The impact of unrestricted access to direct-acting antiviral among incarcerated hepatitis C virus-infected patients

Background/Aims@#Despite the disproportionally high prevalence rates of hepatitis C virus (HCV) amongst the incarcerated population, eradication remains challenging due to logistic and financial barriers. Although treatment prioritization based on disease severity is commonly practiced, the efficacy of such approach remained uncertain. We aimed to compare the impact of unrestricted access to direct-acting antiviral (DAA) among incarcerated HCV-infected patients in Singapore. @*Methods@#In this retrospective study, we reviewed all incarcerated HCV-infected patients treated in our hospital during the restricted DAA era (2013–2018) and unrestricted DAA access era (2019). Study outcomes included the rate of sustained virological response (SVR), treatment completion and treatment default. Subgroup analysis was performed based on the presence of liver cirrhosis, HCV genotype and HCV treatment types. @*Results@#A total of 1,001 HCV patients was followed-up for 1,489 person-year. They were predominantly male (93%) with genotype-3 HCV infection (71%), and 38% were cirrhotic. The overall SVR during the restricted DAA access era and unrestricted DAA access era were 92.1% and 99.1%, respectively. Unrestricted access to DAA exponentially improved the treatment access among HCV-infected patients by 460%, resulting in a higher SVR rate (99% vs. 92%, P=0.003), higher treatment completion rate (99% vs. 93%, P<0.001) and lower treatment default rate (1% vs. 9%, P<0.001). @*Conclusion@#In this large cohort of incarcerated HCV-infected patients, we demonstrated that unrestricted access to DAA is an impactful strategy to allow rapid treatment up-scale in HCV micro-elimination.

The impact of unrestricted access to direct-acting antiviral among incarcerated hepatitis C virus-infected patients

Background/Aims@#Despite the disproportionally high prevalence rates of hepatitis C virus (HCV) amongst the incarcerated population, eradication remains challenging due to logistic and financial barriers. Although treatment prioritization based on disease severity is commonly practiced, the efficacy of such approach remained uncertain. We aimed to compare the impact of unrestricted access to direct-acting antiviral (DAA) among incarcerated HCV-infected patients in Singapore. @*Methods@#In this retrospective study, we reviewed all incarcerated HCV-infected patients treated in our hospital during the restricted DAA era (2013–2018) and unrestricted DAA access era (2019). Study outcomes included the rate of sustained virological response (SVR), treatment completion and treatment default. Subgroup analysis was performed based on the presence of liver cirrhosis, HCV genotype and HCV treatment types. @*Results@#A total of 1,001 HCV patients was followed-up for 1,489 person-year. They were predominantly male (93%) with genotype-3 HCV infection (71%), and 38% were cirrhotic. The overall SVR during the restricted DAA access era and unrestricted DAA access era were 92.1% and 99.1%, respectively. Unrestricted access to DAA exponentially improved the treatment access among HCV-infected patients by 460%, resulting in a higher SVR rate (99% vs. 92%, P=0.003), higher treatment completion rate (99% vs. 93%, P<0.001) and lower treatment default rate (1% vs. 9%, P<0.001). @*Conclusion@#In this large cohort of incarcerated HCV-infected patients, we demonstrated that unrestricted access to DAA is an impactful strategy to allow rapid treatment up-scale in HCV micro-elimination.

Endoscopic submucosal dissection of colorectal neoplasms: an audit of its safety and efficacy in a single tertiary centre in Singapore

INTRODUCTION@#Endoscopic submucosal dissection (ESD) provides a higher en bloc and R0 resection rate than endoscopic mucosal resection. Colorectal ESD is not widely used because of its technical difficulty and risk of complications, especially for right-sided colonic lesions. We audited the clinical outcomes of our initial experience with colorectal ESD.@*METHODS@#We reviewed data collected from a prospective registry of patients who underwent colorectal ESD from December 2014 to March 2018. Therapeutic outcomes and procedure-related complications were analysed.@*RESULTS@#A total of 41 patients (mean age 67.4 years, 21 male) underwent colorectal ESD. The distribution of the lesions was as follows: rectum (n = 9), sigmoid colon (n = 8), descending colon (n = 6), splenic flexure (n = 1), transverse colon (n = 5), ascending colon (n = 8) and caecum (n = 4). The mean size was 23 (range 12-50) mm. En bloc resection was achieved in 35 (85.4%) out of 41 patients, and R0 resection or clear resection margins was achieved in 33 (94.3%) of the en bloc resection patients. The lesion was upstaged in 14 (34.1%) patients after ESD. Colonic perforation occurred in 3 (7.3%) patients during ESD and was successfully treated with endoscopic clips. There was no procedure-related bleeding. No patient required surgery for management of complications. The median duration of hospitalisation was 1 (range 0-7) day. Four patients with lesions that were upstaged after ESD, from high-grade dysplasia to intramucosal carcinoma with deep submucosal invasion, were referred for colectomy.@*CONCLUSION@#Our early outcome data was comparable to that from large published series. ESD is an effective and feasible treatment for colorectal lesions.

Current status of functional gastrointestinal evaluation in clinical practice

Neurogastroenterology and motility disorders of the gastrointestinal (GI) tract encompass a broad spectrum of diseases involving the GI tract and central nervous system. They have varied pathophysiology, clinical presentation and management, and make up a substantial proportion of outpatient clinic visits. Typically, patients experience persistent symptoms referable to the GI tract despite normal endoscopic and radiologic findings. An appropriate evaluation is thus important in the patient's care. Advances in technology and understanding of the disease pathophysiology have provided better insight into the physiological basis of disease and a more rational approach to patient management. While technological advances serve to explain patients' persistent symptoms, they should be balanced against the costs of diagnostic tests. This review highlights the GI investigative modalities employed to evaluate patients with persistent GI symptoms in the absence of a structural lesion, with particular emphasis on investigative modalities available locally and the clinical impact of such tools.

Clinical epidemiology of gastric cancer

Gastric cancer is the second leading cause of cancer-related mortality and the fourth most common cancer globally. There are, however, distinct differences in incidence rates in different geographic regions. While the incidence rate of gastric cancer has been falling, that of gastric cardia cancers is reportedly on the rise in some regions. Helicobacter pylori (H. pylori) infection is a major risk factor of non-cardia gastric cancer, and data has emerged concerning the role of H. pylori eradication for primary prevention of gastric cancer. Dietary, lifestyle and metabolic factors have also been implicated. Although addressing these other factors may contribute to health, the actual impact in terms of cancer prevention is unclear. Once irreversible histological changes have occurred, endoscopic surveillance would be necessary. A molecular classification system offers hope for molecularly tailored, personalised therapies for gastric cancer, which may improve the prognosis for patients.

Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

<p><b>INTRODUCTION</b>Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris.</p><p><b>METHODS</b>This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates.</p><p><b>RESULTS</b>Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered.</p><p><b>CONCLUSION</b>DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.</p>

Screening Colonoscopy for Average Risk Individuals in Singapore

In Singapore colorectal cancer (CRC) is the most common cancer for males, second most common cancer for females and most common cancer overall. A national CRC screening program for average risks individuals was started in July 2011, with the primary test modality being the faecal immunochemical test. Individuals may choose to undergo screening colonoscopy directly. Colonoscopy has two roles in CRC screening. It is performed either as a primary screening test or used to evaluate abnormal results from another screening test. Colonoscopy is a safe and effective procedure but potential risks exist. Local complications such as perforation and bleeding, cardiopulmonary events and even mortality may occur. Additionally there could be failed cecal intubation and missed lesions. It is imperative that prior to colonoscopy, there is a proper discussion of risks, benefits and alternatives. To provide quality assurance for colonoscopy in the CRC screening program, a set of quality indicators and criteria for endoscopists and endoscopy centres was established. The endoscopists must be qualified specialists with a lifetime experience of at least 500 colonoscopies and 50 polypectomies, and need to meet annual monitoring parameters that include at least 50 colonoscopies, >95% cecal intubation rate, >95% recovery rate of excised polyps, and withdrawal time of at least 6 minutes. In addition, complication rates must be within acceptable limits such as perforation rate of less than 0.1% and postpolypectomy bleeding rate less than 1%.

Asian Consensus Report on Functional Dyspepsia

BACKGROUND/AIMS: Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared to the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia. METHODS: Consensus team members were selected from Asian experts and consensus development was carried out using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using keypad voting system. A grade of evidence and a strength of recommendation were applied to each statement according to the method of the GRADE Working Group. RESULTS: Twenty-nine consensus statements were finalized, including 7 for definition and diagnosis, 5 for epidemiology, 9 for pathophysiology and 8 for management. Algorithms for diagnosis and management of functional dyspepsia were added. CONCLUSIONS: This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians.

EUS-FNA of the left adrenal gland is safe and useful

<p><b>INTRODUCTION</b>There are limited data on the use of endosonography-guided fine-needle aspiration (EUS-FNA) to determine the nature of left adrenal lesions. We described our experience in performing EUS-FNA of left adrenal lesions.</p><p><b>CLINICAL PICTURE</b>During a 20-week period, data on consecutive patients who underwent EUS with or without EUS-FNA were prospectively captured. Patients with a left adrenal mass and who underwent EUS-FNA formed our study population.</p><p><b>TREATMENT</b>EUS-FNA.</p><p><b>OUTCOME</b>A total of 119 consecutive patients underwent diagnostic EUS +/- FNA, during which the left adrenal gland was routinely examined. Twelve of these patients underwent EUS as part of lung cancer staging and among these 12 lung cancer patients, 2 had left adrenal masses detected by computed tomography (CT). EUS detected left adrenal nodules in 2 other patients which were not visualised by CT. The overall prevalence of a left adrenal mass was 3.4%; in the subgroup with confirmed lung cancer, the prevalence was 33.3%. All 4 patients were male, with a mean age of 76.3 years (range, 67 to 87). The mean size of the left adrenal lesion was 30.4 mm (range, 9 to 84.8). EUS-FNA of the left adrenal lesions was performed under Doppler guidance. The mean number of needle passes was 2 (range, 1 to 4). A cellular aspirate was obtained in all patients. No procedural complications occurred. Metastatic non-small cell lung cancer was diagnosed in 2 patients, including a lesion missed on CT. For the other 2 cases, EUS-FNA revealed benign adrenal cells.</p><p><b>CONCLUSIONS</b>EUS-FNA appears safe and useful for the evaluation of left adrenal masses.</p>

Cutaneous Adverse Drug Reactions in a General Hospital in Singapore: A One-Year Retrospective Analysis

Background Rashes are the most common adverse reaction to drugs. Our aim is to describe (i) the prevalence of cutaneous adverse drug reactions in hospitalised patients over a 1-year period in our hospital; (ii) the variety of cutaneous drug reactions; (iii) the characteristics of patients with cutaneous drug reactions and (iv)the drugs implicated. Methods A retrospective analysis of all adverse drug reactions from the pharmacists’ database from January to December 2003 was conducted. Patients’ records were reviewed to extract demographic data, drug implicated, route of administration, drug allergy history, type of cutaneous reaction, severity and presence of underlying chronic disease. Results Sixty-five patients met our inclusion criteria, giving an estimated prevalence of 1.8/1000 among hospitalised patients. The cases were mostly from the general medicine department (64.6%), with a slight male predominance (males, 53.8%; females 46.2%). Cutaneous adverse drug reactions were more common in the Malay population (32.3%). The mean age was 41.6 years (range, 13 to 85 years). The main drugs implicated were antibiotics (49.2%), mainly penicillins and cephalosporins, and non-steroidal anti-inflammatory agents (16.9%). Urticarial (46.1%) and generalised maculopapular eruptions (40.0%) were the most common patterns encountered. Others included Stevens-Johnson syndrome/toxic epidermal necrolysis (7.7%), drug reaction with eosinophilia and systemic symptoms (1.5%) and erythroderma (1.5%). 29.2% of cases were considered to be severe. There were no deaths. 44.6% had an associated chronic disease and 24.6% had a previous documented drug allergy. Conclusion Antibiotics and NSAIDs were the major drugs involved. The commonest cutaneous manifestations were urticarial and maculopapular eruptions. A high proportion of reactions were considered severe and almost one-quarter had a previous drug allergy.