Risk and time pattern of recurrences after local endoscopic resection of T1 colorectal cancer: a meta-analysis
Growing numbers of T1 CRC patients are being treated with local endoscopic resection only and as a result, the need for optimization of surveillance strategies for these patients also increases. We aimed to estimate the cumulative incidence and time pattern of CRC recurrences for endoscopically treated T1 CRC patients. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 30, 2020 Category: Gastroenterology Authors: Hao Dang, Nik Dekkers, Saskia le Cessie, Jeanin E. van Hooft, Monique E. van Leerdam, Philip P. Oldenburg, Louis Flothuis, Jan W. Schoones, Alexandra M.J. Langers, James C.H. Hardwick, Jolein van der Kraan, Jurjen J. Boonstra Source Type: research

Proton Pump Inhibitors, Histamine-2 Receptor Antagonists, and the Risk of Kidney Stones: Negligible or Not?
We read with great interest the study from Simonov et  al,1 the first study examining the association of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) with the risk of kidney and ureteral stone development. PPIs are the mainstay of acute and long-term management of acid-related disease, especially gastroesophageal reflux d isease; delay progression of Barrett’s esophagus to dysplasia; and can prevent gastrointestinal bleeding in patients on antiplatelet or anticoagulant therapy. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Eva Pella, Maria Chalkidou, Pantelis Sarafidis Tags: Letter to the Editor Source Type: research

May Computed Tomography Scan as First-Line Investigation Reduce the Overuse of Colonoscopy in Post-Polypectomy Bleeding?
We read with great interest the article by Rodr íguez de Santiago et al1 recently published in Clinical Gastroenterology and Hepatology and reporting data on management and outcomes of bleeding within 30 days of colonic polypectomy in a large multicenter cohort. We would like to congratulate the authors for their work, which represents the larg est study to date about the use of colonoscopy for postpolypectomy bleeding in real-life settings. A total of 408 of 548 patients (74.5%) were initially managed with a therapeutic intervention. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Olivier Chevallier, Romaric Loffroy Tags: Letter to the Editor Source Type: research

What Does a Positive Multi-target Stool DNA Test With a Negative Colonoscopy Can AND Cannot Tell Us About Risk of Aerodigestive Cancers Incidence
I read with interest the study by Berger et  al1 that examines the risk/incidence of aerodigestive cancers (ADCs) in patients with positive multi-target stool DNA (mt-sDNA) and negative colonoscopy. This retrospective cohort study presents robust data from well-designed protocols with adequate follow-up time (median,>5 years) and with very few missing data ( (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Ehsan Chitsaz Tags: Letter to the Editor Source Type: research

Response to: Cumulative Exposure to Infliximab, But Not Trough Concentrations, Correlate With Rate of Infection
We read the article by Landemaine et  al1 with interest and commend the authors for their work in attempting to clarify a relationship between infection risk and anti–tumor necrosis factor therapy exposure. Through a well-designed study of 209 patients with inflammatory bowel disease, the authors are the first to postulate that cumu lative dose, but not trough drug levels, of infliximab independently increases the risk of infection, suggesting there is a lasting influence of biologic therapy that may persist beyond the short-term effects exerted by each individual dose. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Danny Con, Daniel R. Van Langenberg, Abhinav Vasudevan Source Type: research

Reply
We thank Papamichail and Cheifetz for their comments about our manuscript “Cumulative Exposure to Infliximab, But Not Trough Concentrations, Correlate With Rate of Infection.”1 Overall we agree with the comments and limitations about the original article outlined in the letter that we discussed in the main paper. Infections related to Crohn’s disease were excluded t o focus on infection related to therapeutic immunosuppression. That said only 2 patients presented such complications during the follow-up period, both with trough level of infliximab greater than 12 mg/L. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Guillaume Bouguen, Tanguy Brunet Tags: Letters to the Editor Source Type: research

Reply
We thank our colleagues Sorrentino et  al for their letter to the editor concerning our study.1 They raise legitimate concerns about genetic testing for disease risk, but the intention of our study was to investigate the validity and informative capacity of a proposed model, rather than to translate to clinical practice at this stage . We believe that our work provides a platform for refining a model with comprehensive (whole-genome) genetic information, which should be validated with longitudinal clinical data, and this is currently underway in our group. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Natalie J. Prescott, Kirstin M. Taylor, Jeremy D. Sanderson Tags: Letter to the Editor Source Type: research

Reply
We thank Ghajari and Sabour for their interest in our recently published article1 and for their insightful comments. We agree that our study population is limited by referral bias, as it is influenced by the regional demographics, practice standards, etc. particular to a single institution. As mentioned in the limitations section of our discussion, this cohort may not reflect all patients with hepatitis C virus (HCV) and end-stage renal disease (ESRD). The study would benefit from validation in a large multicenter trial to reduce the risk of bias and improve generalizability. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Christopher J. Schmoyer, Richard K. Sterling Tags: Letter to the Editor Source Type: research

Reply
We thank Con et  al1 for their comments and their insightful analysis of the results of our study, which explored the relationship between exposure to infliximab and the rate of opportunistic infections in inflammatory bowel disease patients.2 They pointed out the fact that we presented the number of infections ov er a period of time as a linear function of the cumulative exposure to infliximab, as measured by the cumulative area under the curve (AUC). They also noted that AUC (time dependent) is a surrogate marker of time. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Antoine Petitcollin, Guillaume BOuguen Tags: Letter to the Editor Source Type: research

Reply
We thank Drs. Scaioli, Salice, and Belluzzi for their interest in our paper1 and their contributions to advancing nutritional science for inflammatory bowel disease. In their correspondence, they suggest that we should endorse increased consumption of omega-3 fatty acid supplements for ulcerative colitis, possibly in preference to natural sources, such as oily fish. They highlight their recently completed placebo-controlled clinical trial showing benefit of eicosapentaenoic acid as free fatty acid in gastroresistant, sustained-release capsules among 60 asymptomatic patients with ulcerative colitis but with elevated fecal c...
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: James D. Lewis, Arie Levine Tags: Letter to the Editor Source Type: research

Look at Both Sides of the Coin in Determining Risk of Complicated Crohn ’s Disease
We read with interest the recent paper by Yanai et  al1 where they investigated the presence of predictors of early indolent course of Crohn’s disease (CD) using an inception cohort from Israel. Among multiple patient characteristics, genetic variants, and laboratory parameters, a less aggressive disease course was predicted with high accuracy ba sed on 4 easily available factors: (1) low body mass index, (2) low vitamin B12 levels, (3) elevated alanine aminotransferase, and (4) high white blood cell count. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Iago Rodr íguez-Lago, Manuel Barreiro-de Acosta Tags: Letter to the Editor Source Type: research

Diabetes Mellitus and Pancreatic Cancer: A Risk Assessment
In this study, the authors conducted a cohort study to investigate the relationship between diabetes mellitus and subsequent pancreatic cancer. Adjusted hazard ratio (95% confidence interval) of a recent diagnosis of diabetes for incident pancreatic cancer was 6.91 (5.76–8.30). Rapid increa ses in the levels of glucose and glycated hemoglobin (HbA1c), and subtle weight loss preceding the diagnosis of diabetes was closely associated with incident pancreatic cancer. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Tomoyuki Kawada Tags: Letter to the Editor Source Type: research

Reply
Saito and colleagues raise 2 related questions about our study, which found a decreased rate of Helicobacter pylori testing among patients hospitalized with bleeding ulcers in the intensive care unit (ICU) compared with those on regular hospital wards.1 First, they ask whether patient factors may have explained the low (66%) observed rate of H pylori testing among ICU patients with bleeding ulcers. Second, they question whether provider factors, including lack of coordination of care, may have been the cause. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Kenneth W. Hung, Daniel E. Freedberg Tags: Letter to the Editor Source Type: research

Reply
We thank Drs Rodr íguez-Lago and Barreiro-de Acosta for their interest in our work and for their positive comments. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Henit Yanai, Idan Goren, Iris Dotan Tags: Letters to the Editor Source Type: research

Controlled Attenuation Parameter in Nonalcoholic Fatty Liver Disease: The Thresholds Do Matter
We read with interest a recent paper by Caussy et  al1 on a direct comparison of controlled attenuation parameter (CAP) measurements using the M versus the XL probe for the detection of liver steatosis in a well-characterized group of patients at risk of nonalcoholic fatty liver disease (NAFLD) with magnetic resonance imaging (MRI) proton density fat fraction used as the reference. A single time-point assessment clearly demonstrated that in the same participants, CAP values are significantly lower when obtained with the M probe as compared with the XL probe, even when the probe is selected according to participant&rsq...
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Katarzyna Koz łowska-Petriczko, Ewa Wunsch, Piotr Milkiewicz Tags: Letter to the Editor Source Type: research

Disconnected Pancreatic Duct Syndrome and Lumen Apposing Metal Stents
We read with interest the study by Bang et  al1 on the role of replacing lumen apposing metal stents (LAMS) by plastic stents after resolution of pancreatic fluid collections (PFC) in patients with disconnected pancreatic duct syndrome (DPDS). We congratulate the authors for conducting this prospective study that has attempted to answer the clinical dilemma of whether or not to exchange the LAMS with permanent indwelling plastic stents to reduce the recurrence of PFC. DPDS is an often overlooked complication of acute necrotizing pancreatitis that can lead to recurrent PFC, refractory external pancreatic fistulae, and ...
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Surinder Singh Rana, Rajesh Gupta Tags: Letter to the Editors Source Type: research

Extracorporeal Shock Wave Lithotripsy for Pancreaticolithiasis: Do It Now
This study has shown that transition to gastroenterologist-directed ESWL has increased the number of patients being referred for ESWL. This indicates increasing acceptance of ESWL as a therapeutic option for patients with painful chronic calcific pancreatitis by gastroenterologist and patients. A higher number of patients underwent same-session endoscopic retrograde cholangiopancreatography (ERCP) with more ductal stone clearance. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Nitin Jagtap, Manu Tandan, D. Nageshwar Reddy Tags: Letter to the Editors Source Type: research

Tailored Treatment in Obese Patients With Achalasia: Endoscopic or Surgery Treatment?
We read with great interest the systematic review and meta-analysis by Oude Nijhuis et  al1 that identified factors associated with achalasia treatment outcomes. The goal of achalasia treatment is to provide symptom relief, prevent the occurrence of late complications, and improve the quality of life of patients. Although there is no curative treatment, there has been considerable ad vances in the management of achalasia over the past decade, mainly with the introduction of per-oral endoscopic myotomy (POEM). (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Ana Laranjo, Armando Peixoto, Guilherme Macedo Tags: Letter to the Editor Source Type: research

Association Between Provider Connectedness and Inflammatory Bowel Disease Outcomes
We read with interest the research article by Cohen-Mekelburg et  al,1 which found that higher connectedness between healthcare providers is associated with better inflammatory bowel disease (IBD) outcomes. We believe that this is an important area of research because the continuity of care between providers is essential in improving patient outcomes. However, t here are some areas of concern we would like to discuss. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Yu Meng LI, Isabella Stettler, Kanapath Oungpasuk Tags: Letter to the Editor Source Type: research

The Spigelman Staging System for Duodenal Polyposis in Familial Adenomatous Polyposis: A Clarification From its Eponymous Author
The article by Mehta et  al,1 “Risks, Benefits, and Effects on Management for Biopsy of the Papilla in Patients With Familial Adenomatous Polyposis,” makes significant reference to the Spigelman staging system for duodenal polyposis. The hypothesis they successfully address regarding the utility of biopsy of the papil la of Vater was dealt with in our 1989 article2 in The Lancet, published 31 years ago. Random biopsy results from the papilla of Vater and periampullary area from the 102 patients described in that article were available for 97 patients, 72 of whom showed the presence of an adenoma. (Source: ...
Source: Clinical Gastroenterology and Hepatology - November 26, 2020 Category: Gastroenterology Authors: Allan D. Spigelman Tags: Letter to the Editor Source Type: research

Adrenal Insufficiency in Cirrhosis: Don ’t Forget the Hypothalamus
We read with interest the recent article reporting a very high rate of relative adrenal insufficiency (RAI) in patients with cirrhosis admitted to the hospital with acute decompensation.1 We would like to add to their hypothesis that adrenal insufficiency in cirrhosis is caused by adrenal hypoperfusion and impaired substrates for steroidogenesis evidenced by reduced total cholesterol, high-density lipoprotein, and apolipoprotein A1 in patients with RAI. Although RAI may be multifactorial, we previously showed that adrenal insufficiency in patients with advanced cirrhosis predominantly is the result of a defect in the hypot...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: David S. Prince, Geoffrey W. McCaughan Tags: Letter to the Editor Source Type: research

External Validation of the Nonalcoholic Steatohepatitis Scoring System in Patients With Biopsy-Proven Nonalcoholic Fatty Liver Disease in China
We read with great interest the article by Koo et  al1 on a scoring system to determine the risk of nonalcoholic steatohepatitis (NASH) from nonalcoholic fatty liver disease (NAFLD) patients based on genetic and clinical factors. Because the study by Koo et al1 included only patients from a single tertiary center, we aimed to validate the scoring system externally (NASH PT score) in our well-characterized, biopsy-proven NAFLD cohort.2,3 (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Ke Xu, Kenneth I. Zheng, Ming-Hua Zheng Tags: Letter to the Editor Source Type: research

Proactive Measures Aimed at Improving Appropriateness of Use of Proton Pump Inhibitors in Clinical Practice
We read with great interest the article by Lin et  al1 that was recently published in in Clinical Gastroenterology and Hepatology. The authors report on the impact of an educational program aimed at improving the appropriateness of proton pump inhibitors (PPIs) in a large health system in the United States.1 Indeed, we feel that the issue covered by Lin et al, despite being the topic of a long-standing clinical problem with a clear social and health impact, is still timely and relevant. For example, despite several published studies highlighting the inappropriateness of PPI prescriptions in ambulatory care,2&ndas...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Edoardo G. Giannini, Giorgia Bodini, Manuele Furnari, Elisa Marabotto Tags: Letter to the Editor Source Type: research

Reply
We appreciate Xu et  al for the external validation of the NASH PT score that we developed for identifying nonalcoholic steatohepatitis (NASH) among the diverse spectra of nonalcoholic fatty liver disease (NAFLD).1 The NASH PT score is a polygenic risk scoring model incorporating 2 genetic risk factors, PNPLA3 rs73840 9 and TM6SF2 rs58542926. We developed it from the biopsy-proven NAFLD cohort (n = 302) and validated it using an independent replication dataset (n = 151).1 The area under the receiver operating characteristic curve in the replication cohort was 0.787 (95% confidence interval, 0.715–0.860...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Bo Kyung Koo, Won Kim Tags: Letter to the Editor Source Type: research

Reply
We thank Warringa et  al for their comments regarding our article “Assessment of Liver Fibrosis With Elastography Point Quantification vs Other Noninvasive Methods.”1 (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Fabio Conti, C. Serra, P. Andreone Tags: Letter to the Editor Source Type: research

Achieving Virological Response in Patients With Hepatitis C Is Only Half Way for Effective Care
The observational study from Latin America about the incidence of hepatocellular carcinoma (HCC) in patients with hepatitis C virus infection receiving direct-acting antivirals (DAAs) treatment deserved questions.1 (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Alain Braillon Tags: Letter to the Editor Source Type: research

A High-Risk Subpopulation in the U.S. Disproportionately Affected by High Rates of Gastric Cancer: The Alaska Native People
With great interest, we read the article by Thrift and El-Serag1 providing an overview of the epidemiology, risk factors, prevention, and surveillance approaches to gastric cancer. The article highlights one of the most prevalent and under-recognized malignances throughout the world, and we appreciate the authors ’ discussion of this topic. Although they nicely describe varying incidence rates by geography and race/ethnicity in the United States, they failed to describe the population with the highest incidence rate in the United States, Alaska Native (AN) people. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Stephen M. Vindigni, Leisha D. Nolen, Michael G. Bruce Tags: Letter to the Editor Source Type: research

Therapeutic Drug Monitoring and Safety of Anti-Tumor Necrosis Factor Therapy in Inflammatory Bowel Disease
Therapeutic drug monitoring (TDM) studies have shown that higher anti –tumor necrosis factor (anti-TNF) drug concentrations are associated with better clinical outcomes in patients with inflammatory bowel disease (IBD).1 However, there are only limited data whether higher anti-TNF drug concentrations are associated with (serious) adverse events.2–5 These data, whi ch are derived mostly from small retrospective studies, suggest that higher infliximab concentrations are not associated with higher frequency rate of skin lesions, persistence of peripheral arthralgia, and infections. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Konstantinos Papamichael, Adam S. Cheifetz Tags: Letter to the Editor Source Type: research

Risk of HBV Reactivation Among IBD patients With Occult Hepatitis B Virus Infection
We read with great interest the recently published review by Beaugerie et  al1 that looked at treatment-related complications in patients with inflammatory bowel diseases (IBD) and how to predict, prevent, and manage such complications. The authors stated that in patients who are hepatitis B virus (HBV) (hepatitis B surface antigen [HBsAg] positive) carriers, prophylacti c antiviral treatment with nucleotide or nucleoside analogues is recommended and is best started 2 weeks before the introduction of steroids, azathioprine, or anti-tumor necrosis factor (TNF) α therapy and continued for 12 months after their wit...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Turki Alameel, Eman Al Sulais Tags: Letter to the Editor Source Type: research

Screening for Cirrhosis in People With Fatty Liver?
The complex and theoretical decision model by Vilar-Gomez et  al1 to quantify the accuracy and costs of various strategies for detection of cirrhosis in patients with nonalcoholic fatty liver disease deserves clinical comments. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Alain Braillon Tags: Letter to the Editor Source Type: research

Reply
We appreciate the constructive comments provided by Allain Braillon on our study evaluating the incidence of disease progression in patients with hepatitis C virus (HCV) infection who underwent direct-acting antiviral (DAA) treatment.1 Essentially, he highlighted a relevant observation of our study and requested clarification on some issues related to the analysis of the Latin American Liver Research, Educational and Awareness Network cohort. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Manuel Mendizabal, Federico Pi ñero, Ezequiel Ridruejo, Marcelo Silva Tags: Letter to the Editor Source Type: research

Diagnosis of Preclinical Crohn ’s Disease: Hurdles, Challenges, and Hopes
We read with interest the paper by Taylor et  al.1 The authors calculated a risk score for asymptomatic first-degree relatives (FDR) of patients with Crohn's disease (CD) by combining the genetic risk score (a synthesis of 72 CD variants) and smoking status. Such score was used to identify FDRs in the lowest and highest quartiles of CD risk. FDRs were then invited to undergo video capsule endoscopy (VCE). They then built a model to predict inflammation at VCE that included several variables. Variable selection and regularization were carried out using different methods. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Dario Sorrentino, Marco Geraci, Anna Kuballa Tags: Letter to the Editor Source Type: research

Omega-3 as a Part of the Dietary Guidance for Patients with Ulcerative Colitis: Beyond the Natural Sources
We read with great interest the paper by Levine et  al,1 which provides guidance regarding which foods may be beneficial and safe to consume in patients with inflammatory bowel diseases. The paper addresses an unmet need in inflammatory bowel diseases, such as symptom control and clinical relapse prevention, by suggesting to reduce inflammation thr ough specific recommendations in food intake. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Eleonora Scaioli, Marco Salice, Andrea Belluzzi Tags: Letter to the Editor Source Type: research

Reply
We thank Dr. Romaric Loffroy for his interest in  our recent publication and appreciate his expert opinion based on unquestionable extensive personal experience and 1 study that suggest the usefulness of contrast-enhanced multidetector computed tomography (MDCT) for colonic diverticular bleeding.1 However, we would like to emphasize that our stu dy is aimed to identify patients most likely to benefit from colonoscopy after postpolypectomy bleeding (DPPB), which is a very particular scenario and slightly different from lower gastrointestinal bleeding. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Mar ía Hernández-Tejero, Maria Pellisé, Enrique Rodríguez de Santiago Tags: Letter to the Editor Source Type: research

Diagnostic Accuracy of Noninvasive Tests to Detect Advanced Hepatic Fibrosis: Methodological Issues
We read the paper from Schmoyer et  al1 published in Clinical Gastroenterology and Hepatology. The aim of the study was to assess the diagnostic accuracy of noninvasive tests in identifying advanced hepatic fibrosis in patients with hepatitis C virus infection and end-stage renal disease. In a retrospective cohort study, the authors reported receiver operating characteristic, sensitivity, specificity, and predictive values to compare the results of 5 tests including ratio of aspartate aminotransferase/alanine aminotransferase, aspartate aminotransferase platelet ratio index, FIB-4 score, fibrosis index score, and King...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Hadis Ghajari, Siamak Sabour Source Type: research

Reply
We appreciate the points raised by Dr Chitsaz regarding the subsequent risk for aerodigestive cancers (ADCs) and the generalizability of our study findings. On behalf of our co-authors, we agree that both baseline prevalence and subsequent incidence (ie, both subsequent risk and time to that risk) are the most important determinants of finding an ADC. However, we wish to emphasize that although positive and negative predictive values depend on disease prevalence, diagnostic test performance characteristics of accuracy or, more precisely, sensitivity and specificity, do not. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Barry M. Berger, John B. Kisiel, Thomas F. Imperiale Tags: Letter to the Editor Source Type: research

Adrenal insufficiency in cirrhosis – don’t forget the hypothalamus
(Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: David S. Prince, Geoffrey W. McCaughan Source Type: research

Comment on Wu et  al…
In their cohort study, Wu et  al1 reported aspirin therapy to be associated significantly with a reduced risk of hepatitis C virus–related hepatocellular carcinoma. We read the article with great interest and agree with the conclusions, but have some concerns regarding the study design and definitions used. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Tzung-Fang Chuang, Shih-Tien Chen, James Cheng-Chung Wei Tags: Letter to the Editor Source Type: research

Reply
We thank the authors for their interest in our article about relative adrenal insufficiency (RAI) in patients admitted for acute decompensation of cirrhosis.1 The authors correctly pointed out that we highlighted the role of the deficiency of substrates of steroidogenesis and inflammation as relevant mechanisms involved in the pathophysiology of RAI. However, we stated the pathogenesis of RAI is much more complex in patients with cirrhosis, and we fully agree with the authors that abnormalities of hypothalamic-pituitary-adrenal axis can be relevant in the pathogenesis of RAI. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Salvatore Piano, Paolo Angeli Tags: Letter to the Editor Source Type: research

Reply
We read with interest the letter to the Editor by Marabotto et  al with regard to our recent article published in the journal.1 We thank them for their insightful contribution to the discussion around the role of behavioral disorders and mental health conditions in patients diagnosed with reflux hypersensitivity. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Akinari Sawada, Daniel Sifrim Tags: Letter to the Editor Source Type: research

A User ’s Guide to De-Escalating Immunomodulator and Biologic Therapy in Inflammatory Bowel Disease
We found the review written by Hirten et  al1 timely, published at the height of the COVID-19 pandemic, when pervasive concerns about immunomodulators or biologic drugs prevailed. In the review, the authors present a practical guide to de-escalating patients with evidence to support who to de-escalate and what happens after de-escalation. We would like to caution against a monodimensional approach to de-escalation. First, only the detrimental aspect of outcomes was considered (ie, the risk of relapse). (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Naila Arebi, Lovesh Dyall, Nik Kamperidis Tags: Letter to the Editor Source Type: research

Refractoriness to Treatment Suggests That Clinical Evaluation Should Go Beyond the Diagnosis of Reflux Disease
We read with great interest the article recently published in Clinical Gastroenterology and Hepatology by Sawada et  al1 showing that almost half of reflux hypersensitivity (RH) patients present behavior disorders, such as supragastric belching and rumination syndrome. These data help identify one of the underlying mechanisms of symptom generation in patients with RH, and shed some light on the putative reasons why such patients do not respond to proton pump inhibitor treatment, or to therapy with pain modulators. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Elisa Marabotto, Edoardo Savarino, Nicola de Bortoli, Edoardo G. Giannini Tags: Letter to the Editor Source Type: research

Patient Outcomes and Environment May Affect Adherence to Helicobacter pylori Testing
This study showed a surprising lack of proper H pylori testing, especially in critically ill patients, which reflects a very important clinical challenge. We hope that the authors can present some data to help us better understand the results of this study, and we would also like to discuss an appropriate method of H pylori testing. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Hiroaki Saito, Yoshitaka Nishikawa, Yasuhiro Mizuno Tags: Letter to the Editor Source Type: research

The Rising Tide of Nonalcoholic Fatty Liver Disease: How Much Time Until the Flood Reaches Our Coast?
We read with interest the recent publication by Yanoussi et  al,1 which focused on the changing trends in liver transplantation (LT) indications in the American Registry of Transplant Recipients over the past 2 decades. Yanoussi et al1 reported that nonalcoholic steatohepatitis (NASH) has rapidly become the second indication for LT in the United States and the leading indication for LT in women with end-stage liver disease without hepatocellular carcinoma. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Chiara Mazzarelli, Debora Angrisani, Raffaella Vigano Tags: Letter to the Editor Source Type: research

Reply
We are grateful to Mazzarelli and colleagues for their input about our recent paper showing an increase in the prevalence of nonalcoholic steatohepatitis (NASH) among candidates for liver transplantation in the United States.1,2 As we have shown, the impact of NASH to the overall burden of chronic liver disease in the United States is steadily growing so that NASH is currently the second most common indication for transplantation in patients with and without hepatocellular carcinoma (HCC), and the first in some large subgroups, such as women without HCC or older patients. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Maria Stepanova, Zobair Younossi Tags: Letter to the Editor Source Type: research

Tofacitinib is Safe and Effective When Used in Combination With Infliximab for the Management of Refractory Ulcerative Colitis
We read with interest the article by Berinstein et  al1 regarding the use of tofacitinib for the management of acute severe ulcerative colitis (UC). Janus kinase inhibitors in UC targeting multiple inflammatory pathways may offer advantages over monoclonal antibodies targeting specific cytokines;2 however, studies regarding the safety and effective ness of combination biologic and small molecule therapies in UC are limited.3,4 We herein describe the use of tofacitinib in combination with infliximab for the management of UC. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Robert Gilmore, Patrick Hilley, Ashish Srinivasan, Matthew C. Choy, Josephine A. Grace, Peter de Cruz Tags: Letter to the Editor Source Type: research

Reply
We appreciate the letter by Arebi and colleagues regarding our review article on the de-escalation of immunomodulators and biologic therapy in inflammatory bowel disease and agree that this review is timely during the COVID-19 pandemic. We, however, disagree with their comments that our approach was “monodimensional” and only took into account the detrimental aspects of de-escalation (ie, the risk of relapse), which may “misguide” clinicians. We are indeed well aware of the benefit provided by stopping medications, such as reducing the risk of lymphomas when stopping thiopurines, even t hough there ...
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Robert P. Hirten, Peter L. Lakatos, Jonas Halfvarson, Jean Frederic Colombel Tags: Letter to the Editor Source Type: research

Ustekinumab 90 mg Every 2 Weeks for the Treatment of Inflammatory Bowel Disease
We read with interest the article “Effectiveness of Ustekinumab Dose Escalation in Patients With Crohn's Disease” by Ollech et al.1 They describe ustekinumab dose interval shortening from 90 mg every 8 weeks to every 4 weeks in 110 patients with Crohn’s disease. Clinical remission (HBI, ≤4) was achieved in 50.9% at the last follow-up evaluation, with no serious adverse events reported. This is an important study that adds to the limited data to date supporting dose optimization at greater than 90 mg every 8 weeks. (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Darragh Storan, Glen A. Doherty, Garret Cullen Tags: Letter to the Editor Source Type: research

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I would like to commend Long et  al1 for their evaluation of mild and moderate alcohol use in the setting of hepatic steatosis. They sought to clarify the impact of different types of alcoholic drinks and their detailed pattern of use on the presence of hepatic steatosis diagnosed by computed tomography scan. In addition, they se parately reported the prevalence of each individual component of the metabolic syndrome. They showed that hypertriglyceridemia was the most prevalent variable in patients with steatosis (51%) and the lowest in patients without (20%). (Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Maurizio Bonacini Tags: Letter to the Editor Source Type: research

Reply to Tofacitinib is safe and effective when used in combination with Infliximab for the management of Refractory Ulcerative Colitis
(Source: Clinical Gastroenterology and Hepatology)
Source: Clinical Gastroenterology and Hepatology - November 25, 2020 Category: Gastroenterology Authors: Jeffrey A. Berinstein, Calen A. Steiner, Peter D.R. Higgins Source Type: research