Asian Pacific Association Research Articles

Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature.

Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’ comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential.This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.

Models for acute on chronic liver failure development and mortality in a veterans affairs cohort.

The diagnosis of acute on chronic liver failure (ACLF) carries a high short-term mortality, making early identification of at-risk patients crucial. To date, there are no models that predict which patients with compensated cirrhosis will develop ACLF, and limited models exist to predict ACLF mortality. We sought to create novel risk prediction models using a large North American cohort. We performed a retrospective study of 75,922 patients with compensated cirrhosis from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) dataset. Using 70% derivation/30% validation sets, we identified ACLF patients using the Asian Pacific Association of Liver (APASL) definition. Multivariable logistic regression was used to derive prediction models (called VOCAL-Penn) for developing ACLF at 3, 6, and 12months. We then created prediction models for ACLF mortality at 28 and 90days. The VOCAL-Penn models for ACLF development had very good discrimination [concordance (C) statistics of 0.93, 0.92, and 0.89 at 3, 6, and 12months, respectively] and calibration. The mortality models also had good discrimination at 28 and 90days (C statistics 0.89 and 0.88, respectively), outperforming the Model for End-stage Liver Disease (MELD), MELD-sodium, and the APASL ACLF Research Consortium ACLF scores. We have developed novel tools for predicting development of ACLF in compensated cirrhosis patients, as well as for ACLF mortality. These tools may be used to proactively guide patient follow-up, prognostication, escalation of care, and transplant evaluation. Receiver operating characteristic (ROC) curves for predicting development of APASL ACLF at 3months (a), 6months (b), and 1year (c).

Tu1134 CLINICIANS’ ADHERENCE AND PATIENTS’ COMPLIANCE TO GUIDELINES FOR THE MANAGEMENT OF ANTITHROMBOTICS IN PATIENTS UNDERGOING COLONOSCOPIC POLYPECTOMY

Although there are international guidelines on management of antithrombotics (anti-platelet agents and anticoagulants) in patients undergoing colonoscopic polypectomy, both clinicians’ adherence to guidelines and patients’ compliance to clinicians’ instructions are largely unknown. We previously reported in a retrospective study that less than 15% of clinicians documented their peri-endoscopy instructions on anti-thrombotic use. We aim to investigate prospectively clinician’s adherence to international guideline and patients’ compliance to clinicians’ instructions on peri-endoscopic management of antithrombotics. The Colonoscopy Registry was established in November 2017. It collects prospective data from patients on antithrombotics use undergoing elective colonoscopies in a tertiary referral center in Hong Kong. Demographic data, types and indications of antithrombotics, peri-endoscopic management, colonoscopic findings, 7-day and 6-month follow-up for resumption of antithrombotics, post-polypectomy bleeding and serious cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or death from a vascular cause) were collected. Peri-endoscopic management of antithrombotics is defined as thoroughly adherent to the guidelines developed by Asian Pacific Association of Gastroenterology and Asian Pacific Society for Digestive Endoscopy when all conditions are fulfilled: correct decision of withholding/resuming drug, appropriate drug discontinuation, INR <2.0 before colonoscopic polypectomy and appropriate use of bridging therapy in patients on warfarin. Patient’s compliance to clinicians’ instructions is defined whether the use of antithrombotics during the peri-endoscopy period is consistent with clinicians’ advice. Doctors’ adherence was captured from casenotes while patient’s compliance to clinicians’ instructions were collected at face-to-face interview. From November 2017 to September 2019, 610 patients receiving antithrombotics with colonoscopic polypectomy were recruited. One hundred percent, 41.2%, 71.4% of clinicians adhered to the guidelines for aspirin alone, clopidogrel alone, and dual antiplatelet therapy (DAPT), respectively. As for warfarin and direct oral anti-coagulant (DOAC), 10.2% and 41.1% of clinicians respectively has full adherence. Regarding patients’ compliance, 75.3%, 41.2% ,85.7%, 38.8% and 36.8% were compliant in aspirin-alone, clopidogrel alone, DAPT, warfarin, and DOAC, respectively. Twenty patients (3.3%) developed immediate polypectomy bleeding,17 patients (2.8%) had delayed polypectomy bleeding, and 7 had serious cardiovascular events within 6-months of colonoscopy. Both clinicians’ adherence to guidelines and patient’s compliance to instructions on clopidogrel and anticoagulant use were sub-optimal. More emphasis should be put to it.

Asian Pacific Association of Gastroenterology (APAGE) Inflammatory Bowel Disease (IBD) Working Party guidelines on IBD management during the COVID-19 pandemic.

The COVID‐19 pandemic, secondary to SARS‐CoV‐2, has resulted in high mortality and morbidity worldwide. As inflammatory bowel disease (IBD) is a chronic disease, and most patients are on long‐term immunosuppressive agents, there is understandable concern, particularly in terms of therapy. In view of this, experts in IBD across the Asia Pacific region were invited to put together recommendations based on their experience and the currently available data. In general, most IBD therapies (with a few exceptions) can be continued safely, and the general consensus is that maintaining disease control should remain the main principle of management. In addition, social distancing measures and the appropriate use of personal protective equipment should be strictly adhered to. During the current pandemic, face‐to‐face clinic follow ups and non‐urgent procedures should be kept to a minimum.

Clinical practice guidance for hepatology and liver transplant providers during the COVID-19 pandemic: APASL expert panel consensus recommendations.

BackgroundConfronting a once-in-a-century pandemic with COVID-19, tremendous stress has been placed in all walks of life worldwide.AimsIn order to enhance scientific information interflow in the arena of liver diseases in Asia–Pacific region during this difficult time, Asian-Pacific Association for the Study of the Liver (APASL) has taken the initiative to form the APASL COVID-19 Taskforce to formulate a clinical practice guidance in Hepatology, liver-related oncology, transplantation and conduct of clinical trials.MethodsA taskforce with 22 key opinion leaders in Hepatology from 16 countries or administration regions in Asia–Pacific regions was formed and through intense interaction via webinar, this guidance was formulated. Based on scientific data and experiences, recommendations were made in the management of liver injury, liver transplantation, autoimmune diseases, chronic liver diseases, delivery of elective and emergency services and conduct of clinical trials.ConclusionsThis is the first consensus clinical guidance synthesized by APASL for our hepatologist and their allied medical personal.

Anti-stress phytohormones impact on proteome profile of green gram (Vigna radiata) under salt toxicity

Anti-stress phytohormones impact on proteome profile of green gram (Vigna radiata) under salt toxicity

Comparison of guidelines for diagnosis of hepatocellular carcinoma using gadoxetic acid-enhanced MRI in transplantation candidates.

To compare diagnostic performances of current guidelines for the diagnosis of HCC in LT candidates using gadoxetic acid-enhanced liver MRI (Gd-EOB-MRI). Eighty-one patients (119 HCCs and 35 non-HCCs) who underwent preoperative Gd-EOB-MRI and subsequent LT were included. Per-lesion imaging diagnoses of HCCs were made using four different guidelines (American Association for the Study of Liver Disease (AASLD), European Association for the Study of the Liver (EASL), Asian Pacific Association for the Study of the Liver (APASL), and Korean Liver Cancer Association-National Cancer Center (KLCA-NCC) guidelines, and patient allocation was determined according to Milan criteria (MC). Comparisons of per-lesion sensitivity, specificity, and accuracy of patient allocation between guidelines were performed using logistic regression with generalized estimating equations. For diagnosis of HCC, AASLD guideline showed highest specificity (97.4%), followed by EASL and KLCA-NCC guidelines (92.1% and 92.1%, p > 0.99 and = 0.15, respectively, in comparison to AASLD), while the specificity of APASL guideline was significantly lower than that of AASLD guideline (78.9% vs. 97.4%, p = 0.006). APASL and KLCA-NCC guidelines (75.9% and 65.6%) showed significantly higher sensitivities than AASLD/EASL guidelines (34.5% and 38.8%, respectively; all ps < 0.001). For organ allocation, KLCA-NCC guideline showed higher accuracy in selecting unsuitable candidates (with non-HCC malignancies or beyond MC HCCs) than EASL guideline (68.4% vs. 31.8%; p = 0.001). For the diagnosis of HCCs using Gd-EOB-MRI, AASLD guideline provided the highest specificity, followed by EASL, KLCA-NCC, and APASL guidelines with statistically significant difference with only APASL guideline. KLCA-NCC guideline provided the most accurate selection of unsuitable LT candidates. • AASLD/LI-RADS showed the highest specificity, followed by EASL and KLCA-NCC guidelines. • APASL and KLCA-NCC guidelines allowed more sensitive diagnoses of HCCs. • KLCA-NCC more accurately classified patients not appropriate transplantation candidates than EASL.

Preface

The conference proceedings contain the selected papers presented at the 2019 International Conference on Advances in Biological Science and Technology (ICABST2019). The conference is organized by Asia-Pacific Association of Natural Science and Engineering and Maejo University (Thailand), which has been successfully held in Bangkok, Thailand during December 26-28, 2019.As an annual gathering, it provides an extensive platform for scientists, researchers and scholars to present their research results and newest findings in all fields of Biological Science and Technology, discuss the practical challenges encountered recommend better solutions for biotechnology. ICABST2019 includes keynote speeches, invited speeches, oral presentations and poster presentations. It provided unique opportunities for scientists to introduce novel ideas and studies in the following topics:▸ Molecular Biology▸ Biomechanics and Biomechanical Engineering▸ Biomedicine, Biopharmaceuticals and Pharmacology▸ Agricultural Science, Animal & Plant Science▸ Bioinformatics & Biocomputing▸ Application of biotechnology▸ Other Related TopicsList of Logos are available in this pdf.

The efficacy of hepatitis B treatments in achieving HBsAg seroclearance: A systematic review and meta-analysis.

Current therapies for chronic hepatitis B (CHB) include nucleos(t)ide analogues (NAs) and interferon (IFN), but their relative efficacy as monotherapy or in combination has not been examined systematically for HBsAg loss (functional cure). Hence, we systematically reviewed the evidence for HBsAg loss in CHB patients treated with IFN, NA or the combination. We searched PubMed, EMBASE and abstracts from EASL, Asia Pacific Association for study of the Liver and American Association for the Study of Liver Disease for randomized controlled trials of CHB patients, comparing NA, IFN or the combination. The Cochrane Risk of Bias tool v2.0 and GRADE method were used. Analyses were stratified by NA genetic barrier, cirrhosis, type of combination therapy, HBeAg, treatment naivety, IFN dosage/duration and outcome duration. Sensitivity analysis was performed for selected strata, and HBsAg loss was measured at the end-of-study (EOS), end-of-treatment (EOT) or end-of-follow-up (EOF). Effects were reported as risk differences (RD) with 95% confidence intervals (CI) using a random-effects model. Forty-five studies were included, all with low risk of bias. For HBsAg loss at EOS, when comparing combination vs IFN, RD=1%, 95%CI-1%, 2%; combination vs NA, RD=5%, 95%CI 3%,7%; IFN vs NA, RD=3%, 95%CI 2%,5%. Subgroup analysis showed a significant effect of standard IFN dose vs nonstandard; IFN duration ≥48weeks vs <48weeks, and loss of efficacy >2years of follow-up. Similar findings were seen in HBsAg seroconversion, but only three studies reported HBsAg seroreversion. In conclusion, IFN monotherapy/combination had a small but significant increase in HBsAg loss over NA, associated with standard dose of IFN and ≥48weeks of therapy, although this effect faded over time.

Down-regulation of ER-α36 mRNA in serum exosomes of the patients with hepatocellular carcinoma.

Down-regulation of ER-α36 mRNA in serum exosomes of the patients with hepatocellular carcinoma.

Proceedings of the 18th Annual Scientific Congress of the Asia Pacific Association of Medical Toxicology, Purajaya, Malaysia, 4th–7th November 2019

Proceedings of the 18th Annual Scientific Congress of the Asia Pacific Association of Medical Toxicology, Purajaya, Malaysia, 4th–7th November 2019

Hepatitis B: Who to treat? A critical review of international guidelines.

Chronic hepatitis B remains a global problem, affecting more than 250 million individuals worldwide. Around one-fifth of infected individuals develop advanced fibrosis or hepatocellular carcinoma (HCC). The World Health Organization (WHO) guidelines as well as the 2016 American Association for the Study of Liver Diseases (AASLD) guidelines are based on robust data and relied on multiple external systematic reviews to answer identified questions. In contrast, the latest guidelines from the European Association for the Study of the Liver (EASL), Asia Pacific Association for the Study of the Liver (APASL) and AASLD (2018 version) were developed by consensus of expert panels. Treatment is generally recommended for individuals at a high risk of disease progression, namely those with high alanine aminotransferase (ALT) levels, active viral replication and advanced fibrosis or cirrhosis. Although guidelines generally agree on treatment indications for special populations, current guidelines do not factor in clinically relevant factors such as age, gender and genotype into the treatment decision process. There is an unmet need for a better predictive model to select high-risk individuals, thus, more high-quality studies are needed.

Asia Pacific Association of Allergy Asthma and Clinical Immunology White Paper 2020 on climate change, air pollution, and biodiversity in Asia-Pacific and impact on allergic diseases

Air pollution, climate change, and reduced biodiversity are major threats to human health with detrimental effects on a variety of chronic noncommunicable diseases in particular respiratory and cardiovascular diseases. The extent of air pollution both outdoor and indoor air pollution and climate change including global warming is increasing-to alarming proportions particularly in the developing world especially rapidly industrializing countries worldwide. In recent years, Asia has experienced rapid economic growth and a deteriorating environment and increase in allergic diseases to epidemic proportions. Air pollutant levels in many Asian countries especially in China and India are substantially higher than are those in developed countries. Moreover, industrial, traffic-related, and household biomass combustion, indoor pollutants from chemicals and tobacco are major sources of air pollutants, with increasing burden on respiratory allergies. Here we highlight the major components of outdoor and indoor air pollutants and their impacts on respiratory allergies associated with asthma and allergic rhinitis in the Asia-Pacific region. With Asia-Pacific comprising more than half of the world's population there is an urgent need to increase public awareness, highlight targets for interventions, public advocacy and a call to action to policy makers to implement policy changes towards reducing air pollution with interventions at a population-based level.

A Review of Skin Banking Guidelines and Standards Worldwide: Towards the Harmonization of Guidelines for Skin Banking in Therapeutic Applications for the Regions under the Asia Pacific Burn Association (APBA).

Currently, there are no harmonized guidelines which govern skin banking in the Asia Pacific region. Therefore, skin banks are either unregulated or rely on their nation’s legislation or international accreditation to uphold their quality standards. A new set of skin banking guidelines was developed through a comprehensive review and collation of best international practices for the Asia Pacific Burn Association (APBA) members, from donor screening and testing, to skin recovery, processing, storage and distribution, and quality assurance. National regulatory requirements reviewed include the European directives, Australia’s Therapeutic Goods Administration and Singapore’s tissue banking standards. Further technical and quality management recommendations are referenced from the American Association of Tissue Banks (AATB), the United States Food and Drug Administration standards and guidance documents, various relevant European guides, Japanese Society of Tissue Transplantation guidelines and the Asia Pacific Association of Surgical Tissue Banking. Adapted mainly from the AATB standards, the new Asia Pacific Burn Association Guidelines for Skin Banking in Therapeutic Applications offer a comprehensive manual, addressing: governance and contracts; staff responsibilities; quality management; facilities, equipment and supplies management; donor consent and testing; and recommendations of good practices pertaining to skin recovery, processing, storage and distribution. Besides complementing current generic regulations, they provide technical specifications of major aspects unaddressed in most legislations. This inaugural set of new regional skin banking guidelines would be a start for regional members of the APBA to adopt, and will hopefully culminate in a set of standards so that, in the long run, skin allografts from this region can be of similar quality, which can simplify import process and facilitate the exchange of allografts between members.

Diagnostic procedures & practices in drug allergy/hypersensitivity: a survey of 13 Asian countries.

BackgroundThe issues and challenges in the diagnosis of drug allergy/hypersensitivity among children and adults in Asia are likely to be different from non-Asian countries.ObjectiveTo study the diagnostic modalities used in the evaluation and management of drug allergy/drug hypersensitivity reactions (DHRs) among member societies of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI).MethodsA questionnaire comprising 41 questions was circulated electronically to member societies and individual members of APAAACI between January 23, 2020 and March 6, 2020.ResultsTwenty-six respondents from 15 member societies and 1 individual member responded. European DHR guidelines were most commonly used. Skin prick and intradermal testing was used by 100%, with only 60% having access to commercial penicillin skin test reagents. In vitro-specific IgE tests were used by 75%, and basophil activation test by 56.3% for immediate DHR. Patch tests were used by 75% in contrast to lymphocyte transformation tests by 25% for nonimmediate DHR. Drug provocation tests were used by 68.8%, the most common indication being to exclude hypersensitivity where history/symptoms were not suggestive of drug hypersensitivity/allergy (93.3%). Human leukocyte antigen (HLA) genotype testing was mandatory among 25% respondents before new carbamazepine prescriptions, and 8.3% for allopurinol prescriptions.ConclusionsThere was increased use of skin testing for iodinated contrast media hypersensitivity and patch testing for nonimmediate DHR. HLA genotype testing prior to new carbamazepine, allopurinol and abacavir prescriptions remain variable despite strong associations for severe cutaneous adverse reactions with Asian ethnicity. Results of this survey form a useful framework for developing educational and training needs and for improving access to drug allergy diagnostic and treatment modalities across APAAACI member societies.

Open Access: DOAJ and Plan S, Digitization and Disruption

Open Access: DOAJ and Plan S, Digitization and Disruption

Towards Genotype-Specific Care for Chronic Hepatitis B: The First 6 Years Follow Up From the CHARM Cohort Study

ObjectiveThere is increasing evidence to suggest that, among those with chronic hepatitis B virus infection, the natural history and rate of progression to cirrhosis and hepatocellular carcinoma is influenced by hepatitis B virus genotype. The unique hepatitis B virus genotype C4 circulates among Indigenous Australians. The aim of this work is to describe the process of establishing this cohort and review the first 6 years of available data in an effort to understand the real-world clinical care and natural history of this subgenotype.MethodWe followed a longitudinal cohort of Indigenous Australians from the Northern Territory of Australia with established subgenotype C4 infections. We assigned phases of disease according to Gastroenterological Society of Australia and Asian Pacific Association for the Study of the Liver criteria using clinical and laboratory information that had been collected for clinical management.ResultsOf 193 patients followed over a median of 38 months, 58 (30%) individuals transitioned from 1 disease phase to another, 10 (5%) cleared hepatitis B e antigen, and 6 cleared hepatitis B surface antigen (3%). In this relatively young cohort (median age 40.3 years), 26 (13%) had cirrhosis by the end of the follow up period, with the majority of these being in the immune control phase of disease.ConclusionsIn this cohort of hepatitis B subgenotype C4 patients, we report an aggressive and dynamic clinical phenotype. High rates of cirrhosis at a young age appear to occur in the early phases of disease.

Proceedings of the 17th Annual Scientific Congress of the Asia Pacific Association of Medical Toxicology, Bali, Indonesia, 16th–18th November 2018

Proceedings of the 17th Annual Scientific Congress of the Asia Pacific Association of Medical Toxicology, Bali, Indonesia, 16th–18th November 2018

Scientific frontiers in faecal microbiota transplantation: joint document of Asia-Pacific Association of Gastroenterology (APAGE) and Asia-Pacific Society for Digestive Endoscopy (APSDE)

ObjectiveThe underlying microbial basis, predictors of therapeutic outcome and active constituent(s) of faecal microbiota transplantation (FMT) mediating benefit remain unknown. An international panel of experts presented key elements that will...

1119 Assessment of Utility of Prognostic Models for Predicting Short-Term Mortality of Patients With Acute-on-Chronic Liver Failure

INTRODUCTION: Acute-on-chronic liver failure (ACLF) is a clinical syndrome associated with high short-term mortality. Numerous models have been proposed to predict outcomes in ACLF patients, including novel ones by Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC), but their utility in a heterogeneous population of ACLF patients remains inconclusive. The study aims to assess the performance of established and newer models for predicting mortality of ACLF patients. METHODS: A retrospective study of 96 patients fulfilling either APASL or European Association for the Study of the Liver (EASL) criteria for ACLF admitted to a tertiary hospital in Singapore between 2004 and 2018 was performed. Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD)-Na, Chronic Liver Failure Consortium (CLIF)-SOFA, CLIF-C ACLF and AARC prognostic scores (MELD-lactate, AARC-ACLF) were calculated on days 1, 4, 7 of hospital admission and days 1, 4 of ICU admission. Outcomes assessed were survival to discharge without transplant, 30-day survival and 90-day survival. The scores were evaluated by measuring area under receiver operating characteristic (AUROC) curve at each time point and compared. RESULTS: 28 patients (29.2%) survived to discharge without transplant, 21 patients (21.9%) underwent urgent transplant and 47 patients (49%) died before discharge. 30-day transplant-free survival was 21.9% and 90-day survival was 19.8%. CTP, MELD-Na, MELD-lactate, CLIF-C ACLF and AARC-ACLF scores had high accuracy in predicting hospital mortality on day 4 admission (CTP D1 AUROC 0.642, D4 0.715; MELD-Na D1 0.607, D4 0.721; MELD-lactate D1 0.664, D4 0.861; CLIF-C ACLF D1 0.559, D4 0.697; AARC-ACLF D1 0.571, D4 0.747). CTP, MELD-Na and MELD-lactate scores also had good predictive utility on day 7 admission (CTP D7 0.684; MELD-Na 0.67; MELD-lactate 0.848). This held true regardless of whether APASL or EASL criteria was applied. In addition, the sequential change in CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 was significantly associated with need for urgent transplant or death before discharge. CONCLUSION: CTP, MELD-Na and MELD-lactate scores are superior at prognosticating outcomes on day 4 and 7 of admission in our multi-ethnic Asian population. The trend of CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 of admission may also contribute valuable information to our assessment of ACLF patients.