Muhammad K. Hasan

Fluvastatin Inhibits Hepatitis C Replication in Humans

BACKGROUNDHepatitis C viral (HCV) infection is the leading cause of death due to liver disease in the United States. Currently, pegylated interferon and ribavirin produce sustained viral remission in only 50% of patients. Additional agents are needed to increase the cure rate. In vitro experiments show strong antiviral effects of fluvastatin against HCV.OBJECTIVES:To assess the safety and antiviral effects of fluvastatin in chronic HCV carriers.METHODS:31 veterans with chronic HCV were prospectively given oral doses of fluvastatin, 20 to 320 mg/day, for 2–12 weeks with weekly monitoring of HCV RNA and liver tests. Reductions of viral load (P < 0.01) versus a control group were considered suppressive.RESULTS:With 80 mg a day or less, 11/22 (50%) patients responded by lowering HCV RNA. The first lowering occurred within 4 weeks (9/11, 82%). The greatest weekly change in HCV RNA level was a 1.75 log10 reduction. When lowered in responders, the viral load remained relatively constant for 2–5 weeks (7/9, 78%), or on the next test rebounded immediately to a non-significant change from, baseline (n = 2). Continued lowering of virus was seen in 2/19 (22 %) patients when the study ended. We found no evidence of liver tests worsening.CONCLUSIONS:FLV used as monotherapy in vivo showed suppressive effects of HCV clinically that are modest, variable, and often short-lived. These findings support “proof-of-concept” for pilot trials combining fluvastatin with standard therapy. Statins and fluvastatin, in particular, appear to be safe for use in hepatitis C.

Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual

Lumen-apposing metal stents (LAMS) have been recently developed to improve treatment outcomes in the endoscopic management of pancreatic fluid collections (PFC), particularly in walled-off necrosis (WON), to facilitate better drainage of necrotic contents and minimise the risk of perforation and peritoneal leakage. In an ongoing randomised trial, we observed serious adverse events that included delayed bleeding, buried stent syndrome and biliary stricture that necessitated a change in the management protocol for patients with PFC treated with LAMS. Randomised trials comparing endoscopic and surgical techniques for the management of PFCs have favoured the endoscopic approach.1 ,2 Endoscopy is less expensive, associated with shorter hospital stay and the clinical outcomes are comparable. To compare the clinical outcomes of patients undergoing endoscopic drainage of WON using LAMS or plastic stents, a randomised trial (NCT02685865) was initiated at our institution. Included in the study were patients with symptomatic WON measuring >6 cm in size and located adjacent to the gastric or duodenal lumen. Excluded were patients with pseudocysts, WON inaccessible for endoscopic ultrasound-guided drainage and irreversible coagulopathy. The LAMS (Hot AXIOS, Boston Scientific) used in this trial had a single-step cautery-tipped delivery system with dimensions of 15 mm (diameter) by 10 mm (length). In the plastic stent cohort, two 7 Fr by 4 cm double pigtail stents were deployed after dilation of the transmural tract to 12 mm. Per study protocol, a follow-up CT was obtained at 4–6 weeks after the index intervention to assess treatment response with treatment success defined as resolution of WON to <3 cm in conjunction with symptom relief. The main outcome measure was to compare the median number of interventions required to achieve treatment success. The secondary outcome measures were to compare the rates of treatment success and clinical and stent-related adverse events. The total sample size was estimated at 62 patients. In this ongoing …

Factors impacting treatment outcomes in the endoscopic management of walled-off pancreatic necrosis

Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled‐off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset.

Lumen‐apposing metal stents for drainage of pancreatic fluid collections: When and for whom?

Although lumen‐apposing metal stents (LAMS) are increasingly being used for drainage of pancreatic fluid collections (PFC), their advantage over plastic stents is unclear.

EUS-Guided FNA of Solid Pancreas Tumors

Although endoscopic ultrasonography (EUS) is considered superior to MRI and CT in detecting pancreatic masses, it is the ability to target and place a needle into suspicious lesions that has made EUS indispensible in the evaluation of patients with solid pancreatic tumors. Endoscopic ultrasound-guided-fine-needle aspiration (EUS-FNA) is an accurate and safe technique to confirm the diagnosis of pancreatic cancer. EUS-FNA is now the principal technique applied to obtain the diagnosis of malignancy. We have designed this article to address a number of the key technical aspects of EUS-FNA of solid pancreatic masses.

Endosonographic features predictive of malignancy in mediastinal lymph nodes in patients with lung cancer.

BACKGROUND EUS is useful in determining mediastinal lymph node (LN) metastases in patients undergoing staging for lung cancer. However, FNA of LNs is often performed only if suspicious features are present. The utility of individual LN features in predicting malignant cytology remains unclear. OBJECTIVE To evaluate the utility of EUS-determined LN features for predicting malignant cytology. DESIGN Prospective observational study. SETTING Two U.S. tertiary-care centers. PATIENTS This study involved 425 patients with primary lung cancer who underwent EUS. INTERVENTION All mediastinal LNs were described according to size, shape, echogenicity, and margin characteristics. FNA was performed on LNs with any features suggestive of malignancy. EUS-guided FNA cytology was classified as benign or abnormal (suspicious/malignant). The utility of LN features in predicting malignant cytology was determined and further analyzed by logistic regression, and a predictive model was established. MAIN OUTCOME MEASUREMENTS Accuracy of individual LN features for predicting malignancy. RESULTS EUS detected 836 LNs in 425 patients, and FNA was obtained in 698 patients. On multivariable analysis, only round shape, a short axis of >8.3 mm, and sharp margins were predictive of malignant cytology. According to the predictive model, the calculated probability of having malignancy is less than 4% (95% confidence interval [CI], 0.022-0.064) when none of the LN features are present and 63% (95% CI, 51%-72.2%) when all features were seen. LIMITATIONS No surgical histology as the criterion standard. CONCLUSION Among patients with lung cancer, EUS features of round shape, sharp margins, and short axis of >8.3 mm are significant predictors of malignancy. The probability of malignancy is low when none of the features are present.

Lumen Apposing Metal Stents (LAMS) for Drainage of Pancreatic Fluid Collections: When and for whom?

Although lumen‐apposing metal stents (LAMS) are increasingly being used for drainage of pancreatic fluid collections (PFC), their advantage over plastic stents is unclear.

Outcomes after implementing a tailored endoscopic step‐up approach to walled‐off necrosis in acute pancreatitis

The aim of the study was to compare the outcomes of patients with pancreatic or peripancreatic walled‐off necrosis by endoscopy using the conventional approach versus an algorithmic approach based on the collection size, location and stepwise response to intervention.

Severe Cholestatic Jaundice in Hyperthyroidism after Treatment with 131-Iodine

A 39-year-old white man was referred to our hospital for evaluation of his jaundice and pruritus. The patient was treated with I for diffuse toxic goiter prior to his referral to our hospital. Clinical examination and laboratory investigations excluded viral hepatitis, autoimmune hepatitis, granulomatous disease, primary biliary disease, extrahepatic biliary obstruction, and heart failure. Liver biopsy showed severe intrahepatic and canalicular cholestasis with minimal inflammatory changes. The patients jaundice promptly resolved with therapy for hyperthyroidism and thyroid storm as bilirubin levels decreased from 35 mg/dL (normal: 0.5-1.2 mg/dL) to 0.4 mg/dL. Thyrotoxicosis can be an uncommon cause of profound cholestasis. Our case differs from all other reports in the literature because of the severity of the cholestasis and its prompt resolution with treatment for thyrotoxicosis.

Endoscopic Management of Acute Cholecystitis

Acute cholecystitis is a commonly encountered medical emergency that is managed surgically with excellent results. Recent experiences with endoscopic cystic duct stent placement and cholecystectomy using the NOTES (Natural Orifice Transluminal Endoscopic Surgery) approach have inspired endoscopists to identify other less invasive means for treating cholecystitis. The ability to access and drain obstructive bile ducts in real time using endoscopic ultrasound guidance has led to recent reports of successful gallbladder drainage using similar techniques. This article discusses the current state of the endoscopic management of acute and acalculous cholecystitis, and outlines a consensus approach to the management of these patients.