Background & AimsNon-invasive diagnostic methods for liver fibrosis predict clinical outcomes in viral hepatitis and nonalcoholic fatty liver disease (NAFLD). We specifically evaluated prognostic value of non-invasive fibrosis methods in nonalcoholic steatohepatitis (NASH) against hepatic venous pressure gradient (HVPG) and liver histology.MethodsThis was a retrospective cohort study of 148 consecutive patients who met the following criteria: transjugular liver biopsy with HVPG measurement; biopsy-proven NASH; absence of decompensation; AST-to-Platelets Ratio Index (APRI), fibrosis-4 (FIB-4), NAFLD fibrosis score, ultrasound, hepatic steatosis index and Xenon-133 scan available within 6 months from biopsy; a minimum follow-up of 1 year. Outcomes were defined by death, liver transplantation, cirrhosis complications. Kaplan–Meier and Cox regression analyses were employed to estimate incidence and predictors of outcomes, respectively. Prognostic value was expressed as area under the curve (AUC).ResultsDuring a median follow-up of 5 years (interquartile range 3-8), 16.2% developed outcomes, including 7.4% who died or underwent liver transplantation. After adjustment for age, sex, diabetes, the following fibrosis tools predicted outcomes: HVPG >10mmHg (HR=9.60; 95% confidence interval [CI] 3.07-30.12), histologic fibrosis F3-F4 (HR=3.14; 1.41-6.95), APRI >1.5 (HR=5.02; 1.6-15.7), FIB-4 >3.25 (HR=6.33; 1.98-20.2), NAFLD fibrosis score >0.676 (HR=11.9; 3.79-37.4). Prognostic value was as follows: histologic fibrosis stage, AUC=0.85 (95% CI 0.76-0.93); HVPG, AUC=0.81 (0.70-0.91); APRI, AUC=0.89 (0.82-0.96); FIB-4, AUC=0.89 (0.83-0.95); NAFLD fibrosis score, AUC=0.79 (0.69-0.91). Neither histologic steatosis nor non-invasive steatosis methods predicted outcomes (AUC<0.50).ConclusionsNon-invasive methods for liver fibrosis predict outcomes of patients with NASH. They could be used for serial monitoring, risk stratification and targeted interventions.

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become an essential tool in the management of multiple diseases. Its accuracy is related to different aspects of the technique, one of the most important being the experience and interaction of the endosonographer and pathologist. Certain studies over the past years have highlighted the importance of having rapid on-site evaluation (ROSE) of samples obtained at the time of EUS-FNA. We have reviewed the role of ROSE, performed by the same endosonographer, a cytotechnologist and an expert cytopathologist. The available data suggest that ROSE (either by the endosonographer, the cytotechnologist, or the cytopathologist) improves sample adequacy and diagnostic yield, with the best option to have ROSE performed by an expert cytopathologist. However, if non-ROSE accuracy is already very high, any improvement is harder to achieve.

Background Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue. Methods This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN. Results Ninety‐eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty‐three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty‐seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN. Conclusions PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

Managed care companies implemented step therapy (ST) policies to reduce utilization of infused biologics in new patients. The purpose of this analysis was to compare market shares for biologic products for plans identified with ST policies versus all other claims (Other) in a large US administrative database. METHODS: Data from all plans with a ST policy throughout 2010 were compared to all other biologic claims during the same time period using data from the Wolters Kluwer Prometis ® and Medical databases. Available data included payer, prescription (Rx), diagnosis (Dx) and procedure (Px) claims with unique anonymised patient identifiers. For 2010, biologic claims were evaluated based on: patients with Rx data having at least one biologic prescription and patients with Rx and Px data, for the subset with ≥ 1 Rx claim (any type) and ≥ 1 medical claim (all cause). The number and percentage of patients receiving a biologic in 2010, was described. A secondary analysis of only subcutaneous (SC) products in the Rx database was conducted. RESULTS: Sixteen different plans had a ST policy in 2010. There were 280,271 patients (5,960 ST and 275,927 Other) with at least one biologic in the Rx claims, 274,495 with at least one claim in the Rx and Px combined data (7,936 ST and 266,559 Other), and 271,635 with claims for SC biologics in the Rx data (5,853 ST and 267,379 Other). There was less than a 4.6% difference in patient market share within any individual products, when comparing market shares of products within ST policies vs Other policies. These results were consistent for all Rx, Rx and Px, and for the Rx only cohort, including when restricted to only SC products. CONCLUSIONS: Policies designed to reduce overall patient proportions using infusion biologics suggest only a very modest effect in this population-level comparison.