Treatment outcomes and costs of a simplified antiviral treatment strategy for hepatitis C among monoinfected and HIV and/or hepatitis B virus-co-infected patients in Myanmar.

Access to hepatitis C virus (HCV) testing and treatment is limited in Myanmar. We assessed an integrated HIV and viral hepatitis testing and HCV treatment strategy. Sofosbuvir/velpatasvir (SOF/VEL) ± weight-based ribavirin for 12 weeks was provided at three treatment sites in Myanmar and sustained virologic response (SVR) assessed at 12 weeks after treatment. Participants co-infected with HBV were treated concurrently with tenofovir. Cost estimates in 2018 USD were made at Yangon and Mandalay using standard micro-costing methods. 803 participants initiated SOF/VEL; 4.8% were lost to follow-up. SVR was achieved in 680/803 (84.6%) by intention-to-treat analysis. SVR amongst people who inject drugs (PWID) was 79.7% (381/497), but 92.5% among PWID on opioid substitution therapy (OST) (74/80), and 97.4% among non-PWID (298/306). Utilizing data from 492 participants, of whom 93% achieved SVR, the estimated average cost of treatment per patient initiated was $1030 (of which 54% were medication costs), with a production cost per successful outcome (SVR) of $1109 and real-world estimate of $1250. High SVR rates were achieved for non-PWID and PWID on OST. However, the estimated average cost of the intervention (under the assumption of no genotype testing and reduced real-world effectiveness) of $1250/patient is unaffordable for a national elimination strategy. Reductions in the cost of antivirals and linkage to social and behavioural health services including substance use disorder treatment to increase retention and adherence to treatment are critical to HCV elimination in this population.

Evaluation of GeneXpert and advanced biological laboratories UltraGene HCV diagnostic detection and performance against Roche real time PCR in Myanmar.

BACKGROUND: Developing countries experience limited access to HCV laboratory tests for different reasons. Providing near to real-time HCV testing and results especially to at-risk populations including those in rural settings for timely initiation to treatment is key. Within a rural Myanmar setting, we compared HCV diagnostic detection and quantification of the GeneXpert, and Advanced Biological Laboratories UltraGene-HCV assays against the gold standard and reference method Roche real-time HCV in Myanmar. METHODS: Blood samples from 158 high-risk individuals were assessed using three different methods at baseline. Results were checked for normality and log transformed. Log differences and bias between methods were calculated and correlated. Pearson's correlation coefficient was used to determine the association of HCV viral loads across all methods. The level of agreement with the standard method (Roche real time HCV) was assessed using Bland-Altman analyses. RESULTS: There was a strong positive correlation coefficient between all three methods with GeneXpert and Roche having the strongest, r = 0.96, (p<0.001). Compared to Roche, ABL (mean difference, 95 % limits of agreement; -0.063 and -1.4 to 1.3 Log10IU/mL) and GeneXpert (mean difference, 95 % limits of agreement; -0.28 and -0.7 to 1.8 Log10IU/mL) showed a good level of agreement with the GeneXpert being slightly superior. CONCLUSION: We demonstrate the excellent performance and no-inferiority, in terms of levels of agreements of both GeneXpert and ABL compared to the Roche platform and supporting the use of the POC assays as alternative a cost-effective methods in HCV detection and diagnosis in developing and low resource settings countries.

Urothelial Carcinoma of the Renal Pelvis and Ureter: Does Location Make a Difference?

BACKGROUND: There is a paucity of data on outcomes of upper tract urothelial carcinoma (UTUC) arising from the renal pelvis (RPUC) versus UTUC arising from the ureter (UUC). The published literature is conflicting, and there is no consensus on patient prognosis based on disease location. The aim of this study is to compare clinical and survival outcomes based on location of primary tumor using a large national registry. MATERIALS AND METHODS: The National Cancer Database was queried from 2010 to 2016 for patients with localized (cN0M0) UTUC. Patients were stratified based on location of tumor. Survival analysis was performed using Cox proportional hazard regression and inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves. We also performed exploratory analyses based on tumor stage. RESULTS: We identified 11,922 patients who underwent surgical treatment. The median follow-up was 32.1 months. Patients with RPUC presented with higher tumor stage and grade. Patients with UUC were treated with less radical nephroureterectomy (56.4% vs. 84.3%; P < .01). IPTW-adjusted Kaplan-Meier curves demonstrated higher median overall survival for RPUC versus UUC (71.1 vs. 66.8 months, respectively; P = .01). This benefit was consistent across tumor stage subgroups, reaching statistical significance in patients with T1 disease. On multivariable analysis, ureteral location of tumor was a predictor of worse survival. CONCLUSION: Patients with UUC were found to be treated with less radical surgery and to have worse survival than those with RPUC. These patients may suffer from poor initial staging and suboptimal treatments. Further studies are needed to evaluate potential biological differences of UTUC based on tumor location.

Holmium Laser Enucleation of the Prostate Is Safe and Feasible as a Same Day Surgery.

OBJECTIVE: To assess the safety, feasibility and treatment outcomes of holmium laser enucleation of the prostate (HoLEP) as a same day surgery (SDS). METHODS: HoLEPs performed from November 2013 to December 2018 at our institution were reviewed retrospectively. Inclusion criteria for same day surgery (SDS) included living in the local metropolitan area with access to local hospital and Eastern Cooperative Oncology Group (ECOG) 0-2, regardless of prostate size and anticoagulation status. Those patients who were discharged directly from the postoperative care unit were identified as SDS cases. Patients admitted overnight after HoLEP during the same period were used as a matched cohort. Patient demographics, disease characteristics and treatment outcomes were compared. RESULTS: A total of 377 patients were identified, including 199 SDS and 178 non-SDS patients. No statistical difference was present between the 2 groups regarding the post-op complication and readmission rates. The non-SDS group had a significantly higher percentage of patients with history of urinary retention, lower pre-op Qmax, and larger prostate volume. The SDS group had shorter operative time, length of stay (LOS), and catherization time (all P <.05). At 1-year follow-up, no statistically different change in Qmax, PVR, or IPSS score was noted between the 2 groups. CONCLUSION: Same day outpatient surgery for HoLEP is safe in patients who live in close proximity and have ECOG status 0-2. Our readmission rate and complication rate are comparable to those reported in the literature with markedly decreased LOS. Long-term functional outcome is not compromised by SDS.

Pantoea agglomerans liver abscess presenting with a painful thigh.

This case highlights that an acute myositis leading to rhabdomyolysis may occur as a rare complication of hepatic abscess and shows the benefit of early recognition of this possible association. A 70-year-old man presented with fever and lower limb myalgia, with laboratory evidence of acute renal failure secondary to rhabdomyolysis. Blood cultures revealed Pantoea agglomerans, which led to identification of a hepatic abscess on computed tomography scan. Supportive care together with antibiotics led to normalization of renal function and resolution of the abscess. This appears to be the first report of a patient with a liver abscess presenting with myositis and rhabdomyolysis. Early recognition of this possible association is vital to limit morbidity and mortality.

Current medical management of endocrine-related male infertility.

Male factor contributes to 50%-60% of overall infertility but is solely responsible in only 20% of couples. Although most male factor infertility is ascertained from an abnormal semen analysis, other male factors can be contributory especially if the sample returns normal. Male infertility can be due to identifiable hormonal or anatomical etiologies that may be reversible or irreversible. This manuscript will highlight existing guidelines and our recommendations for hormone evaluation for male infertility and empiric therapies including multivitamins, estrogen receptor modulators (clomiphene), estrogen conversion blockers (anastrozole), and hormone replacement.