I am a gastroenterologist who hopes to provide high-quality and exceptional medical care to every patient, every day. I hope to provide care that focuses on their wishes and provides the best outcomes and experience. I have an interest in advanced endoscopy and hope to pursue an additional fellowship in this upon completion of my current fellowship in gastroenteroloy and hepatology. I have a passion for research to help improve our clinical care of our patients.
M.D., Weill Cornell Medical College
B.S., Stanford University
Evaluation of ethnic influence in the application of a hepatocellular carcinoma predictive model for chronic hepatitis C.
Journal of medical virology
Currently, there is no well-established algorithm predicting HCC development in untreated HCV patients. We aimed to validate an algorithm (REVEAL-HCV: age, AST, ALT, HCV RNA, HCV genotype, and cirrhosis) developed in Taiwanese patients.We analyzed 1,381 (50.1% White, 14.7% Hispanic, 13.8% Asian of diverse origin, and 7.8% African-American) adult treatment-naïve HCV patients (no viral co-infection, no HCC within 6 months) at 4 U.S. and one Hong Kong centers (11/1994-10/2017).Compared to the non-Asian cohort, the Asian cohort had higher percentage of patients in the low-risk group (46.1% vs. 26.1%) and lower percentage in the high-risk group (12.0% vs. 20.3%, p<0.01). Overall, 5-year HCC incidence were 1.75%, 4.71%, and 24.4% for low, medium and high-risk patients, respectively (p<0.0001). For the overall cohort, AUROC for HCC prediction were 0.83 (95% CI: 0.72-0.93), 0.82 (95% CI: 0.75-0.88), and 0.84 (95% CI: 0.77-0.89) for 1-year, 3-year and 5-year HCC risk, respectively. There was slightly lower AUROC for Asian compared to the non-Asian cohort at 3 years (0.75 vs. 0.83) and 5 years (0.78 vs. 0.84), though this was not statistically significant. In multivariable analysis, we found male sex, presence of metabolic syndrome as well as the risk score categories to be independently associated with HCC but not ethnicity.The REVEAL-HCV risk score has good validity for both Asian and non-Asian populations. Further studies should consider additional factors such as sex, metabolic syndrome and treatment status. This article is protected by copyright. All rights reserved.
View details for DOI 10.1002/jmv.27168
View details for PubMedID 34219250
Artificial intelligence applications in inflammatory bowel disease: Emerging technologies and future directions.
World journal of gastroenterology
2021; 27 (17): 1920-1935
Inflammatory bowel disease (IBD) is a complex and multifaceted disorder of the gastrointestinal tract that is increasing in incidence worldwide and associated with significant morbidity. The rapid accumulation of large datasets from electronic health records, high-definition multi-omics (including genomics, proteomics, transcriptomics, and metagenomics), and imaging modalities (endoscopy and endomicroscopy) have provided powerful tools to unravel novel mechanistic insights and help address unmet clinical needs in IBD. Although the application of artificial intelligence (AI) methods has facilitated the analysis, integration, and interpretation of large datasets in IBD, significant heterogeneity in AI methods, datasets, and clinical outcomes and the need for unbiased prospective validations studies are current barriers to incorporation of AI into clinical practice. The purpose of this review is to summarize the most recent advances in the application of AI and machine learning technologies in the diagnosis and risk prediction, assessment of disease severity, and prediction of clinical outcomes in patients with IBD.
View details for DOI 10.3748/wjg.v27.i17.1920
View details for PubMedID 34007130
View details for PubMedCentralID PMC8108036
- Use of a rigidizing overtube for altered-anatomy ERCP. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 2020; 5 (12): 664–66
- Use of a rigidizing overtube to complete an incomplete colonoscopy. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 2020; 5 (11): 583–85
- Gut Dysthymia: Paraneoplastic Chronic Watery Diarrhea. Digestive diseases and sciences 2020
- The Mettle to Use the Petals: Using Over-the-Scope Rings to Optimize Endoscopic Submucosal Dissection. Digestive diseases and sciences 2020
Novel rigidizing overtube for colonoscope stabilization and loop prevention (with video).
Loop formation can impede scope advancement, destabilize the tip and cause pain. Strategies to mitigate looping include torque-based reduction maneuvers, variable stiffness shafts and abdominal splinting. In some cases, these strategies are insufficient and there is need for novel instruments. Loop formation is of particular concern in colonoscopy, but it can also impact performance of other endoscopic procedures such as enteroscopy and altered-anatomy ERCP. In this case series we demonstrate the utility of a novel rigidizing overtube (Pathfinder, Neptune Medical, Burlingame, Calif, USA) in colonoscopy and other endoscopic procedures where loop management is critical.We describe our initial experience with the Pathfinder overtube in 29 patients. The overtube is 85 centimeters long and can accommodate a pediatric colonoscope. In its native state, the overtube is extremely flexible. Once the overtube is advanced to the desired location, application of a vacuum to the device causes the device to become 15 times stiffer. The endoscope can then be advanced through the overtube without loop formation in the region that the overtube traverses.The overtube was used in 29 patients to assist with difficult procedures. The patients were predominantly male (N=18; 62.1%), with median age 66 (interquartile range 57-72). One patient received an upper endoscopy (3.4%), 24 received colonoscopy (82.8%), and 4 received enteroscopy (13.8%). The overtube was used in 12 for incomplete colonoscopy (41.4%), 6 for depth (20.7%), and 11 for stability (37.9%). Colonoscopy was performed in the setting of screening (N=3), surveillance given polyp history (N=7), referrals for polyp removal (N=10), workup of iron deficiency anemia (N=2), and incomplete colonoscopy (N=1). The lower endoscopy cases had a median cecal intubation time of 5 minutes and had interquartile range (4.25 - 7 minutes). Enteroscopy was performed in 4 patients. (1) The distal 60 cm of the ileum was examined with a pediatric colonoscope to exclude ileitis. (2) The overtube was used to stabilize a 6 mm endoscope to traverse a tight Crohn's ileocolonic stricture. (3) Altered-anatomy ERCP was performed using an enteroscope through the overtube to reach a hepaticojejunostomy. (4) Upper enteroscopy was performed and the mid-jejunum was reached. We present 4 cases that demonstrate the use of the overtube. There were no adverse events.Initial experience with a novel rigidizing overtube suggests that this tool can be useful in colonoscopy and other endoscopic procedures that are affected by looping.
View details for DOI 10.1016/j.gie.2020.07.054
View details for PubMedID 32739483
Hepatitis B Virus Reactivation Potentiated by Biologics.
Infectious disease clinics of North America
Hepatitis B virus (HBV) reactivation can be a serious complication for patients with chronic or resolved HBV infection when treated with biologics. For HBsAg-positive patients receiving biologics, the risk of HBV reactivation is moderate to high. HBsAg-negative/anti-HBc positive patients are at lower risk of HBV reactivation than HBsAg-positive patients. However, patients taking anti-CD20 agents, such as rituximab, have high risk of HBV reactivation (>10%), so antiviral prophylactic therapies are required. This review provides the different classes of biologics associated with HBV reactivation, stratifies the various reactivation risk levels by HBV status and biologic agent, and discusses management strategies.
View details for DOI 10.1016/j.idc.2020.02.009
View details for PubMedID 32334985
- Provider Perspectives on HCC Surveillance in Patients With Cirrhosis: Community Provider Perspectives Matter. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2020
- What to Do When Fecal Immunochemical Test (FIT) Is Positive Following Normal Colonoscopy? Comparison of Adenoma Detection Rate (ADR) of Standard FIT-Colonoscopy and Relook Colonoscopy LIPPINCOTT WILLIAMS & WILKINS. 2019: S192
- Sustained virologic response to direct-acting antiviral therapy in patients with chronic hepatitis C and hepatocellular carcinoma: A systematic review and meta-analysis JOURNAL OF HEPATOLOGY 2019; 71 (3): 473–85
- Antiviral therapy and the development of osteopenia/osteoporosis among Asians with chronic hepatitis Bn JOURNAL OF MEDICAL VIROLOGY 2019; 91 (7): 1288–94
- Prevalence, incidence, and outcome of non-alcoholic fatty liver disease in Asia, 1999-2019: a systematic review and meta-analysis LANCET GASTROENTEROLOGY & HEPATOLOGY 2019; 4 (5): 389–98
- Hospital Cirrhosis Volume and Readmission in Patients with Cirrhosis in California (vol 63, pg 2267, 2018) DIGESTIVE DISEASES AND SCIENCES 2019; 64 (5): 1392–94
Prevalence, incidence, and outcome of non-alcoholic fatty liver disease in Asia, 1999-2019: a systematic review and meta-analysis.
The lancet. Gastroenterology & hepatology
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. Asia is a large, heterogeneous area with substantial variation in socioeconomic status and prevalence of obesity. We estimated the prevalence, incidence, and outcomes of NAFLD in the Asian population to assist stakeholders in understanding NAFLD disease burden.METHODS: We searched PubMed, EMBASE, and the Cochrane Library from database inception to Jan 17, 2019, for studies reporting NAFLD prevalence, incidence, or outcome in Asia. We included only cross-sectional and longitudinal observational studies of patients with NAFLD diagnosed by imaging, serum-based indices, or liver biopsy. Studies that included patients with overlapping liver disease or that did not screen for excess alcohol consumption were excluded. Two investigators independently screened and extracted data. The main outcomes were pooled NAFLD prevalence, incidence, and hepatocellular carcinoma incidence and overall mortality in patients with NAFLD. Summary estimates were calculated using a random-effects model. This study is registered with PROSPERO, number CRD42018088468.FINDINGS: Of 4995 records identified, 237 studies (13 044 518 participants) were included for analysis. The overall prevalence of NAFLD regardless of diagnostic method was 29·62% (95% CI 28·13-31·15). NAFLD prevalence increased significantly over time (25·28% [22·42-28·37] between 1999 and 2005, 28·46% [26·70-30·29] between 2006 and 2011, and 33·90% [31·74-36·12] between 2012 and 2017; p<0·0001). The pooled annual NAFLD incidence rate was 50·9 cases per 1000 person-years (95% CI 44·8-57·4). In patients with NAFLD, the annual incidence of hepatocellular carcinoma was 1·8 cases per 1000 person-years (0·8-3·1) and overall mortality rate was 5·3 deaths per 1000 person-years (1·5-11·4).INTERPRETATION: NAFLD prevalence in Asia is increasing and is associated with poor outcomes including hepatocellular carcinoma and death. Targeted public health strategies must be developed in Asia to target the drivers of this rising epidemic and its associated complications, especially in high-risk groups, such as older obese men.FUNDING: None.
View details for PubMedID 30902670
- Nonliver Comorbidities in Patients With Chronic Hepatitis B. Clinical liver disease 2019; 14 (3): 126–30
Antiviral therapy and the development of osteopenia/osteoporosis among Asians with chronic hepatitis B.
Journal of medical virology
Recent studies have suggested a potential increase in the incidence of osteoporosis for patients receiving tenofovir disoproxil fumarate (TDF), but this issue remains controversial.Retrospective cohort study of 1,224 Asian chronic hepatitis B (CHB) patients >18 years without baseline osteopenia/osteoporosis seen at four U.S. centers from 2008-2016. Patients were categorized into three groups-treatment naive patients who initiated therapy with TDF (1) or entecavir (ETV) (2), or untreated patients (3). Patients were followed until development of osteopenia/osteoporosis or end of study.Of the 1,224 study patients, 276 were treated with TDF, 335 with ETV, and 613 were untreated. The prevalence of cirrhosis was lower for untreated patients (2.6% vs. 16.3% for TDF and 17.6% for ETV, p<0.001). The 8-year cumulative incidence rate of osteopenia/osteoporosis was 13.17% for TDF, 15.09% for ETV and 10.17% for untreated patients, with no statistically significant difference among the three groups (p=0.218). On multivariate Cox regression controlling for demographics, osteoporosis risk factors, albumin, and hepatitis B virus (HBV) DNA levels, neither TDF (adjusted HR 0.74, 95% CI: 0.34, 1.59) nor ETV (adjusted HR 0.98, 95% CI: 0.51, 1.90) were associated with increased osteopenia/osteoporosis risk compared to untreated patients.Our retrospective study suggests there is no significant increase in incidence of osteopenia/osteoporosis for CHB patients treated with TDF or ETV during median follow-up of about 4-5 years. However, further study with longer follow-up is needed as anti-HBV therapy is often lifelong or long-term and the development of osteopenia/osteoporosis can be a slow process. This article is protected by copyright. All rights reserved.
View details for PubMedID 30776311
Sustained virologic response to direct-acting antiviral therapy in patients with chronic hepatitis C and hepatocellular carcinoma: A systematic review and meta-analysis.
Journal of hepatology
Questions remain about the effect of hepatocellular carcinoma (HCC) on response to interferon-free direct-acting antiviral (DAA) therapy for chronic hepatitis C (CHC) patients compared to those without HCC. Using a systematic review and meta-analysis approach, we aimed to investigate the effect of DAA therapy on sustained virologic response among CHC patients with active, inactive and no HCC.PubMed, Embase, Web of Science, and the Cochrane Controlled Trials Register were searched from 1/1/2013 to 9/24/2018. The pooled sustained virologic response (SVR) rates were computed using DerSimonian-Laird random-effects models.We included 49 studies from 15 countries, comprised of 3,341 HCC and 35,701 non-HCC patients. Overall, the pooled SVR was lower in HCC than in non-HCC patients (89.6%, 95% CI 86.8-92.1%, I2=79.1% vs. 93.3%, 95% CI 91.9-94.7%, I2=95.0%, P=0.0012), translating to a 4.8% (95% CI 0.2-7.4%) SVR reduction by meta-regression analysis. Also on meta-regression analyses, the largest SVR reduction (18.8%) occurred in patients with active/residual HCC vs. inactive/ablated HCC (SVR 73.1% vs. 92.6%, P=0.002). Meanwhile, HCC patients with prior liver transplant (LT) had higher SVR compared to non-LT HCC patients (P<0.001). Regarding specific DAA regimens, HCC patients treated with ledipasvir/sofosbuvir had lower SVR rates than non-HCC patients (92.6%, n=884 vs. 97.8%, n=13,141, P=0.026) but heterogeneity was high (I2=84.7%, P<0.001). For the few HCC patients treated with paritaprevir/ritonavir, ombitasvir ± dasabuvir (n=101), SVR was similar to non-HCC patient (97.2% vs. 94.8%, P=0.79). Daclatasvir/asunaprevir-treated HCC and non-HCC patients also had similar SVR rates though both were low (91.7% vs. 89.8%, P=0.66).Overall, SVR was lower in HCC compared to non-HCC patients, especially in those with active HCC though heterogeneity was high. Continued efforts are needed to aggressively screen, diagnose and treat HCC to ensure higher CHC cure rates.There are now medications ("DAAs") that can "cure" hepatitis C virus, but patients with hepatitis C and liver cancer may be less likely to achieve cure than those without liver cancer. However, liver cancer patients are also more likely to have advanced liver disease and risk factors that can decrease cure rates, so better controlled studies are needed to confirm these findings.
View details for PubMedID 31096005
Increased Prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) in Asia: A Systematic Review and Meta-Analysis of 164 Studies and 1,704,963 Subjects from 13 Countries
WILEY. 2018: 983A
View details for Web of Science ID 000446020502522
Distribution of Etiologies in Cirrhosis Admissions and Its Year Trend Burden in California (CA): A Population-Based Study with the Office of Statewide Health Planning and Development (OSHPD)
WILEY. 2018: 461A
View details for Web of Science ID 000446020500796
Hospital Cirrhosis Volume and Readmission in Patients with Cirrhosis in California.
Digestive diseases and sciences
Patients with cirrhosis are at high readmission risk. Using a large statewide database, we evaluated the effect of hospital cirrhosis-related patient volume on 30-day readmissions in patients with cirrhosis.We conducted a retrospective study of the Healthcare Cost and Utilization Project State Inpatient Database for adult patients with cirrhosis, as defined by International Classification of Diseases, Ninth Revision (ICD-9) codes, hospitalized in California between 2009 and 2011. Multivariable logistic regression analysis was performed to evaluate the effect of hospital volume on 30-day readmissions.A total of 69,612 patients with cirrhosis were identified in 405 hospitals; 24,062 patients were discharged from the top 10% of hospitals (N = 41) by cirrhosis volume, and 45,550 patients in the bottom 90% (N = 364). Compared with higher-volume centers, lower-volume hospitals cared for patients with similar average Quan-Charlson-Deyo (QCD) comorbidity scores (6.54 vs. 6.68), similar proportion of hepatitis B and fatty liver disease, lower proportion of hepatitis C (34.8 vs. 41.5%) but greater proportion of alcoholic liver disease (53.1 vs. 47.4%). Multivariable logistic regression analysis demonstrated admission to a lower-volume hospital did not predict 30-day readmission (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.92-1.01) after adjusting for sociodemographics, QCD score, cirrhosis severity, and hospital characteristics. Instead, liver transplant center status significantly decreased the risk of readmission (OR 0.87, 95% CI 0.80-0.94). Ascites, hepatic encephalopathy, hepatocellular carcinoma, higher QCD, and presence of alcoholic liver disease and hepatitis C were also independent predictors.Readmissions within 30 days were common among patients with cirrhosis hospitalized in California. While hospital cirrhosis volume did not predict 30-day readmissions, liver transplant center status was protective of readmissions. Medically complicated patients with cirrhosis at hospitals without liver transplant centers may benefit from additional support to prevent readmission.
View details for PubMedID 29457210
Is antiviral treatment for chronic hepatitis B (CHB) in Asian patients associated with osteopenia/osteoporosis? A comparison study of tenofovir (TDF), entecavir (ETV) and untreated (UTx) patients
WILEY. 2017: 516A–517A
View details for Web of Science ID 000412089801108
Hepatocellular carcinoma decreases the effectiveness of hepatitis C antiviral treatment: does direct-acting antiviral regimens matter?
Hepatology (Baltimore, Md.)
View details for PubMedID 29194694
Tenofovir alafenamide as compared to tenofovir disoproxil fumarate in the management of chronic hepatitis B with recent trends in patient demographics.
Expert review of gastroenterology & hepatology
Tenofovir alafenamide (TAF) has recently been approved for chronic hepatitis B (CHB). It is more stable than tenofovir disoproxil fumarate (TDF) in the plasma and can provide similar efficacy with lower circulating concentration in patients with hepatitis B virus (HBV) infection. Areas covered: This synopsis will review the current anti-HBV standard practice and the changing epidemiology of CHB, specifically the controversies surrounding the renal and bone safety associated with TDF use in the context of an aging CHB population. We will review data from phase 3 registration trials, which demonstrated TAF was not inferior to TDF in antiviral efficacy for both HBeAg-positive and HBeAg-negative patients, while associated with less reduction in the estimated glomerular filtration rate and bone mineral density. Expert commentary: Current data supports the use of TAF as one of the first-line antiviral agents for general CHB patients without hepatic decompensation. However, more real-world data with long-term observation are needed to better define the role of TAF among other oral regimens. Additional studies are also needed to evaluate the efficacy and safety of TAF in special populations such as those with impaired hepatic function, existing impaired renal and/or bone function, and in pregnant women.
View details for PubMedID 28965428