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Since the introduction of direct-acting antivirals (DAAs), the outcomes of hepatitis C (HCV) treatment have shown an improvement in cure rates with minimal side effects. However, to date, the safety and efficacy of DAAs have not been specifically examined in elderly patients. The treatment of HCV in the era of pegylated interferon and ribavirin was more challenging among elderly patients due to the increased prevalence of multiple comorbid conditions associated with an increased risk of side effects, including anemia, and high rates of discontinuation, likely as a result of poor tolerability, resulting in lower rates of sustained virologic response (SVR). The advent of highly efficacious all-oral DAA agents with minimal adverse events has provided more data on the outcomes of treatment in the elderly population. The current evidence shows that DAA agents have been effective and safe in the elderly population, with comparable rates of SVR. The aim of this article was to review the safety and efficacy of commonly prescribed DAA agents in the management of chronic HCV in the elderly population.

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Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by chronic granulomatous lymphocytic cholangitis of the small bile ducts. PBC was a leading indication for liver transplant in the United States; with early diagnosis and treatment, the majority of patients with PBC have a normal life expectancy. Pathogenesis involves inflammatory damage of bile duct epithelium secondary to innate and adaptive immune responses, and toxicity from accumulated bile acids. Cholestasis and disease progression can lead to cirrhosis. Extrahepatic complications include dyslipidemia, metabolic bone disease, and fat-soluble vitamin deficiency. Ursodeoxycholic acid is a well-established therapy. Novel targeted therapeutics are being developed.

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Primary biliary cholangitis (PBC) is a chronic autoimmune cholestatic liver disease that predominantly affects women in early to middle age. It is typically associated with autoantibodies to mitochondrial antigens and results in immune-mediated destruction of small and medium-sized intrahepatic bile ducts leading to cholestasis, hepatic fibrosis and may progress to cirrhosis or hepatic failure and, in some cases, hepatocellular carcinoma. The clinical presentation and the natural history of PBC have improved over the years due to recognition of earlier widespread use of ursodeoxycholic acid (UDCA); about one-third of patients show suboptimal biochemical response to UDCA with poor prognosis. Until recently, UDCA was the only US Food and Drug Administration approved agent for this disease for more than two decades; obeticholic acid was approved in 2016 for treatment of patients with PBC with a suboptimal response or intolerance to UDCA. Currently, liver transplantation is the most effective treatment modality for PBC patients with end-stage liver disease. This review will focus on the recent advances in therapy of primary biliary cholangitis, with emphasis on obeticholic acid.

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INTRODUCTION: Humidity is commonly associated with increased airway hyperresponsiveness in asthma. OBJECTIVE: To examine mold sensitization in patients with allergic asthma or allergic rhinitis and self-reports of humidity as exacerbating factors of clinical symptoms. METHODS: A retrospective, cross-sectional study at a University hospital outpatient allergy and asthma clinic was performed. A total of 106 patients with either allergic asthma or allergic rhinitis completed standard prick-puncture skin testing with 17 allergens and controls and completed standardized forms addressing trigger factors for clinical symptoms. RESULTS: Allergic asthmatics sensitized to Cladosporium were more likely to have a more severe asthma severity class (odds ratio = 4.26, confidence interval = 1.30-16.93). Sensitization to Alternaria, Cladosporium, Helminthosporium, Aspergillus and Dermatophagoides pteronyssinus in asthma was associated with higher likelihood for previous hospitalization, while sensitization to Cladosporium, Helminthosporium, Aspergillus, Dermatophagoides pteronyssinus and cockroach in asthma was associated with higher likelihood of having reduced pulmonary function based on forced expiratory volume in 1s. Furthermore, allergic asthmatics more commonly reported humidity as an exacerbating factor of symptoms than did patients only with allergic rhinitis (68.42% vs 42.86%, respectively; P < 0.05). CONCLUSION: Mold sensitization is highly associated with more severe asthma, while humidity is more of an exacerbating factor in patients with allergic asthma as compared with allergic rhinitis alone. Further delineation between mold sensitization and humidity is needed to determine whether these are independent factors in asthma.

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Medical costs of obesity in the United States exceed $147 billion annually with medication costs making a sizable contribution. We examined medication costs associated with substantial weight losses in an intensive behavioral weight loss program. Inclusion criteria were medication use for obesity co-morbidities: hypertension, diabetes, dyslipidemia, degenerative joint disease, or gastroesophageal reflux disease. Group A, 83 obese patients on medications completed 8 weeks of classes, lost 19 kg in 20 weeks. Group B, 100 severely obese patients, lost 59 kg in 45 weeks. Medications were discontinued: Group A, 18%; Group B, 64%. Mean numbers of medications decreased significantly for all co-morbidities. Mean numbers of daily medications, initial and final, respectively were: Group A, total, 3.0 ± 0.2 (mean ± SEM) and 1.7 ± 0.2; Group B, total, 2.5 ± 0.2 and 0.7 ± 0.1. Monthly costs for all medications decreased significantly for all co-morbidities and were as follows: Group A, total, $249 ± 25 and $153 ± 19; Group B: total, $237 ± 27 and $65 ± 12. Medically supervised weight loss is very effective approach for improving cardiovascular risk factors and reducing medical costs.

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Nonalcoholic fatty liver disease (NAFLD) is very prevalent in obese patients. However, increases in serum aminotransferase levels after weight loss have raised clinical concerns. This study documented sequential changes of serum aminotransferase levels for severely obese patients who lost a substantial amount of weight in a behavioral weight loss program. One hundred three severely obese patients who lost > 45.5 kg were treated in our clinic's weight management program. The prevalence of all risk factors except diabetes was higher among those with elevated (AE) baseline serum alanine transferase (ALT) levels than those with normal levels (AN). Weight losses at 8 and 24 weeks were 19.8 and 43.5 kg in the AN group (n = 79 patients) and 21.8 and 45.5 kg in the AE group (n = 24 patients), respectively. Total weight losses after completion of the program were 58.4 kg in the AN group and 57.6 kg in the AE group. The baseline levels for the AN group were: ALT, 25.4 U/L and aspartate aminotransferase (AST)/ALT ratio, 0.87. The baseline levels for the AE group were: ALT, 68.0 U/L and AST/ALT ratio, 0.61. Peak ALT levels were 75.4 U/L in the AN group and 94.0 U/L in the AE group. The final serum ALT levels were 23.7 U/L and 27.3 U/L in the AN and AE groups, respectively. This severely obese population had a very high frequency of ALT elevations with weight loss, but elevations were transient; values usually returned to below baseline levels after substantial weight loss.

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