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Switching to Disposable Duodenoscopes: Risks and Rewards

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Switching to Disposable Duodenoscopes: Risks and Rewards
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Rajesh N. Keswani, MD, MS

Click to view more from Gastroenterology Data Trends 2022.

References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
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References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
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In 2013, the CDC warned the FDA that patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were being infected with multidrug-resistant bacteria, and that the bacteria were likely coming from the duodenoscopes.1 Subsequent changes to the instrument’s cleaning protocols did not significantly improve infection rates.2 Thus in 2019, the FDA urged endoscopists to abandon use of reusable, hard-to-clean duodenoscopes when performing ERCP.3 The FDA wanted surgeons to adopt either single-use models or reusable tools redesigned with disposable tips.

The FDA’s request has created a lively debate among endoscopists.4 While single-use instruments would, by definition, eliminate risk of infection and save time related to endoscope cleanings, the constant replacement costs and the environmental impact of their disposal have prompted much discussion.2,4 The estimated amount of greenhouse gas emissions, for example, from manufacturing the single-use instruments is remarkably higher than for other instruments.5

Alternatively, a “hybrid” duodenoscope, a reusable instrument equipped with a one-time-use tip, has been available for a few years; its use has been shown to significantly reduce bacterial contamination.6 However, that use has not entirely eliminated risk of microbial contamination despite adherence to high-level disinfection  and reprocessing.7

Although the primary driver for disposable duodenoscopes has been reduction of infection risk from ERCP, other improvements are anticipated changes in ergonomic design for instrument operators with smaller hands, for example. A small case study has shown that expert endoscopists can finish ERCPs of different levels of complexity using disposable duodenoscopes.8

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Post-COVID-19 Effects

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Post-COVID-19 Effects
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Viren Kaul, MD, FCCP, FACP

Click to view more from Pulmonology Data Trends 2022.

References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
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Viren Kaul, MD, FCCP, FACP

Click to view more from Pulmonology Data Trends 2022.

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References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
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Millions of Americans have been affected by the COVID-19 pandemic, with 93.2 million cases as of August 19, 2022.1 Many of these individuals are experiencing long-term effects after infection with the COVID-19 virus, and various disparities are affecting access to care. Post-acute COVID-19 syndrome is defined as symptoms that persist 4 weeks after the onset of symptoms from COVID-19 infection. Although COVID-19 is primarily a respiratory infection, the long-term effects have been seen in various organ systems. The effects of this condition reach beyond physical health, taking a toll on a patient’s economic and psychological well-being. Different racial/ethnic and economic factors also influence likelihood of illness and disease outcomes. Physicians must remain aware of the long-term role these factors will continue to play in patient outcomes.

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Painful and Pruritic Eruptions on the Entire Body

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Faraz Yousefian, DO
Liliana Espinoza, BS
Terri J. Nutt, MD

The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
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Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

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Liliana Espinoza, BS
Terri J. Nutt, MD
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Liliana Espinoza, BS
Terri J. Nutt, MD
Author and Disclosure Information

Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

Author and Disclosure Information

Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

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The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
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Painful and Pruritic Eruptions on the Entire Body
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A 36-year-old man presented with painful tender blisters and rashes on the entire body, including the ears and tongue. The rash began as a few pinpointed red dots on the abdomen, which subsequently increased in size and spread over the last week. He initially felt red and flushed and noticed new lesions appearing throughout the day. He did not attempt any specific treatment for these lesions. The patient tested positive for COVID-19 four months prior to the skin eruption. He denied systemic symptoms, smoking, or recent travel. He had no history of skin cancer, skin disorders, HIV, or hepatitis. He had no known medication allergies. Physical examination revealed multiple disseminated pustules on the ears, superficial ulcerations on the tongue, and blisters on the right lip. Few lesions were tender to the touch and drained clear fluid. Bacterial, viral, HIV, herpes, and rapid plasma reagin culture and laboratory screenings were negative. He was started on valaciclovir and cephalexin; however, no improvement was noticed. Punch biopsies were taken from the blisters on the chest and perilesional area.

Painful and pruritic eruptions on the entire body

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COPD Characteristics and Health Disparities

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References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

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References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

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An estimated 16 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), which is the fourth leading cause of death in the United States.1 Many of the health disparities in COPD diagnosis and care stem from the usual suspects: racial and ethnic barriers, lack of access, and socioeconomic burdens. Overall, COPD affects about 6.1% of Black Americans and 6.3% of non-Hispanic White Americans.2

However, while lower education and income are generally associated with poorer outcomes, Black and Hispanic patients with COPD who are highly educated and who have high incomes still show worse health status than their White counterparts.3 Incidence of COPD also varies by region, with rural states such as Alabama, Arkansas, and Kentucky having some of the highest rates.2,4  These inequalities support the need for continued research to address the varying health behaviors, comorbidities, and systemic barriers causing disparities for Black and Hispanic patients with COPD.

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Early Onset Colorectal Cancer: Trends in Incidence and Screening

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References
  1. Nfonsam VN, Jecius HC, Janda J, et al. Cartilage oligomeric matrix protein (COMP) promotes cell proliferation in early-onset colon cancer tumorigenesis. Surg Endosc. 2020;34(9):3992-3998. doi:10.1007/s00464-019-07185-z
  2. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst. 2017;109(8):djw322. doi:10.1093/jnci/djw322
  3. Loomans-Kropp HA, Umar A. Increasing incidence of colorectal cancer in young adults. J Cancer Epidemiol. 2019;2019:9841295. doi:10.1155/2019/9841295
  4. Gausman V, Dornblaser D, Anand S, et al. Risk factors associated with early-onset colorectal cancer. Clin Gastroenterol Hepatol. 2020;18(12):2752-2759.e2. doi:10.1016/j.cgh.2019.10.009
  5. Use of colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated November 3, 2021. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/statistics/use-screening-tests-BRFSS.htm
  6. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  7. Zhao G, Li H, Yang Z, et al. Multiplex methylated DNA testing in plasma with high sensitivity and specificity for colorectal cancer screening. Cancer Med. 2019;8:5619-5628. doi:10.1002/cam4.2475
  8. Abualkhair WH, Zhou M, Ahnen D, Yu Q, Wu XC, Karlitz JJ. Trends in incidence of early-onset colorectal cancer in the United States among those approaching screening age. JAMA Netw Open. 2020;3(1):e1920407. doi:10.1001/jamanetworkopen.2019.20407
  9. Burnett-Hartman AN, Lee JK, Demb J, Gupta S. An update on the epidemiology, molecular characterization, diagnosis, and screening strategies for early-onset colorectal cancer. Gastroenterology. 2021;160(4):1041-1049. doi:10.1053/j.gastro.2020.12.068
  10. Gu J, Li Y, Yu J, et al. A risk scoring system to predict the individual incidence of early-onset colorectal cancer. BMC Cancer. 2022;22(1):122. doi:10.1186/s12885-022-09238-4
  11. Lou S, Shaukat A. Noninvasive strategies for colorectal cancer screening: opportunities and limitations. Curr Opin Gastroenterol. 2021;37(1):44-51. doi:10.1097/MOG.0000000000000688
  12. Fecal immunochemical test (FIT). MedlinePlus. Updated July 1, 2021. Accessed July 7, 2022. https://medlineplus.gov/ency/patientinstructions/000704.htm
  13. Colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated February 17, 2022. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm
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Author(s)
Aasma Shaukat, MD, MPH, AGAF
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Aasma Shaukat, MD, MPH, AGAF

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References
  1. Nfonsam VN, Jecius HC, Janda J, et al. Cartilage oligomeric matrix protein (COMP) promotes cell proliferation in early-onset colon cancer tumorigenesis. Surg Endosc. 2020;34(9):3992-3998. doi:10.1007/s00464-019-07185-z
  2. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst. 2017;109(8):djw322. doi:10.1093/jnci/djw322
  3. Loomans-Kropp HA, Umar A. Increasing incidence of colorectal cancer in young adults. J Cancer Epidemiol. 2019;2019:9841295. doi:10.1155/2019/9841295
  4. Gausman V, Dornblaser D, Anand S, et al. Risk factors associated with early-onset colorectal cancer. Clin Gastroenterol Hepatol. 2020;18(12):2752-2759.e2. doi:10.1016/j.cgh.2019.10.009
  5. Use of colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated November 3, 2021. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/statistics/use-screening-tests-BRFSS.htm
  6. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  7. Zhao G, Li H, Yang Z, et al. Multiplex methylated DNA testing in plasma with high sensitivity and specificity for colorectal cancer screening. Cancer Med. 2019;8:5619-5628. doi:10.1002/cam4.2475
  8. Abualkhair WH, Zhou M, Ahnen D, Yu Q, Wu XC, Karlitz JJ. Trends in incidence of early-onset colorectal cancer in the United States among those approaching screening age. JAMA Netw Open. 2020;3(1):e1920407. doi:10.1001/jamanetworkopen.2019.20407
  9. Burnett-Hartman AN, Lee JK, Demb J, Gupta S. An update on the epidemiology, molecular characterization, diagnosis, and screening strategies for early-onset colorectal cancer. Gastroenterology. 2021;160(4):1041-1049. doi:10.1053/j.gastro.2020.12.068
  10. Gu J, Li Y, Yu J, et al. A risk scoring system to predict the individual incidence of early-onset colorectal cancer. BMC Cancer. 2022;22(1):122. doi:10.1186/s12885-022-09238-4
  11. Lou S, Shaukat A. Noninvasive strategies for colorectal cancer screening: opportunities and limitations. Curr Opin Gastroenterol. 2021;37(1):44-51. doi:10.1097/MOG.0000000000000688
  12. Fecal immunochemical test (FIT). MedlinePlus. Updated July 1, 2021. Accessed July 7, 2022. https://medlineplus.gov/ency/patientinstructions/000704.htm
  13. Colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated February 17, 2022. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm
References
  1. Nfonsam VN, Jecius HC, Janda J, et al. Cartilage oligomeric matrix protein (COMP) promotes cell proliferation in early-onset colon cancer tumorigenesis. Surg Endosc. 2020;34(9):3992-3998. doi:10.1007/s00464-019-07185-z
  2. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst. 2017;109(8):djw322. doi:10.1093/jnci/djw322
  3. Loomans-Kropp HA, Umar A. Increasing incidence of colorectal cancer in young adults. J Cancer Epidemiol. 2019;2019:9841295. doi:10.1155/2019/9841295
  4. Gausman V, Dornblaser D, Anand S, et al. Risk factors associated with early-onset colorectal cancer. Clin Gastroenterol Hepatol. 2020;18(12):2752-2759.e2. doi:10.1016/j.cgh.2019.10.009
  5. Use of colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated November 3, 2021. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/statistics/use-screening-tests-BRFSS.htm
  6. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  7. Zhao G, Li H, Yang Z, et al. Multiplex methylated DNA testing in plasma with high sensitivity and specificity for colorectal cancer screening. Cancer Med. 2019;8:5619-5628. doi:10.1002/cam4.2475
  8. Abualkhair WH, Zhou M, Ahnen D, Yu Q, Wu XC, Karlitz JJ. Trends in incidence of early-onset colorectal cancer in the United States among those approaching screening age. JAMA Netw Open. 2020;3(1):e1920407. doi:10.1001/jamanetworkopen.2019.20407
  9. Burnett-Hartman AN, Lee JK, Demb J, Gupta S. An update on the epidemiology, molecular characterization, diagnosis, and screening strategies for early-onset colorectal cancer. Gastroenterology. 2021;160(4):1041-1049. doi:10.1053/j.gastro.2020.12.068
  10. Gu J, Li Y, Yu J, et al. A risk scoring system to predict the individual incidence of early-onset colorectal cancer. BMC Cancer. 2022;22(1):122. doi:10.1186/s12885-022-09238-4
  11. Lou S, Shaukat A. Noninvasive strategies for colorectal cancer screening: opportunities and limitations. Curr Opin Gastroenterol. 2021;37(1):44-51. doi:10.1097/MOG.0000000000000688
  12. Fecal immunochemical test (FIT). MedlinePlus. Updated July 1, 2021. Accessed July 7, 2022. https://medlineplus.gov/ency/patientinstructions/000704.htm
  13. Colorectal cancer screening tests. Centers for Disease Control and Prevention. Updated February 17, 2022. Accessed July 7, 2022. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm
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The literature calls early-onset CRC a “distinct disease,” because of its molecular characteristics, challenges in diagnosis, and often poor prognosis.1 Patients with early-onset CRC often have a close family member with colon cancer, yet often ignore symptoms like abdominal pain. Among individuals with a firstdegree relative with colon cancer, those younger than age 50 years are half as likely to have undergone a colonoscopy as those 50 years and older.2 When symptoms do appear, the average time to diagnosis is 128 days for those younger than 50 vs 79 days for those older than 50.3

What is important to consider is the life stage in which these patients find themselves. A cancer diagnosis in a patient’s 40s—accounting for about three-quarters of early-onset cases4—comes in the middle of a career, of raising a family, of living a full life. Therefore, noninvasive screening is so important for those at risk of early onset CRC: An easier screening procedure takes less time than a colonoscopy procedure can consume.

CRC screening rates remain suboptimal, even among persons aged 50 and older. As of 2020, approximately 30% to 35% of adults older than 50 in the United States had never been screened for colorectal cancer.5 Strategies to improve CRC screening rates include organized outreach programs and use of noninvasive CRC screening tests. These tests do not replace colonoscopy but complement them.

Acceptance of FIT is high and can reduce CRC incidence and mortality.6 Industry has been working on devising other noninvasive options, which in their newer iterations are starting to show diagnostic relevance.7 These options may help all individuals due or overdue for CRC screening.

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New Treatment Pathways for Cystic Fibrosis

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David Finklea, MD

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References
  1. Cystic Fibrosis Foundation. What is cystic fibrosis? https://www. cff.org/intro-cf/about-cystic-fibrosis. Accessed June 17, 2022.
  2. Middleton PG, Mall MA, Dřevínek P, et al. Elexacaftor-tezacaftor-ivacaftor for cystic fibrosis with a single Phe508del allele. N Engl J Med. 2019;381(19):1809-1819. doi:10.1056/NEJMoa1908639
  3. McGarry ME, McColley SA. Cystic fibrosis patients of minority race and ethnicity less likely eligible for CFTR modulators based on CFTR genotype. Pediatr Pulmonol. 2021;56(6):1496-1503. doi:10.1002/ppul.25285
  4. O’Connor KE, Goodwin DL, NeSmith A, et al. Elexacaftor/ tezacaftor/ivacaftor resolves subfertility in females with CF: a two center case series. J Cyst Fibros. 2021;20(3):399-401. doi:10.1016/j.jcf.2020.12.011
  5. Shteinberg M, Taylor-Cousar JL, Durieu I, Cohen-Cymberknoh M. Fertility and Pregnancy in Cystic Fibrosis. Chest. 2021;160(6):2051-2060. doi:10.1016/j.chest.2021.07.024
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David Finklea, MD
Author(s)
David Finklea, MD

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References
  1. Cystic Fibrosis Foundation. What is cystic fibrosis? https://www. cff.org/intro-cf/about-cystic-fibrosis. Accessed June 17, 2022.
  2. Middleton PG, Mall MA, Dřevínek P, et al. Elexacaftor-tezacaftor-ivacaftor for cystic fibrosis with a single Phe508del allele. N Engl J Med. 2019;381(19):1809-1819. doi:10.1056/NEJMoa1908639
  3. McGarry ME, McColley SA. Cystic fibrosis patients of minority race and ethnicity less likely eligible for CFTR modulators based on CFTR genotype. Pediatr Pulmonol. 2021;56(6):1496-1503. doi:10.1002/ppul.25285
  4. O’Connor KE, Goodwin DL, NeSmith A, et al. Elexacaftor/ tezacaftor/ivacaftor resolves subfertility in females with CF: a two center case series. J Cyst Fibros. 2021;20(3):399-401. doi:10.1016/j.jcf.2020.12.011
  5. Shteinberg M, Taylor-Cousar JL, Durieu I, Cohen-Cymberknoh M. Fertility and Pregnancy in Cystic Fibrosis. Chest. 2021;160(6):2051-2060. doi:10.1016/j.chest.2021.07.024
References
  1. Cystic Fibrosis Foundation. What is cystic fibrosis? https://www. cff.org/intro-cf/about-cystic-fibrosis. Accessed June 17, 2022.
  2. Middleton PG, Mall MA, Dřevínek P, et al. Elexacaftor-tezacaftor-ivacaftor for cystic fibrosis with a single Phe508del allele. N Engl J Med. 2019;381(19):1809-1819. doi:10.1056/NEJMoa1908639
  3. McGarry ME, McColley SA. Cystic fibrosis patients of minority race and ethnicity less likely eligible for CFTR modulators based on CFTR genotype. Pediatr Pulmonol. 2021;56(6):1496-1503. doi:10.1002/ppul.25285
  4. O’Connor KE, Goodwin DL, NeSmith A, et al. Elexacaftor/ tezacaftor/ivacaftor resolves subfertility in females with CF: a two center case series. J Cyst Fibros. 2021;20(3):399-401. doi:10.1016/j.jcf.2020.12.011
  5. Shteinberg M, Taylor-Cousar JL, Durieu I, Cohen-Cymberknoh M. Fertility and Pregnancy in Cystic Fibrosis. Chest. 2021;160(6):2051-2060. doi:10.1016/j.chest.2021.07.024
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CHEST Physician
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New Treatment Pathways for Cystic Fibrosis
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Cystic fibrosis is a deadly genetic disorder, affecting 80,000 people worldwide.1,2 The disorder is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene.2 This gene codes for a protein that creates epithelial channels in the respiratory track, along with other organs. Mutations in this gene can create improper ion balance, leading to thick and sticky mucus that blocks airways in the lungs and contributes to infections in people with CF (pwCF).1

Currently, there is no cure for cystic fibrosis, but newer research is looking into modulating the CFTR gene from multiple pathways by repairing, restoring, or replacing the CFTR protein.1,2 At this point, CFTR modulators are the most promising new treatments for cystic fibrosis.

CFTR modulators involve repairing the CFTR protein made from this gene. To qualify for treatment with this class of drugs, people with cystic fibrosis need to have certain CFTR mutations. Fortunately, approximately 90% of pwCF qualify for CFTR modulators.1,2 Due to this, the Cystic Fibrosis Foundation is working on finding alternative therapies that are listed below.1

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Risk Assessment in Pulmonary Arterial Hypertension

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Risk Assessment in Pulmonary Arterial Hypertension
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Sandeep Sahay, MD, MSc, FCCP, ATSF

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References
  1. Sahay S, Balasubramanian V, Memon H, et al. Utilization of risk assessment tools in management of PAH: a PAH provider survey. Pulm Circ. 2022;12(2):e12057. doi:10.1002/pul2.12057
  2. Sahay S, Tonelli AR, Selej M, Watson Z, Benza RL. Risk assessment in patients with functional class II pulmonary arterial hypertension: comparison of physician gestalt with ESC/ERS and the REVEAL 2.0 risk score. PLoS One. 2020;15(11):e0241504. doi:10.1371/journal.pone.0241504
  3. Galiè N, Channick RN, Frantz RP, et al. Risk stratification and medical therapy of pulmonary arterial hypertension. Eur Respir J. 2019;53(1):1801889. doi:10.1183/13993003.01889-2018
  4. Boucly A, Weatherald J, Savale L, et al. Risk assessment, prognosis and guideline implementation in pulmonary arterial hypertension. Eur Respir J. 2017;50(2):1700889. doi:10.1183/13993003.00889-2017
  5. Wilson M, Keeley J, Kingman M, Wang J, Rogers F. Current clinical utilization of risk assessment tools in pulmonary arterial hypertension: a descriptive survey of facilitation strategies, patterns, and barriers to use in the United States. Pulm Circ. 2020;10(3):2045894020950186. doi:10.1177/2045894020950186
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CHEST Physician
Topics
Pulmonary Arterial Hypertension
Author(s)
Sandeep Sahay, MD, MSc, FCCP, ATSF
Author(s)
Sandeep Sahay, MD, MSc, FCCP, ATSF

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References
  1. Sahay S, Balasubramanian V, Memon H, et al. Utilization of risk assessment tools in management of PAH: a PAH provider survey. Pulm Circ. 2022;12(2):e12057. doi:10.1002/pul2.12057
  2. Sahay S, Tonelli AR, Selej M, Watson Z, Benza RL. Risk assessment in patients with functional class II pulmonary arterial hypertension: comparison of physician gestalt with ESC/ERS and the REVEAL 2.0 risk score. PLoS One. 2020;15(11):e0241504. doi:10.1371/journal.pone.0241504
  3. Galiè N, Channick RN, Frantz RP, et al. Risk stratification and medical therapy of pulmonary arterial hypertension. Eur Respir J. 2019;53(1):1801889. doi:10.1183/13993003.01889-2018
  4. Boucly A, Weatherald J, Savale L, et al. Risk assessment, prognosis and guideline implementation in pulmonary arterial hypertension. Eur Respir J. 2017;50(2):1700889. doi:10.1183/13993003.00889-2017
  5. Wilson M, Keeley J, Kingman M, Wang J, Rogers F. Current clinical utilization of risk assessment tools in pulmonary arterial hypertension: a descriptive survey of facilitation strategies, patterns, and barriers to use in the United States. Pulm Circ. 2020;10(3):2045894020950186. doi:10.1177/2045894020950186
References
  1. Sahay S, Balasubramanian V, Memon H, et al. Utilization of risk assessment tools in management of PAH: a PAH provider survey. Pulm Circ. 2022;12(2):e12057. doi:10.1002/pul2.12057
  2. Sahay S, Tonelli AR, Selej M, Watson Z, Benza RL. Risk assessment in patients with functional class II pulmonary arterial hypertension: comparison of physician gestalt with ESC/ERS and the REVEAL 2.0 risk score. PLoS One. 2020;15(11):e0241504. doi:10.1371/journal.pone.0241504
  3. Galiè N, Channick RN, Frantz RP, et al. Risk stratification and medical therapy of pulmonary arterial hypertension. Eur Respir J. 2019;53(1):1801889. doi:10.1183/13993003.01889-2018
  4. Boucly A, Weatherald J, Savale L, et al. Risk assessment, prognosis and guideline implementation in pulmonary arterial hypertension. Eur Respir J. 2017;50(2):1700889. doi:10.1183/13993003.00889-2017
  5. Wilson M, Keeley J, Kingman M, Wang J, Rogers F. Current clinical utilization of risk assessment tools in pulmonary arterial hypertension: a descriptive survey of facilitation strategies, patterns, and barriers to use in the United States. Pulm Circ. 2020;10(3):2045894020950186. doi:10.1177/2045894020950186
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Properly assessing risk level at the time of diagnosis and follow up is crucial for understanding each patient’s case, identifying modifiable barriers and the most appropriate treatment options, and, ultimately, optimizing survival outcomes for pulmonary arterial hypertension (PAH). Despite the variety of risk assessment tools and electronic medical records at clinicians’ disposal, these resources remain underutilized.1

A survey, designed by CHEST’s Pulmonary Vascular Disease section of the Pulmonary Vascular and Cardiovascular Network, asked members to share insight into their use and perceptions of PAH risk assessment tools in clinical practice. Although the ability of proper risk assessment to greatly improve patient care has been demonstrated in the literature and is recommended by most clinical guidelines, the results of this survey revealed that more than one-third of specialists were not using guideline-recommended risk tools to assess PAH, and only 7% reported that risk assessment tools impacted their treatment decision in new patient care and evaluation.1-4

There is a lack of consensus in patterns of risk tool use among physicians, with 58% reporting that they use more than one tool. In addition to continued clinical research to support the use of available tools and the development of new ones, clinician education programs can help increase the positive impact that risk assessment has on patient survival and other outcomes.1,5

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Diversity in the Gastroenterology Workforce and its Implications for Patients

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Diversity in the Gastroenterology Workforce and its Implications for Patients
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Sandra Quezada, MD, MS, AGAF

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References
  1. Welch M. Required curricula in diversity and cross-cultural medicine: the time is now. J Am Med Womens Assoc (1972). 1998;53(3 Suppl):121-3, 130. PMID:17598289. 
  2. Carethers JM. Toward realizing diversity in academic medicine. J Clin Invest. 2020;130(11):5626-5628. doi:10.1172/JCI144527 
  3. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. doi:10.1001/jama.2013.282116 
  4. Guevara JP, Wade R, Aysola J. Racial and ethnic diversity at medical schools – why aren’t we there yet? N Engl J Med. 2021;385(19):1732-1734. doi:10.1056/NEJMp2105578
  5. Dill J, Akosionu O, Karbeah JM, Henning-Smith C. Addressing systemic racial inequity in the health care workforce. Health Affairs. September 10, 2020. Accessed July 12, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20200908.133196/full/ 
  6. Carr RM, Quezada SM, Gangarosa LM, et al; Governing Board of the American Gastroenterological Association. From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology. Gastroenterology. 2020;159(5):1637-1647. doi:10.1053/j.gastro.2020.07.044 
  7. American Gastroenterological Association. AGA equity project. Accessed July 11, 2022. https://gastro.org/aga-leadership/initiatives-and-programs/aga-equity-project/ 
  8. Barnes EL, Loftus EV Jr, Kappelman MD. Effects of race and ethnicity on diagnosis and management of inflammatory bowel diseases. Gastroenterology. 2021;160(3):677-689. doi:10.1053/j.gastro.2020.08.064 
  9. White PM, Iroku U, Carr RM, May FP; Association of Black Gastroenterologists and Hepatologists Board of Directors. Advancing health equity: The Association of Black Gastroenterologists and Hepatologists. Nat Rev Gastroenterol Hepatol. 2021;18(7):449-450. doi: 10.1038/s41575-021-00464-y 
  10. Ogunyemi D, Okekpe CC, Barrientos DR, Bui T, Au MN, Lamba S. United States medical school academic faculty workforce diversity, institutional characteristics, and geographical distributions from 2014-2018. Cureus. 2022;14(2):e22292. doi:10.7759/cureus.22292 
  11. Weiss J, Balasuriya L, Cramer LD, et al. Medical students’ demographic characteristics and their perceptions of faculty role modeling of respect for diversity. JAMA Netw Open. 2021;4(6):e2112795. doi:10.1001/jamanetworkopen.2021.12795 
  12. Association of American Medical Colleges (AAMC). Medical school enrollment more diverse in 2021. December 8, 2021. Accessed June 29, 2022. https://www.aamc.org/news-insights/press-releases/medical-school-enrollment-more-diverse-2021 
  13. Silvernale C, Kuo B, Staller K. Racial disparity in healthcare utilization among patients with irritable bowel syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2020;33(5):e14039. doi: 10.1111/nmo.14039 
  14. Robinett K, Kareem R, Reavis K, Quezada S. A multi-pronged, antiracist approach to optimize equity in medical school admissions. Med Educ. 2021;55(12):1376-1382. doi:10.1111/medu.14589 
Publications
GI and Hepatology News
Topics
Practice Management
Author(s)
Sandra Quezada, MD, MS, AGAF
Author(s)
Sandra Quezada, MD, MS, AGAF

Click to view more from Gastroenterology Data Trends 2022.

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References
  1. Welch M. Required curricula in diversity and cross-cultural medicine: the time is now. J Am Med Womens Assoc (1972). 1998;53(3 Suppl):121-3, 130. PMID:17598289. 
  2. Carethers JM. Toward realizing diversity in academic medicine. J Clin Invest. 2020;130(11):5626-5628. doi:10.1172/JCI144527 
  3. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. doi:10.1001/jama.2013.282116 
  4. Guevara JP, Wade R, Aysola J. Racial and ethnic diversity at medical schools – why aren’t we there yet? N Engl J Med. 2021;385(19):1732-1734. doi:10.1056/NEJMp2105578
  5. Dill J, Akosionu O, Karbeah JM, Henning-Smith C. Addressing systemic racial inequity in the health care workforce. Health Affairs. September 10, 2020. Accessed July 12, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20200908.133196/full/ 
  6. Carr RM, Quezada SM, Gangarosa LM, et al; Governing Board of the American Gastroenterological Association. From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology. Gastroenterology. 2020;159(5):1637-1647. doi:10.1053/j.gastro.2020.07.044 
  7. American Gastroenterological Association. AGA equity project. Accessed July 11, 2022. https://gastro.org/aga-leadership/initiatives-and-programs/aga-equity-project/ 
  8. Barnes EL, Loftus EV Jr, Kappelman MD. Effects of race and ethnicity on diagnosis and management of inflammatory bowel diseases. Gastroenterology. 2021;160(3):677-689. doi:10.1053/j.gastro.2020.08.064 
  9. White PM, Iroku U, Carr RM, May FP; Association of Black Gastroenterologists and Hepatologists Board of Directors. Advancing health equity: The Association of Black Gastroenterologists and Hepatologists. Nat Rev Gastroenterol Hepatol. 2021;18(7):449-450. doi: 10.1038/s41575-021-00464-y 
  10. Ogunyemi D, Okekpe CC, Barrientos DR, Bui T, Au MN, Lamba S. United States medical school academic faculty workforce diversity, institutional characteristics, and geographical distributions from 2014-2018. Cureus. 2022;14(2):e22292. doi:10.7759/cureus.22292 
  11. Weiss J, Balasuriya L, Cramer LD, et al. Medical students’ demographic characteristics and their perceptions of faculty role modeling of respect for diversity. JAMA Netw Open. 2021;4(6):e2112795. doi:10.1001/jamanetworkopen.2021.12795 
  12. Association of American Medical Colleges (AAMC). Medical school enrollment more diverse in 2021. December 8, 2021. Accessed June 29, 2022. https://www.aamc.org/news-insights/press-releases/medical-school-enrollment-more-diverse-2021 
  13. Silvernale C, Kuo B, Staller K. Racial disparity in healthcare utilization among patients with irritable bowel syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2020;33(5):e14039. doi: 10.1111/nmo.14039 
  14. Robinett K, Kareem R, Reavis K, Quezada S. A multi-pronged, antiracist approach to optimize equity in medical school admissions. Med Educ. 2021;55(12):1376-1382. doi:10.1111/medu.14589 
References
  1. Welch M. Required curricula in diversity and cross-cultural medicine: the time is now. J Am Med Womens Assoc (1972). 1998;53(3 Suppl):121-3, 130. PMID:17598289. 
  2. Carethers JM. Toward realizing diversity in academic medicine. J Clin Invest. 2020;130(11):5626-5628. doi:10.1172/JCI144527 
  3. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. doi:10.1001/jama.2013.282116 
  4. Guevara JP, Wade R, Aysola J. Racial and ethnic diversity at medical schools – why aren’t we there yet? N Engl J Med. 2021;385(19):1732-1734. doi:10.1056/NEJMp2105578
  5. Dill J, Akosionu O, Karbeah JM, Henning-Smith C. Addressing systemic racial inequity in the health care workforce. Health Affairs. September 10, 2020. Accessed July 12, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20200908.133196/full/ 
  6. Carr RM, Quezada SM, Gangarosa LM, et al; Governing Board of the American Gastroenterological Association. From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology. Gastroenterology. 2020;159(5):1637-1647. doi:10.1053/j.gastro.2020.07.044 
  7. American Gastroenterological Association. AGA equity project. Accessed July 11, 2022. https://gastro.org/aga-leadership/initiatives-and-programs/aga-equity-project/ 
  8. Barnes EL, Loftus EV Jr, Kappelman MD. Effects of race and ethnicity on diagnosis and management of inflammatory bowel diseases. Gastroenterology. 2021;160(3):677-689. doi:10.1053/j.gastro.2020.08.064 
  9. White PM, Iroku U, Carr RM, May FP; Association of Black Gastroenterologists and Hepatologists Board of Directors. Advancing health equity: The Association of Black Gastroenterologists and Hepatologists. Nat Rev Gastroenterol Hepatol. 2021;18(7):449-450. doi: 10.1038/s41575-021-00464-y 
  10. Ogunyemi D, Okekpe CC, Barrientos DR, Bui T, Au MN, Lamba S. United States medical school academic faculty workforce diversity, institutional characteristics, and geographical distributions from 2014-2018. Cureus. 2022;14(2):e22292. doi:10.7759/cureus.22292 
  11. Weiss J, Balasuriya L, Cramer LD, et al. Medical students’ demographic characteristics and their perceptions of faculty role modeling of respect for diversity. JAMA Netw Open. 2021;4(6):e2112795. doi:10.1001/jamanetworkopen.2021.12795 
  12. Association of American Medical Colleges (AAMC). Medical school enrollment more diverse in 2021. December 8, 2021. Accessed June 29, 2022. https://www.aamc.org/news-insights/press-releases/medical-school-enrollment-more-diverse-2021 
  13. Silvernale C, Kuo B, Staller K. Racial disparity in healthcare utilization among patients with irritable bowel syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2020;33(5):e14039. doi: 10.1111/nmo.14039 
  14. Robinett K, Kareem R, Reavis K, Quezada S. A multi-pronged, antiracist approach to optimize equity in medical school admissions. Med Educ. 2021;55(12):1376-1382. doi:10.1111/medu.14589 
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As the US population has become more diverse, the medical community has advocated for students, faculty, and curricula to reflect these changes. Understanding and addressing a patient’s culture and socioeconomic situation is vital to their well-being, and physicians who share in the cultural backgrounds and lived experiences of their patients are more likely to bring this insight and understanding to medicine.1 Yet over the last 2 decades, diversity among medical faculty is largely unchanged. One author recently wrote that students who are Black, Indigenous, and people of color (BIPOC) would be hard-pressed to find role models that look like them, as these populations are underrepresented among medical faculty.2-4

In 2020, the upsurge of the Black Lives Matter movement combined with the COVID-19 pandemic’s exposure of health disparities prompted society to better acknowledge socioeconomic inequalities and health organizations to revisit these issues.5,6 The AGA has introduced many crucial initiatives in collaboration with its Diversity Committee, including the AGA Equity  Project – a multiyear strategic plan designed to: eliminate health disparities and inequities in access, support GI research that aligns with the realities of multicultural patient populations, and educate AGA members and staff about unconscious bias.7

Further diversification of the gastroenterology workforce will ultimately benefit all patients – perhaps most notably patients from diverse backgrounds and lived experiences. Diagnosis and treatment outcomes in multiple digestive-tract diseases are disparate across different races and ethnicities. The literature has demonstrated that patients are more comfortable discussing sensitive health issues and undergoing procedures in the care of doctors with whom they share a similar  cultural background.8,9

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Increasing Surveillance Programs and Expanding Treatment Options in HCC

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Increasing Surveillance Programs and Expanding Treatment Options in HCC
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Amit Singal, MD, MS

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References
  1. Llovet JM, Kelley RK, Villanueva A, et al. Hepatocellular carcinoma. Nat Rev Dis Primers. 2021;7(1):6. doi:10.1038/s41572-020-00240-3
  2. Dasgupta P, Henshaw C, Youlden DR, Clark PJ, Aitken JF, Baade PD. Global trends in incidence rates of primary adult liver cancers: a systematic review and meta-analysis. Front Oncol. 2020;10:171. doi:10.3389/fonc.2020.00171
  3. Lee YT, Wang JJ, Luu M, et al. The mortality and overall survival trends of primary liver cancer in the United States. J Natl Cancer Inst. 2021;113(11):1531-1541. doi:10.1093/jnci/djab079
  4. Wolf E, Rich NE, Marrero JA, Parikh ND, Singal AG. Use of hepatocellular carcinoma surveillance in patients with cirrhosis: a systematic review and meta-analysis. Hepatology. 2021;73(2):713-725. doi:10.1002/hep.31309
  5. Parikh ND, Mehta AS, Singal AG, Block T, Marrero JA, Lok AS. Biomarkers for the early detection of hepatocellular carcinoma. Cancer Epidemiol Biomarkers Prev. 2020;29(12):2495-2503. doi:10.1158/1055-9965.EPI-20-0005
  6. Berhane S, Toyoda H, Tada T, et al. Role of the GALAD and BALAD-2 serologic models in diagnosis of hepatocellular carcinoma and prediction of survival in patients. Clin Gastroenterol Hepatol. 2016;14(6):875-886.e6. doi:10.1016/j.cgh.2015.12.042
  7. Lin N, Lin Y, Xu J, et al. A multi-analyte cell-free DNA-based blood test for early detection of hepatocellular carcinoma. Hepatol Commun. 2022;6(7):1753-1763. doi:10.1002/hep4.1918
  8. Del Poggio P, Mazzoleni M, Lazzaroni S, D'Alessio A. Surveillance for hepatocellular carcinoma at the community level: Easier said than done. World J Gastroenterol. 2021;27(37):6180-6190. doi:10.3748/wjg.v27.i37.6180
  9. Byrd K, Alqahtani S, Yopp AC, Singal AG. Role of Multidisciplinary Care in the Management of Hepatocellular Carcinoma. Semin Liver Dis. 2021;41(1):1-8. doi:10.1055/s-0040-1719178
  10. Mazzaferro V, Citterio D, Bhoori S, et al. Liver transplantation in hepatocellular carcinoma after tumour downstaging (XXL): a randomised, controlled, phase 2b/3 trial [published correction appears in Lancet Oncol. 2020;21(8):e373]. Lancet Oncol. 2020;21(7):947-956. doi:10.1016/S1470-2045(20)30224-2
  11. Makary MS, Khandpur U, Cloyd JM, Mumtaz K, Dowell JD. Locoregional therapy approaches for hepatocellular carcinoma: recent advances and management strategies. Cancers (Basel). 2020;12(7):1914. doi:10.3390/cancers12071914
  12. Salem R, Johnson GE, Kim E, et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY study. Hepatology. 2021;74(5):2342-2352. doi:10.1002/hep.31819
  13. Cheng AL, Qin S, Ikeda M, et al. Updated efficacy and safety data from IMbrave150: atezolizumab plus bevacizumab vs. sorafenib for unresectable hepatocellular carcinoma. J Hepatol. 2022;76(4):862-873. doi:10.1016/j.jhep.2021.11.030
  14. Tzartzeva K, Obi J, Rich NE, et al. Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis. Gastroenterology. 2018;154(6):1706-1718.e1. doi:10.1053/j.gastro.2018.01.064
Publications
GI and Hepatology News
Topics
Hepatocellular Carcinoma
Author(s)
Amit Singal, MD, MS
Author(s)
Amit Singal, MD, MS

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References
  1. Llovet JM, Kelley RK, Villanueva A, et al. Hepatocellular carcinoma. Nat Rev Dis Primers. 2021;7(1):6. doi:10.1038/s41572-020-00240-3
  2. Dasgupta P, Henshaw C, Youlden DR, Clark PJ, Aitken JF, Baade PD. Global trends in incidence rates of primary adult liver cancers: a systematic review and meta-analysis. Front Oncol. 2020;10:171. doi:10.3389/fonc.2020.00171
  3. Lee YT, Wang JJ, Luu M, et al. The mortality and overall survival trends of primary liver cancer in the United States. J Natl Cancer Inst. 2021;113(11):1531-1541. doi:10.1093/jnci/djab079
  4. Wolf E, Rich NE, Marrero JA, Parikh ND, Singal AG. Use of hepatocellular carcinoma surveillance in patients with cirrhosis: a systematic review and meta-analysis. Hepatology. 2021;73(2):713-725. doi:10.1002/hep.31309
  5. Parikh ND, Mehta AS, Singal AG, Block T, Marrero JA, Lok AS. Biomarkers for the early detection of hepatocellular carcinoma. Cancer Epidemiol Biomarkers Prev. 2020;29(12):2495-2503. doi:10.1158/1055-9965.EPI-20-0005
  6. Berhane S, Toyoda H, Tada T, et al. Role of the GALAD and BALAD-2 serologic models in diagnosis of hepatocellular carcinoma and prediction of survival in patients. Clin Gastroenterol Hepatol. 2016;14(6):875-886.e6. doi:10.1016/j.cgh.2015.12.042
  7. Lin N, Lin Y, Xu J, et al. A multi-analyte cell-free DNA-based blood test for early detection of hepatocellular carcinoma. Hepatol Commun. 2022;6(7):1753-1763. doi:10.1002/hep4.1918
  8. Del Poggio P, Mazzoleni M, Lazzaroni S, D'Alessio A. Surveillance for hepatocellular carcinoma at the community level: Easier said than done. World J Gastroenterol. 2021;27(37):6180-6190. doi:10.3748/wjg.v27.i37.6180
  9. Byrd K, Alqahtani S, Yopp AC, Singal AG. Role of Multidisciplinary Care in the Management of Hepatocellular Carcinoma. Semin Liver Dis. 2021;41(1):1-8. doi:10.1055/s-0040-1719178
  10. Mazzaferro V, Citterio D, Bhoori S, et al. Liver transplantation in hepatocellular carcinoma after tumour downstaging (XXL): a randomised, controlled, phase 2b/3 trial [published correction appears in Lancet Oncol. 2020;21(8):e373]. Lancet Oncol. 2020;21(7):947-956. doi:10.1016/S1470-2045(20)30224-2
  11. Makary MS, Khandpur U, Cloyd JM, Mumtaz K, Dowell JD. Locoregional therapy approaches for hepatocellular carcinoma: recent advances and management strategies. Cancers (Basel). 2020;12(7):1914. doi:10.3390/cancers12071914
  12. Salem R, Johnson GE, Kim E, et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY study. Hepatology. 2021;74(5):2342-2352. doi:10.1002/hep.31819
  13. Cheng AL, Qin S, Ikeda M, et al. Updated efficacy and safety data from IMbrave150: atezolizumab plus bevacizumab vs. sorafenib for unresectable hepatocellular carcinoma. J Hepatol. 2022;76(4):862-873. doi:10.1016/j.jhep.2021.11.030
  14. Tzartzeva K, Obi J, Rich NE, et al. Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis. Gastroenterology. 2018;154(6):1706-1718.e1. doi:10.1053/j.gastro.2018.01.064
References
  1. Llovet JM, Kelley RK, Villanueva A, et al. Hepatocellular carcinoma. Nat Rev Dis Primers. 2021;7(1):6. doi:10.1038/s41572-020-00240-3
  2. Dasgupta P, Henshaw C, Youlden DR, Clark PJ, Aitken JF, Baade PD. Global trends in incidence rates of primary adult liver cancers: a systematic review and meta-analysis. Front Oncol. 2020;10:171. doi:10.3389/fonc.2020.00171
  3. Lee YT, Wang JJ, Luu M, et al. The mortality and overall survival trends of primary liver cancer in the United States. J Natl Cancer Inst. 2021;113(11):1531-1541. doi:10.1093/jnci/djab079
  4. Wolf E, Rich NE, Marrero JA, Parikh ND, Singal AG. Use of hepatocellular carcinoma surveillance in patients with cirrhosis: a systematic review and meta-analysis. Hepatology. 2021;73(2):713-725. doi:10.1002/hep.31309
  5. Parikh ND, Mehta AS, Singal AG, Block T, Marrero JA, Lok AS. Biomarkers for the early detection of hepatocellular carcinoma. Cancer Epidemiol Biomarkers Prev. 2020;29(12):2495-2503. doi:10.1158/1055-9965.EPI-20-0005
  6. Berhane S, Toyoda H, Tada T, et al. Role of the GALAD and BALAD-2 serologic models in diagnosis of hepatocellular carcinoma and prediction of survival in patients. Clin Gastroenterol Hepatol. 2016;14(6):875-886.e6. doi:10.1016/j.cgh.2015.12.042
  7. Lin N, Lin Y, Xu J, et al. A multi-analyte cell-free DNA-based blood test for early detection of hepatocellular carcinoma. Hepatol Commun. 2022;6(7):1753-1763. doi:10.1002/hep4.1918
  8. Del Poggio P, Mazzoleni M, Lazzaroni S, D'Alessio A. Surveillance for hepatocellular carcinoma at the community level: Easier said than done. World J Gastroenterol. 2021;27(37):6180-6190. doi:10.3748/wjg.v27.i37.6180
  9. Byrd K, Alqahtani S, Yopp AC, Singal AG. Role of Multidisciplinary Care in the Management of Hepatocellular Carcinoma. Semin Liver Dis. 2021;41(1):1-8. doi:10.1055/s-0040-1719178
  10. Mazzaferro V, Citterio D, Bhoori S, et al. Liver transplantation in hepatocellular carcinoma after tumour downstaging (XXL): a randomised, controlled, phase 2b/3 trial [published correction appears in Lancet Oncol. 2020;21(8):e373]. Lancet Oncol. 2020;21(7):947-956. doi:10.1016/S1470-2045(20)30224-2
  11. Makary MS, Khandpur U, Cloyd JM, Mumtaz K, Dowell JD. Locoregional therapy approaches for hepatocellular carcinoma: recent advances and management strategies. Cancers (Basel). 2020;12(7):1914. doi:10.3390/cancers12071914
  12. Salem R, Johnson GE, Kim E, et al. Yttrium-90 radioembolization for the treatment of solitary, unresectable HCC: the LEGACY study. Hepatology. 2021;74(5):2342-2352. doi:10.1002/hep.31819
  13. Cheng AL, Qin S, Ikeda M, et al. Updated efficacy and safety data from IMbrave150: atezolizumab plus bevacizumab vs. sorafenib for unresectable hepatocellular carcinoma. J Hepatol. 2022;76(4):862-873. doi:10.1016/j.jhep.2021.11.030
  14. Tzartzeva K, Obi J, Rich NE, et al. Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis. Gastroenterology. 2018;154(6):1706-1718.e1. doi:10.1053/j.gastro.2018.01.064
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Increasing Surveillance Programs and Expanding Treatment Options in HCC
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The incidence of HCC has increased over the last 10 years, with more than 1 million cases projected by 2025.1,2 Although mortality rates—which have risen over the past decade—appear to be leveling out, improved surveillance and screening efforts are still critical for decreasing mortality.3 More intensive, multifaceted interventions—such as increasing patient and provider education, which are currently underutilized in clinical care—are needed, as well as the start of earlier screening for HCC.4 The use of new imaging and biomarker, GALAD, and liquid biopsy techniques is also being explored, although these techniques still require validation prior to routine use in clinical practice.5-7 The  current ultrasound screening methods alone are not ideal, with sensitivity as low as 47% for detecting  early-stage HCC.8

Generally, multidisciplinary care has also been emphasized in the treatment process, using oncologists, radiologists, hepatologists, and surgeons working together to improve clinical outcomes.9 Recent treatment advances have been reported for early-, intermediate-, and late-stage disease. For early-stage HCC, surgical resection and transplant criteria have been expanded through downstaging techniques.10 For intermediate-stage HCC, radioembolization has been incorporated as another therapy, beyond transarterial chemoembolization.11,12 For late-stage HCC, treatment is moving toward immunotherapy, which has generated longer survival than older therapies.13 While HCC remains a cancer of concern, new interventions, tools, and treatments on the horizon can help expand screening and improve treatment outcomes.

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New Pathogens, COVID-19, and Antibiotic Resistance in the Field of Pneumonia

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New Pathogens, COVID-19, and Antibiotic Resistance in the Field of Pneumonia
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Marcos I. Restrepo, MD, MSc, PhD, FCCP

Click to view more from Pulmonology Data Trends 2022. 

References
  1. Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med. 2015;373(5):415-427. doi:10.1056/NEJMoa1500245
  2. Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet. 2021;398(10303):906-919. doi:10.1016/S0140-6736(21)00630-9
  3. Pagliano P, Sellitto C, Conti V, Ascione T, Esposito S. Characteristics of viral pneumonia in the COVID-19 era: an update.  Infection. 2021;49(4):607-616. doi:10.1007/s15010-021-01603-y
  4.  Maes M, Higginson E, Pereira-Dias J, et al. Ventilator-associated pneumonia in critically ill patients with COVID-19 [published correction appears in Crit Care. 2021 Apr 6;25(1):130]. Crit Care. 2021;25(1):25. doi:10.1186/s13054-021-03460-5
  5. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-655. doi:10.1016/S0140- 6736(21)02724-0
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Marcos I. Restrepo, MD, MSc, PhD, FCCP
Author(s)
Marcos I. Restrepo, MD, MSc, PhD, FCCP

Click to view more from Pulmonology Data Trends 2022. 

Click to view more from Pulmonology Data Trends 2022. 

References
  1. Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med. 2015;373(5):415-427. doi:10.1056/NEJMoa1500245
  2. Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet. 2021;398(10303):906-919. doi:10.1016/S0140-6736(21)00630-9
  3. Pagliano P, Sellitto C, Conti V, Ascione T, Esposito S. Characteristics of viral pneumonia in the COVID-19 era: an update.  Infection. 2021;49(4):607-616. doi:10.1007/s15010-021-01603-y
  4.  Maes M, Higginson E, Pereira-Dias J, et al. Ventilator-associated pneumonia in critically ill patients with COVID-19 [published correction appears in Crit Care. 2021 Apr 6;25(1):130]. Crit Care. 2021;25(1):25. doi:10.1186/s13054-021-03460-5
  5. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-655. doi:10.1016/S0140- 6736(21)02724-0
References
  1. Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med. 2015;373(5):415-427. doi:10.1056/NEJMoa1500245
  2. Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet. 2021;398(10303):906-919. doi:10.1016/S0140-6736(21)00630-9
  3. Pagliano P, Sellitto C, Conti V, Ascione T, Esposito S. Characteristics of viral pneumonia in the COVID-19 era: an update.  Infection. 2021;49(4):607-616. doi:10.1007/s15010-021-01603-y
  4.  Maes M, Higginson E, Pereira-Dias J, et al. Ventilator-associated pneumonia in critically ill patients with COVID-19 [published correction appears in Crit Care. 2021 Apr 6;25(1):130]. Crit Care. 2021;25(1):25. doi:10.1186/s13054-021-03460-5
  5. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-655. doi:10.1016/S0140- 6736(21)02724-0
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 Before the onset of the COVID-19 pandemic, researchers in the feld of pneumonia were grappling with the increase in the number of pathogens, antimicrobial-resistant strains causing pneumonia, and high mortality in short-term and long-term cases in those with comorbidites and with severe pneumonia.1,2 In 2015, a landmark study identified that the most common pathogens causing community-acquired pneumonia (CAP) were viruses such as rhinovirus and influenza virus, and that the most common bacterial pathogen remained Streptococcus pneumoniae.1 Just as the rest of world was forced to shift their focus in 2020 because of the pandemic, those of us in the pulmonary space were challenged to understand the impact that COVID-19 would have on treating our patients, particularly those with pneumonia. SARS-CoV-2, the virus that causes COVID-19, in a short time became the leading pathogen causing pneumonia. In addition, severely ill patients with COVID-19 were found to have a higher risk of developing hospital-acquired pneumonia and ventilator-associated pneumonia (VAP). The rate of VAP increased during the pandemic due to several factors, one of them being the time patients with COVID-19 spent on ventilators.3,4

Now that the pandemic has passed its peak, the field of pneumonia is revisiting earlier concerns—assessment of new pathogens and antibiotic resistance—as well as addressing issues brought to light by the COVID-19 pandemic.

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