives

To examine the management of acute diarrhea in the emergency department (ED) of a large university medical center.

Methods

Retrospective cross-sectional study over a 10-month period of adult patients (age ≥18 years) presenting to the ED with acute diarrhea.

Results

Data for 780 patients were reviewed; 101 met the exclusion criteria. Of the 679 patients with acute community-acquired diarrhea, 582 (85.7%) were discharged home and constituted the study cohort of mostly healthy adults (mean age: 32.5 ± 14.5 years). The rate of antibiotic prescription at discharge was 26%. Inappropriate use of antibiotics occurred in 28% of the patients. The presence of fever (odds ratio (OR) = 3.52), leukocytosis (OR = 1.72), and older age (OR = 1.16) were predictors of antibiotic prescription. Patients with dehydration, comorbidities, or bloody diarrhea were more likely to receive antibiotics. Microbiological studies and cross-sectional imaging were ordered in 12.4% and 11.7% of the patients, respectively, but provided very low yield (<10% for both) resulting in significantly higher visit charges. Inappropriately prescribed antibiotics at discharge resulted in higher charges in the ED compared with no antibiotic prescription.

Conclusion

Acute diarrhea management in our ED is suboptimal and does not adhere to practice guidelines, resulting in unnecessary antibiotic prescriptions, investigations, and cost.

Global change in hepatitis C virus prevalence and cascade of care between 2015 and 2020: a modelling study

BACKGROUND

Since the release of the first global hepatitis elimination targets in 2016, and until the COVID-19 pandemic started in early 2020, many countries and territories were making progress toward hepatitis C virus (HCV) elimination. This study aims to evaluate HCV burden in 2020, and forecast HCV burden by 2030 given current trends.

METHODS

This analysis includes a literature review, Delphi process, and mathematical modelling to estimate HCV prevalence (viraemic infection, defined as HCV RNA-positive cases) and the cascade of care among people of all ages (age ≥0 years from birth) for the period between Jan 1, 2015, and Dec 31, 2030. Epidemiological data were collected from published sources and grey literature (including government reports and personal communications) and were validated among country and territory experts. A Markov model was used to forecast disease burden and cascade of care from 1950 to 2050 for countries and territories with data. Model outcomes were extracted from 2015 to 2030 to calculate population-weighted regional averages, which were used for countries or territories without data. Regional and global estimates of HCV prevalence, cascade of care, and disease burden were calculated based on 235 countries and territories.

FINDINGS

Models were built for 110 countries or territories: 83 were approved by local experts and 27 were based on published data alone. Using data from these models, plus population-weighted regional averages for countries and territories without models (n=125), we estimated a global prevalence of viraemic HCV infection of 0·7% (95% UI 0·7-0·9), corresponding to 56·8 million (95% UI 55·2-67·8) infections, on Jan 1, 2020. This number represents a decrease of 6·8 million viraemic infections from a 2015 (beginning of year) prevalence estimate of 63·6 million (61·8-75·8) infections (0·9% [0·8-1·0] prevalence). By the end of 2020, an estimated 12·9 million (12·5-15·4) people were living with a diagnosed viraemic infection. In 2020, an estimated 641 000 (623 000-765 000) patients initiated treatment.

INTERPRETATION

At the beginning of 2020, there were an estimated 56·8 million viraemic HCV infections globally. Although this number represents a decrease from 2015, our forecasts suggest we are not currently on track to achieve global elimination targets by 2030. As countries recover from COVID-19, these findings can help refocus efforts aimed at HCV elimination.

FUNDING

John C Martin Foundation, Gilead Sciences, AbbVie, ZeShan Foundation, and The Hepatitis Fund.

Efficacy and Safety of Tofacitinib in Ulcerative Colitis Based on Prior Tumor Necrosis Factor Inhibitor Failure Status

BACKGROUND & AIMS

Tofacitinib is an oral, small-molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). We summarize the efficacy and safety data of tofacitinib 5 or 10 mg twice daily in the UC clinical program, stratified by prior tumor necrosis factor inhibitor (TNFi) failure status.

METHODS

Efficacy was assessed in the pooled phase 3 OCTAVE Induction 1 and 2 studies (N = 1139), the phase 3 OCTAVE Sustain maintenance study (N = 593), and the dose-escalation subpopulation of the open-label, long-term extension OCTAVE Open study (N = 59). Safety was assessed in OCTAVE Sustain, the dose-escalation subpopulation, and the Overall Cohort, which included patients from OCTAVE Induction 1 and 2, OCTAVE Sustain, and OCTAVE Open (N = 1124; no prior TNFi failure N = 541; prior TNFi failure N = 583; phase 2 data were excluded when stratified by prior TNFi failure status). The dose-escalation subpopulation received tofacitinib 10 mg twice daily in OCTAVE Induction 1 and 2, tofacitinib 5 mg twice daily in OCTAVE Sustain, and tofacitinib 10 mg twice daily in OCTAVE Open.

RESULTS

Tofacitinib had greater efficacy than placebo, regardless of prior TNFi failure status. In OCTAVE Sustain and the Overall Cohort, herpes zoster [HZ] (nonserious and serious) rates were numerically higher in tofacitinib-treated patients with vs without prior TNFi failure. Dose escalation to tofacitinib 10 mg twice daily generally recaptured clinical response for most patients. HZ (nonserious and serious) rates were numerically higher in the dose-escalation subpopulation vs the Overall Cohort.

CONCLUSIONS

Tofacitinib was efficacious in patients with UC regardless of prior TNFi failure status. HZ (nonserious and serious) rates were numerically higher in patients who had previously failed TNFi. ClinicalTrials.gov: A3921063 (NCT00787202); OCTAVE Induction 1 (NCT01465763); OCTAVE Induction 2 (NCT01458951); OCTAVE Sustain (NCT01458574); and OCTAVE Open (NCT01470612).

Review article: randomised controlled trials in inflammatory bowel disease-common challenges and potential solutions

BACKGROUND

Recruitment rates for Crohn's disease and ulcerative colitis clinical trials continue to decrease annually. The inability to reach recruitment targets and complete trials has serious implications for stakeholders in the inflammatory bowel disease (IBD) community. Action is required to ensure patients with an unmet medical need have access to new therapies to improve the management of their IBD.

AIMS

Identify challenges contributing to recruitment decline in IBD clinical trials and propose potential solutions.

METHODS

PubMed and Google were used to identify literature, regulatory guidelines and conference proceedings related to IBD clinical trials and related concepts. Data on IBD clinical trials conducted between 1989 and 2020 were extracted from the Trialtrove database.

RESULTS

Key aspects that may improve recruitment rates were identified. An increasingly patient-centric approach should be taken to study design including improvements to the readability of key trial documentation and inclusion of patient representatives in trial planning. Placebo is unappealing to patients; approaches including platform trials should be explored to minimise placebo exposure. Non-invasive imaging, biomarkers and novel digital endpoints should continue to be examined to reduce the burden on patients. Reducing the administrative burden associated with trials via the use of electronic signatures, for example, may benefit study sites and investigators. Changes implemented to IBD trials during the COVID-19 pandemic provided examples of how trial conduct can be rapidly and constructively adapted.

CONCLUSIONS

To improve recruitment in Crohn's disease and ulcerative colitis trials, the IBD community should address a broad range of issues related to clinical trial conduct.

Development and multicenter validation of FIB-6: A novel, machine learning, simple bedside score to rule out liver cirrhosis and compensated advanced chronic liver disease in patients with chronic hepatitis C

BACKGROUND

Non-invasive tests (NITs), such as Fibrosis-4 index (FIB-4) and the aspartate aminotransferase-to-platelet ratio index (APRI), developed using classical statistical methods, are increasingly used for determining liver fibrosis stages and recommended in treatment guidelines replacing the liver biopsy. Application of conventional cutoffs of FIB-4 and APRI resulted in high rates of misclassification of fibrosis stages.

AIM

There is an unmet need for more accurate NITs that can overcome the limitations of FIB-4 and APRI.

PATIENTS AND METHODS

Machine learning with the random forest algorithm was used to develop a non-invasive index using retrospective data of 7238 patients with biopsy-proven chronic hepatitis C from two centers in Egypt; derivation dataset (n = 1821) and validation set in the second center (n = 5417). Receiver operator curve analysis was used to define cutoffs for different stages of fibrosis. Performance of the new score was externally validated in cohorts from two other sites in Egypt (n = 560) and seven different countries (n = 1317). Fibrosis stages were determined using the METAVIR score. Results were also compared with three established tools (FIB-4, APRI, and the aspartate aminotransferase-to-alanine aminotransferase ratio [AAR]).

RESULTS

Age in addition to readily available laboratory parameters such as aspartate, and alanine aminotransferases, alkaline phosphatase, albumin (g/dl), and platelet count (/cm³ ) correlated with the biopsy-derived stage of liver fibrosis in the derivation cohort and were used to construct the model for predicting the fibrosis stage by applying the random forest algorithm, resulting in an FIB-6 index, which can be calculated easily at http://fib6.elriah.info. Application of the cutoff values derived from the derivation group on the validation groups yielded very good performance in ruling out cirrhosis (negative predictive value [NPV] = 97.7%), compensated advance liver disease (NPV = 90.2%), and significant fibrosis (NPV = 65.7%). In the external validation groups from different countries, FIB-6 demonstrated higher sensitivity and NPV than FIB-4, APRI, and AAR.

CONCLUSION

FIB-6 score is a non-invasive, simple, and accurate test for ruling out liver cirrhosis and compensated advance liver disease in patients with chronic hepatitis C and performs better than APRI, FIB-4, and AAR.

Mucosal Healing in Crohn's Disease: Bull's Eye or Bust? The "Relative" Con Position

BACKGROUND

Crohn's disease is a progressive inflammatory bowel disease. Persistent untreated inflammation can cumulatively result in bowel damage in the form of strictures, fistulas, and fibrosis, which can ultimately result in the need for major abdominal surgery. Mucosal healing has emerged as an attractive, yet ambitious goal in the hope of preventing long-term complications.

SUMMARY

Clinical remission is an inadequate measure of disease activity. Noninvasive markers such as fecal calprotectin, CRP, or small bowel ultrasound are useful adjunct tools. However, endoscopic assessment remains the cornerstone in building a treatment plan. Achieving complete mucosal healing has proved to be an elusive goal even in the ideal setting of a clinical trial.

KEY MESSAGES

Aiming for complete mucosal healing in all patients may result in overuse of medications, higher costs, and potential side effects of aggressive immunosuppressive treatment. More practical goals such as relative or partial healing, for example, 50% improvement in inflammation and reduction in size of ulcers, ought to be considered, particularly in difficult-to-treat populations.

Assessment of Endoscopic Disease Activity in Ulcerative Colitis: Is Simplicity the Ultimate Sophistication?

BACKGROUND

Endoscopic remission is an increasingly recognized important therapeutic endpoint in the management of patients with UC.

SUMMARY

The Mayo Endoscopic Score (MES) remains the most common endoscopic index recommended in guidelines and widely used in clinical trials and in clinical practice. The MES is easy, simple, and practical but is suboptimal at providing an accurate depiction of segmental healing and/or at measuring a substantial but incomplete response across the spectrum of endoscopic inflammation. Other endoscopic scores have been proposed but have not received wide recognition or adoption.

Increased rebleeding and mortality in patients with gastrointestinal bleeding treated with anticoagulant drugs compared to antiplatelet drugs

BACKGROUND/AIM

We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding.

METHODS

This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis.

RESULTS

A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease.

CONCLUSION

In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.

Biologic monotherapy versus combination therapy with immunomodulators in the induction and maintenance of remission of Crohn's disease and ulcerative colitis

Despite current guidelines, the optimal treatment of patients with inflammatory bowel disease (IBD) remains challenging. The available medications are not without risk and there is not a single correct treatment regimen for every patient. Personalizing treatment and selecting the most appropriate therapy is crucial for optimal response, remission, quality of life, and healthcare utilization. Biologics, especially anti-tumor necrosis factor-α medications, are widely used in the induction and maintenance of disease remission in patients with IBD. Similarly, immunomodulators, including thiopurines and methotrexate, are traditionally popular for the maintenance of remission. In this manuscript, we review the use of biologic monotherapy vs. combination therapy with immunomodulators for the treatment of ulcerative colitis and Crohn’s disease. We examine overall remission, immunogenicity and adverse effects, mainly serious infections and malignancy, in an effort to help guide treatment decisions and weigh the risks and benefits of biologic monotherapy vs. combination therapy.

Prevalence and characteristics of post-gastroscopy gastric cancer: A retrospective study from an academic medical center

BACKGROUND AND STUDY AIMS

Gastric cancer is diagnosed by endoscopy but false negative rates of up to 10% in the west and 40% in Asia have been reported. In Lebanon, little is known about the rates of post-gastroscopy gastric cancer (PGGC), defined as the proportion of patients diagnosed with gastric cancer with a negative previous examination within 2 years of diagnosis. We aimed to examine the rate of PGGC and its risk factors, clinico-pathologic and endoscopic characteristics at a University medical Center.

PATIENTS AND METHODS

Retrospective analysis of patients with histologically proven gastric malignancy over the last 14 years. Patients with history of upper endoscopy preceding the index diagnostic endoscopy by 6 to 24 months were included.

RESULTS

18,976 patients underwent upper endoscopy and gastric cancer was diagnosed in 323 (1.7%). Of those, only 4 (1.2%) had a preceding endoscopy within 6 to 24 months of diagnosis: 3 adenocarcinoma and one MALT lymphoma. Upon review of the initial endoscopy, a mucosal abnormality had been noted in all 4 patients and biopsies taken in 3 were negative for cancer. The mean time to cancer diagnosis was 8 months (range 6-13 months).

CONCLUSION

A small proportion of gastric carcinomas are missed on endoscopy in this study. Patients with endoscopic evidence of mucosal abnormalities and negative biopsies should undergo repeat examination with multiple biopsies. Proper endoscopic technique, lesion recognition and adoption of performance improvement measures are important to optimize endoscopic practice.

Positive predictive value of fecal immunochemical test for high-risk colonic adenomas and carcinoma: A health maintenance organization cohort screening study in Lebanon

BACKGROUND AND STUDY AIMS

Fecal Immunochemical Test (FIT) is one of the leading modalities for colorectal cancer screening. Studies show that FIT is highly sensitive for the detection of colorectal cancer (CRC) but not similarly accurate for detection of pre-cancerous advanced adenomas (AA). We studied the performance metrics of FIT for the detection of CRC and AA in ahealth maintenance organization (HMO) cohort screening program.

PATIENTS AND METHODS

Retrospective cohort study of asymptomatic persons of screening age belonging to a HMO. Endoscopy and pathology reports of those who tested positive were used to calculate the positive predictive value (PPV) of FIT, and characterize endoscopic findings on colonoscopy.

RESULTS

Between 1995 and 2017, 3000 persons had screening fecal occult testing as part of their Employee Health Care plan. Of those, 150 had a positive qualitative FIT (cutoff 10 Âµg hemoglobin/g feces). All underwentcolonoscopy, and median time to colonoscopy was 27 days. 4 (2.6%) had carcinoma(2 stage IIIA and 2 stage IIIB), 106 (70.6%) had adenomas of which 40 (26.6% of the total cohort) had advanced adenomas (≥1 cm, villous features, or high-grade dysplasia) giving a PPV for AA and carcinoma of 29% and 3% respectively. When stratified by age, the PPV of AA; carcinoma was [50-59 (21.7%; 0.0%)], [60-69 (14.6%; 4.2%)], [70-79 (42.6%; 2.1%)], [80-89 (33.3%; 11.1%)].

CONCLUSION

The performance characteristics of FIT testing are acceptable for population screening in resource-limited settings. The resultsof this study are helpful when discussing expectations prior to colonoscopy in people with positive FIT.

The case for simplifying and using absolute targets for viral hepatitis elimination goals

The 69th World Health Assembly endorsed the Global Health Sector Strategy for Viral Hepatitis, embracing a goal to eliminate hepatitis infection as a public health threat by 2030. This was followed by the World Health Organization's (WHO) global targets for the care and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. These announcements and targets were important in raising awareness and calling for action; however, tracking countries' progress towards these elimination goals has provided insights to the limitations of these targets. The existing targets compare a country's progress relative to its 2015 values, penalizing countries who started their programmes prior to 2015, countries with a young population, or countries with a low prevalence. We recommend that (1) WHO simplify the hepatitis elimination targets, (2) change to absolute targets and (3) allow countries to achieve these disease targets with their own service coverage initiatives that will have the maximum impact. The recommended targets are as follows: reduce HCV new chronic cases to ≤5 per 100 000, reduce HBV prevalence among 1-year-olds to ≤0.1%, reduce HBV and HCV mortality to ≤5 per 100 000, and demonstrate HBV and HCV year-to-year decrease in new HCV- and HBV-related HCC cases. The objective of our recommendations is not to lower expectations or diminish the hepatitis elimination standards, but to provide clearer targets that recognize the past and current elimination efforts by countries, help measure progress towards true elimination, and motivate other countries to follow suit.

Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa

With the increasing prevalence of obesity and type 2 diabetes, fatty liver disease associated with metabolic dysfunction is a global health problem, especially because it is one of the earliest consequences of obesity and it precedes diabetes development. Fatty liver disease associated with metabolic dysfunction is of particular concern in the Middle East and north Africa, where its prevalence is greater than that in the rest of the world. Despite the magnitude of the problem, no regional guidelines have been developed to address this disease. This Review describes suggestions of redefining fatty liver disease associated with metabolic dysfunction, including its terminology and criteria for diagnosis. Experts have raised serious concerns on the current nomenclature, which labels the disease as non-alcoholic fatty liver disease (NAFLD), and its diagnostic criteria. The panel reached a consensus that the disease should be renamed as metabolic-associated fatty liver disease (MAFLD) and that the disease should be diagnosed by positive criteria. The aim is now to work with authorities across the region to implement these proposed changes and reflect them in health-care policy and to improve health care for patients in this region.

Identification and management of Lynch syndrome in the Middle East and North African countries: outcome of a survey in 12 countries

BACKGROUND

Lynch syndrome (LS), the most common inherited form of colorectal cancer (CRC), is responsible for 3% of all cases of CRC. LS is caused by a mismatch repair gene defect and is characterized by a high risk for CRC, endometrial cancer and several other cancers. Identification of LS is of utmost importance because colonoscopic surveillance substantially improves a patient's prognosis. Recently, a network of physicians in Middle Eastern and North African (ME/NA) countries was established to improve the identification and management of LS families. The aim of the present survey was to evaluate current healthcare for families with LS in this region.

METHODS

A questionnaire was developed that addressed the following issues: availability of clinical management guidelines for LS; attention paid to family history of cancer; availability of genetic services for identification and diagnosis of LS; and assessment of knowledge of LS surveillance. Members of the network and authors of recent papers on LS from ME/NA and neighbouring countries were invited to participate in the survey and complete the online questionnaire.

RESULTS

A total of 55 individuals were invited and 19 respondents from twelve countries including Algeria, Azerbaijan, Cyprus, Egypt, Iran, Jordan, Kuwait, Lebanon, Morocco, Palestine, Tunisia, and Turkey completed the questionnaire. The results showed that family history of CRC is considered in less than half of the surveyed countries. Guidelines for the management of LS are available in three out of twelve countries. The identification and selection of families for genetic testing were based on clinical criteria (Amsterdam criteria II or Revised Bethesda criteria) in most countries, and only one country performed universal screening. In most of the surveyed countries genetic services were available in few hospitals or only in a research setting. However, surveillance of LS families was offered in the majority of countries and most frequently consisted of regular colonoscopy.

CONCLUSION

The identification and management of LS in ME/NA countries are suboptimal and as a result most LS families in the region remain undetected. Future efforts should focus on increasing awareness of LS amongst both the general population and doctors, and on the improvement of the infrastructure in these countries.

Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals

BACKGROUND

In resource-limited countries, risk stratification can be used to optimize colorectal cancer screening. Few prospective risk prediction models exist for advanced neoplasia (AN) in true average-risk individuals.

AIM

To create and internally validate a risk prediction model for detection of AN in average-risk individuals.

METHODS

Prospective study of asymptomatic individuals undergoing first screening colonoscopy. Detailed characteristics including diet, exercise and medications were collected. Multivariate logistic regression was used to elucidate risk factors for AN (adenoma ≥1 cm, villous histology, high-grade dysplasia or carcinoma). The model was validated through bootstrapping, and discrimination and calibration of the model were assessed.

RESULTS

980 consecutive individuals (51% F; 49% M) were enrolled. Adenoma and AN detection rates were 36.6% (F 29%: M 45%; P < 0.001) and 5.1% (F 3.8%; M 6.5%) respectively. On multivariate analysis, predictors of AN [OR (95%CI)] were age [1.036 (1.00-1.07); P = 0.048], BMI [overweight 2.21 (0.98-5.00); obese 3.54 (1.48-8.50); P = 0.018], smoking [< 40 pack-years 2.01 (1.01-4.01); ≥ 40 pack-years 3.96 (1.86-8.42); P = 0.002], and daily red meat consumption [2.02 (0.92-4.42) P = 0.079]. Nomograms of AN risk were developed in terms of risk factors and age separately for normal, overweight and obese individuals. The model had good discrimination and calibration.

CONCLUSION

The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West. Age, smoking, and BMI are important predictors of AN, with obesity being particularly powerful. Though external validation is needed, this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.