Krishna V. Venkata

Hepatitis C Treatment in Patients With Porphyria Cutanea Tarda

Background Hepatitis C virus (HCV) infection is a common susceptibility factor for porphyria cutanea tarda (PCT). Experience on HCV treatment in patients with PCT is limited. Recently, HCV treatment has improved with direct‐acting antivirals (DAA). We review our experience on HCV treatment in patients with PCT with older and newer regimens. Materials and Methods A retrospective chart review was conducted. HCV treatment was attempted 22 times in 13 patients with PCT (5 attempts in 1, 2 in 5 and 1 in the other 7 patients). Results Before starting HCV treatment, PCT was in complete remission in 16, partial remission in 2, unknown status in 2 and active in 2 instances. PCT relapsed during therapy 6 times (all interferon‐based regimens and 2 including telaprevir), 4 requiring treatment interruption. Treatment was interrupted for reasons other than PCT relapse in 2 patients treated with interferon‐based regimens. To prevent PCT recurrence, hydroxychloroquine was continued during HCV therapy 6 times (3 interferon regimens, 2 ribavirin regimens without interferon and 1 DAA alone). Twelve patients achieved sustained viral response, 3 with interferon regimens and 9 with DAA. Two patients with active PCT were treated with DAA, with reduction of plasma porphyrins in 1 and normalization in the other at the end of HCV therapy. Conclusions HCV treatment regimens including interferon or ribavirin may precipitate PCT relapse. Hydroxychloroquine may be useful to prevent such relapses. In this limited experience, DAA were not associated with PCT relapse. Studies are needed to examine DAA as a primary PCT treatment in HCV‐infected patients.

Short article: Alcohol and substance use, race, and insurance status predict nontreatment for hepatitis C virus in the era of direct acting antivirals

Objective Direct acting antivirals (DAAs) have overcome many long-standing medical barriers to hepatitis C virus (HCV) treatment (i.e. host characteristics and medical contraindications) and treatment outcome disparities that were associated with interferon regimens. The public health and clinical benefit of current and forthcoming DAA discoveries will be limited if efforts are not made to examine racial, psychological, and socioeconomic factors associated with being treated with DAAs. This study examined racial, psychological, and socioeconomic factors that facilitate and inhibit patients receiving DAAs for HCV. Patients and methods This was a single-center retrospective cohort study at a large urban tertiary center of patients (n=747) who were referred for evaluation and treatment of HCV. Results Sixty-eight percent of patients were non-Hispanic White, 31% were African American, and 1% were of other ethnicities. The majority of patients received treatment, but 29% (218/747) did not. Patients who were older [odds ratio (OR)=1.02, 95% confidence interval (CI): 1.01–1.04] and insured (OR=2.73, 95% CI: 1.12–6.97) were more likely to receive HCV treatment. Patients who were African American (OR=0.46, 95% CI: 0.46–1.06), used drugs (OR=0.09, 95% CI: 0.04–0.17), smoked (OR=0.55, 95% CI: 0.37–0.81), and used alcohol (OR=0.11, 95% CI: 0.06–0.20) were less likely to receive HCV treatment. Conclusion Though DAAs have eliminated many historically, long-standing medical barriers to HCV treatment, several racial, psychological and socioeconomic barriers, and disparities remain. Consequently, patients who are African American, uninsured, and actively use drugs and alcohol will suffer from increased HCV-related morbidity and mortality in the coming years if deliberate public health and clinical efforts are not made to facilitate access to DAAs.

Comparative Effectiveness of Vedolizumab vs. Infliximab Induction Therapy in Ulcerative Colitis: Experience of a Real-World Cohort at a Tertiary Inflammatory Bowel Disease Center

Background Vedolizumab (VDZ), an adhesion molecule inhibitor and infliximab (IFX), a tumor necrosis factor (TNF) blocker, are both approved as first-line induction agents in moderately to severely active ulcerative colitis (UC). However, there are no head-to-head studies comparing the relative effectiveness of the two agents. Here we provide a real-world comparison of these two agents. Methods We conducted an ambidirectional cohort study of adult UC patients seen at our tertiary inflammatory bowel disease (IBD) center from 2012 to 2017. Each patient had moderately to severely active UC via partial Mayo score and was induced with IFX or VDZ. They were followed until assessment of clinical response. Poisson regression was used to calculate clinical response rates and rate ratios. Results Of 59 patients who met inclusion criteria, 27 and 32 patients were induced with IFX and VDZ, respectively. Totally, 18/27 (66.7%) patients induced with IFX vs. 24/32 (78.1%) patients induced with VDZ were clinical responders. Response rates per 100 person-weeks (PW) were similar for VDZ (5.21) and IFX (5.38). The effectiveness in terms of induction of clinical response (incidence rate ratio, IRR) was not statistically significant for VDZ vs. IFX (IRR 0.97, 95% confidence interval (CI) 0.53 - 1.77). Among TNF blocker naive patients, IRR was also not statistically significant between VDZ (6.74/100 PW) and IFX (6.48/100 PW) (IRR 1.04, 95% CI 0.47 - 2.29). Among TNF blocker experienced patients, there was a higher response rate for VDZ (4.52) vs. IFX (2.29) per 100 PW, but the IRR did not reveal statistical significance (IRR 1.97, 95% CI 0.45 - 8.63) due to small sample size of TNF blocker experienced patients who received IFX. Five patients developed severe infection or adverse reaction during IFX induction requiring exclusion, whereas no VDZ patients were excluded for this reason. Conclusions Our study revealed a higher proportion of patients who responded to VDZ vs. IFX; however when accounting for period between induction and assessment of clinical response, rates of clinical response were similar. A key difference between the two groups was the higher response rate in the VDZ group among TNF blocker experienced patients; however, a larger cohort is needed to further elaborate on this difference. VDZ held its own against IFX and this study strengthens its standing as a first-line agent among TNF blocker naive as well as TNF blocker experienced UC patients.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience

Aim  The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission. Methods  We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest. Results  Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort’s rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P  = 0.027) and had longer procedural time (38.68 vs 46.57, P  = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 – 4.859, P  = 0.011), inpatient status (OR 2.42, CI 1.344 – 4.346, P  = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 – 1.029, P  = 0.008) were associated positively with readmission. Conclusion  DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.

Impact of vitamin D on the hospitalization rate of Crohn's disease patients seen at a tertiary care center

AIM To study the association between vitamin D level and hospitalization rate in Crohn’s disease (CD) patients. METHODS We designed a retrospective cohort study using adult patients (> 19 years) with CD followed for at least one year at our inflammatory bowel disease center. Vitamin D levels were divided into: low mean vitamin D level (< 30 ng/mL) vs appropriate mean vitamin D level (30-100 ng/mL). Generalized Poisson Regression Models (GPR) for Rate Data were used to estimate partially adjusted and fully adjusted incidence rate ratios (IRR) of hospitalization among CD patients. We also examined IRRs for vitamin D level as a continuous variable. RESULTS Of the 880 CD patients, 196 patients with vitamin D level during the observation period were included. Partially adjusted model demonstrated that CD patients with a low mean vitamin D level were almost twice more likely to be admitted (IRR = 1.76, 95%CI: 1.38-2.24) compared to those with an appropriate vitamin D level. The fully adjusted model confirmed this association (IRR = 1.44, 95%CI: 1.11-1.87). Partially adjusted model with vitamin D level as a continuous variable demonstrated, higher mean vitamin D level was associated with a 3% lower likelihood of admission with every unit (ng/mL) rise in mean vitamin D level (IRR = 0.97, 95%CI: 0.96-0.98). The fully adjusted model confirmed this association (IRR = 0.98, 95%CI: 0.97-0.99). CONCLUSION Normal or adequate vitamin D stores may be protective in the clinical course of CD. However, this role needs to be further characterized and understood.