Neighbourhood factors and tuberculosis incidence in Cape Town: A negative binomial regression and spatial analysis.

OBJECTIVES: Although the link between poverty and tuberculosis (TB) is widely recognised, limited studies have investigated the association between neighbourhood factors and TB incidence. Since the factors influencing different episodes of TB might be different, this study focused on the first episode of TB disease (first-episode TB). METHODS: All first episodes in previously linked and geocoded TB notification data from 2007 to 2015 in Cape Town, South Africa, were aggregated at the neighbourhood level and merged with the 2011 census data. We conducted an ecological study to assess the association between neighbourhood incidence of first-episode TB and neighbourhood factors (total TB burden [all episodes] in the previous year, socioeconomic index, mean household size, mean age, and percentage males) using a negative binomial regression. We also examined the presence of hotspots in neighbourhood TB incidence with the Global Moran's I statistic and assessed spatial dependency in the association between neighbourhood factors and TB incidence using a spatial lag model. RESULTS: The study included 684 neighbourhoods with a median first-episode TB incidence rate of 114 (IQR: 0-345) per 100,000 people. We found lower neighbourhood socioeconomic index (SEI), higher neighbourhood total TB burden, lower neighbourhood mean household size, and lower neighbourhood mean age were associated with increased neighbourhood first-episode TB incidence. Our findings revealed a hotspot of first-episode TB incidence in Cape Town and evidence of spatial dependency in the association between neighbourhood factors and TB incidence. CONCLUSION: Neighbourhood TB burden and SEI were associated with first-episode TB incidence, and there was spatial dependency in this association. Our findings can inform targeted interventions to reduce TB in high-risk neighbourhoods, thereby reducing health disparities and promoting health equity.

Platelet function analyzer-200 closure curve analysis and assessment of flow-obstructed samples.

BACKGROUND: The Platelet function analyzer-200 can determine the effect of clopidogrel in cats. Flow obstruction is an error that causes uninterpretable results. Closure curves and parameters initial flow rate (IF) and total volume (TV) are displayed by the PFA-200 and may allow interpretation of results in cases of flow obstruction. The primary hemostasis components (PHC) are calculated values that normalize these parameters. OBJECTIVES: To determine if closure curves and research parameters allow detecting the effect of clopidogrel in cases of flow obstruction. METHODS: A review of closure curves identified those with flow obstruction and paired analysis that did not. Non-flow-obstructed curves were used to categorize curves with respect to clopidogrel effects. IF, TV, PHC(1), and PHC(2) were evaluated to determine if these could be used to categorize if a sample exhibited the effects of clopidogrel. Curves were visually analyzed, and characteristics identified that were more common with or without the effect of clopidogrel. Visual analysis of curves was performed by blinded observers to determine if a visual analysis was able to predict the effect of clopidogrel. RESULTS: Analysis of parameters was able to predict closure or non-closure in flow-obstructed curves. TV, PHC(1), and PHC(2) had area under the curve of the receiver operating characteristics of 0.79, 0.79, and 0.87. Visual curve analysis was unable to predict closure, with an average accuracy of only 55%, among three reviewers. Agreement between reviewers was poor (Fleiss' Kappa 0.06). CONCLUSIONS: Visual curve analysis was unable to determine the effect of clopidogrel in flow-obstructed samples. Numerical parameters were able to detect the effect of clopidogrel with a high degree of accuracy in flow-obstructed samples.

The humanistic burden associated with caring for patients with advanced non-small cell lung cancer (NSCLC) in three European countries-a real-world survey of caregivers.

PURPOSE: This study evaluated the humanistic burden on caregivers of patients with advanced non-small cell lung cancer (aNSCLC) as the disease progresses. METHODS: Data were drawn from a cross-sectional study of patients with aNSCLC and their caregivers conducted in France, Germany, and Italy between 2015 and 2016. Data were collected by medical chart review and patient and caregiver questionnaires. The EuroQol five-dimension three-level (EQ-5D-3L) was used to evaluate patient and caregiver health status. Caregivers also completed the Work Productivity and Activity Impairment (WPAI) questionnaire and Zarit Burden Interview (ZBI). RESULTS: The population for the analysis consisted of 427 caregivers (mean age 53.5 years; 72.6% female; 54.9% spouse; 36.2% in full-time employment) and 427 matched patients (mean age 66.2 years; 68.6% male). Most (69.5%) patients were receiving first-line therapy for advanced disease. Patients' caregivers provided a mean of 29.5 h of support per week. Significant differences in EQ-5D-3L scores were observed between caregivers of patients receiving first and later lines of therapy in France (0.87 vs. 0.78; p = 0.0055). Among employed caregivers, overall work impairment was considerable and ranged from 21.1% in Germany to 30.4% in France and 29.7% in Italy. Caregivers of patients receiving later lines of therapy in France rated their own health status as significantly worse than did those caring for patients receiving first-line therapy (82.7 vs. 72.9; p = 0.0039). CONCLUSIONS: Informal caregivers provided the majority of support for patients with advanced NSCLC and their caregiving activities impose a significant humanistic burden.

Linking routinely collected social work, education and health data to enable monitoring of the health and health care of school-aged children in state care ('looked after children') in Scotland: a national demonstration project.

BACKGROUND AND OBJECTIVES: Children in state care ('looked after children') have poorer health than children who are not looked after. Recent developments in Scotland and elsewhere have aimed to improve services and outcomes for looked after children. Routine monitoring of the health outcomes of looked after children compared to those of their non-looked after peers is currently lacking. Developing capacity for comparative monitoring of population-based outcomes based on linkage of routinely collected administrative data has been identified as a priority. To our knowledge there are no existing population-based data linkage studies providing data on the health of looked after and non-looked after children at national level. Smaller scale studies that are available generally provide very limited information on linkage methods and hence do not allow scrutiny of bias that may be introduced through the linkage process. STUDY DESIGN AND METHODS: National demonstration project testing the feasibility of linking routinely collected looked after children, education and health data. PARTICIPANTS: All children in publicly funded school in Scotland in 2011/12. RESULTS: Linkage between looked after children data and the national pupil census classified 10,009 (1.5%) and 1757 (0.3%) of 670,952 children as, respectively, currently and previously looked after. Recording of the unique pupil identifier (Scottish Candidate Number, SCN) on looked after children returns is incomplete, with 66% of looked after records for 2011/12 for children of possible school age containing a valid SCN. This will have resulted in some under-ascertainment of currently and, particularly, previously looked after children within the general pupil population. Further linkage of the pupil census to the National Health Service Scotland master patient index demonstrated that a safe link to the child's unique health service (Community Health Index) number could be obtained for a very high proportion of children in each group (94%, 95% and 95% of children classified as currently, previously, and non-looked after, respectively). In general, linkage rates were higher for older children and those living in more affluent areas. Within the looked after group, linkage rates were highest for children with the fewest placements and for those in permanent fostering. CONCLUSIONS: This novel data linkage demonstrates the feasibility of monitoring population-based health outcomes of school-aged looked after and non-looked after children using linked routine administrative data. Improved recording of the unique pupil identifier number on looked after data returns would be beneficial. Extending the range of personal identifiers on looked after children returns would enable linkage to health data for looked after children who are not in publicly funded schooling (i.e. those who are preschool or postschool, home schooled or in independent schooling).

The cost of warfarin treatment for stroke prevention in patients with non-valvular atrial fibrillation in Russia from a collective perspective.

AIMS: Vitamin K antagonists (VKAs) are used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), but necessitate regular monitoring of prothrombin time via international normalized ratio (INR) testing. This study explores the economic burden of VKA therapy for Russian patients with NVAF. METHOD: Cardiologists provided clinical characteristics and healthcare resource use data relating to the patient's first year of treatment. Data were used to quantify direct medical costs (INR testing, consultations, drug costs). The same patients completed a questionnaire providing data on direct non-medical costs (travel/expenses for attendance at VKA appointments) and indirect costs (opportunity cost and reduced work productivity). Mean costs per patient per year are described (US dollars). RESULTS: Cardiologists (n = 50) provided data on 400 patients (mean age = 63, 47% female), and 351 patients (88%) completed the patient questionnaire. Patients had a mean of nine INR tests. Estimated direct medical costs totaled $151.06, and 18.5% of direct medical costs were attributable to drug costs. Estimated annual direct non-medical costs were $22.89 per patient, and indirect costs were $275.59 per patient. LIMITATIONS: Included patients had been treated for 12-24 months, so are not fully representative of the broader treatment population. CONCLUSION: Although VKA drugs costs are relatively low, regular INR testing and consultations drive the economic burden for Russian NVAF patients treated with VKA.

Assessment of platelet function in healthy cats in response to commonly prescribed antiplatelet drugs using three point-of-care platelet function tests.

Objectives The objective was to determine if decreased platelet function could be detected after treatment with aspirin and/or clopidogrel in healthy cats using three point-of-care platelet function tests that evaluate platelet function by different methods: Multiplate (by impedance), Platelet Function Analyzer 100 (by mechanical aperture closure) and Plateletworks (by platelet counting). Methods Thirty-six healthy cats were randomly assigned to receive one of three oral treatments over an 8 day period: (1) aspirin 5 mg q72h; (2) aspirin 20.25 mg q72h; or (3) clopidogrel 18.75 mg q24h. Cats treated with 5 and 20.25 mg aspirin also received clopidogrel on days 4-8. Platelet aggregation in response to adenosine diphosphate and collagen ± arachidonic acid was assessed on days 1 (baseline), 4 and 8. Aspirin and clopidogrel metabolites were measured by high-performance liquid chromatography. Platelet function in response to treatment was analyzed by ANCOVA, linear regression and Spearman correlation. Results The only solitary aspirin effect was detected using Plateletworks with collagen in cats treated with 20.25 mg. The only effect detected by Multiplate was using arachidonic acid in cats treated with both aspirin 20.25 mg and clopidogrel. All clopidogrel treatment effects were detected by Platelet Function Analyzer 100, Plateletworks (adenosine diphosphate) and Plateletworks (collagen). Drug metabolites were present in all cats, but concentrations were minimally correlated to platelet function test results. Conclusions and relevance Platelet Function Analyzer 100 and Plateletworks using adenosine diphosphate ± collagen agonists may be used to detect decreased platelet function in response to clopidogrel treatment. Either aspirin is not as effective an antiplatelet drug as clopidogrel, or the tests used were not optimal to measure aspirin effect. Cats with heart disease are commonly prescribed antiplatelet drugs to decrease the risk of aortic thromboembolism. Platelet Function Analyzer 100 and Plateletworks may be useful for confirming clopidogrel treatment in these cats.

Prevalence and burden of dyspnoea among COPD patients in Japan.

BACKGROUND AND AIMS: Dyspnoea is the most common symptom of chronic obstructive pulmonary disease (COPD) significantly affecting activity, impairing patients' well-being and contributing to the economic burden of COPD. The objective of this study was to estimate the prevalence of dyspnoea and its impact on COPD management costs in Japan. METHODS: A cross-sectional survey was conducted among 82 internal medicine physicians and 85 respiratory specialists representing 420 patients with COPD in Japan. Information was collected on demographic and clinical characteristics, dyspnoea (mMRC scale), and healthcare resource use. Dyspnoea prevalence was estimated among all patients and those on specific COPD treatments. The economic burden was derived from two cohorts based on their level of dyspnoea that were matched by propensity scores balancing their demographic and disease burden characteristics. RESULTS: Moderate-severe dyspnoea (mMRC score ≥ 2) was reported by 37.5% of COPD patients and ranging from 21.5% among patients treated with a mono bronchodilator to 59.8% among patients treated with triple therapy. Descriptive analysis showed that dyspnoeic patients have higher annual costs attributable to consultations (€2999 vs. €1906), medications (€1139 vs. €716), exacerbations (€674 vs. €36), other resources (€1789 vs. €140) and in total (€6348 vs. €2797) (p < 0.0001 for all comparisons) compared to patients with mild or no dyspnoea (mMRC score < 2). The total costs remained significantly higher in a propensity-matched cohort adjusted for severity and cardiovascular comorbidity [€6776.1 vs. €4461.3, p = 0.0236]. CONCLUSION: Moderate-severe dyspnoea is common among consulting COPD patients in Japan and is a significant cost driver for the healthcare system.

Assessment of platelet function in healthy sedated cats using three whole blood platelet function tests.

The objectives of this study were to establish feline references intervals for 3 commercial whole blood platelet function test analyzer systems: Multiplate analyzer (MP; Roche Diagnostics International Ltd., Rotkreuz, Switzerland), Platelet Function Analyzer-100 (PF: Siemens Canada, Mississauga, Ontario, Canada), and Plateletworks Combo-25 kit (PW; Helena Laboratories, Beaumont, TX). Venipuncture was performed on 55 healthy sedated cats, and platelet aggregation in response to adenosine diphosphate (ADP), collagen (COL), and arachidonic acid (AA; MP only) was assessed using citrated blood. For the MP analyzer, median (95% confidence intervals [CIs]) area under curve (Units) for ADP, COL, and AA agonists were 87 (11-176), 81 (32-129), and 91 (59-129), respectively. For the PF analyzer, median (95% CIs) closure time, using COL-ADP cartridges, was 69 (46-89) sec. For the PW assay, median (95% CIs) percent aggregations for ADP and COL agonists were 71 (18-92) and 49 (9-96), respectively, using impedance hematology analyzer platelet counts, and 94 (25-98) and 68 (14-119), respectively, using flow cytometry hematology analyzer platelet counts. There were low correlations between the PF analyzer (COL-ADP cartridge) and MP analyzer (COL agonist; ρ = 0.11), and between the PF analyzer (COL-ADP cartridge) and PW assay (COL agonist using impedance platelet counts; ρ = 0.14). The PW assay percent aggregations using impedance and flow cytometric platelet counts were correlated for both ADP (ρ = 0.64) and COL (ρ = 0.64) agonists. Platelet function testing using these tests are feasible in cats, but 95% CIs are wide, so single results may be difficult to interpret. Platelet counting by impedance or flow cytometry may be used for the PW assay but are not interchangeable.

Isoniazid preventive therapy for tuberculosis in South Africa: an assessment of the local evidence base.

Worldwide, South Africa (SA) has the worst tuberculosis (TB) epidemic. In SA, there are > 6.1 million people living with HIV (PLWH) and the country now has the largest antiretroviral treatment programme with > 2 million people receiving combination therapy. While there has been a marked recent decline in HIV-associated deaths, > 50% of TB cases still continue to be diagnosed in PWLH. The current TB control strategy based on passive case finding, chemotherapy of childhood TB contacts and directly observed therapy has clearly failed to control endemic TB in SA. Two recent meta-analyses have shown a > 60% reduction in TB in HIV-infected adults after isoniazid preventive therapy (IPT). SA has implemented the World Health Organization policy and IPT is now recommended for HIV-positive people for up to 36 months. Originally, there was only one SA study included in the evidence base supporting this policy, but subsequently four randomised controlled trials have been conducted in SA populations. These studies, together with local observational studies, are the subject of this local, evidence-based review.

A dose and time response Markov model for the in-host dynamics of infection with intracellular bacteria following inhalation: with application to Francisella tularensis.

In a novel approach, the standard birth-death process is extended to incorporate a fundamental mechanism undergone by intracellular bacteria, phagocytosis. The model accounts for stochastic interaction between bacteria and cells of the immune system and heterogeneity in susceptibility to infection of individual hosts within a population. Model output is the dose-response relation and the dose-dependent distribution of time until response, where response is the onset of symptoms. The model is thereafter parametrized with respect to the highly virulent Schu S4 strain of Francisella tularensis, in the first such study to consider a biologically plausible mathematical model for early human infection with this bacterium. Results indicate a median infectious dose of about 23 organisms, which is higher than previously thought, and an average incubation period of between 3 and 7 days depending on dose. The distribution of incubation periods is right-skewed up to about 100 organisms and symmetric for larger doses. Moreover, there are some interesting parallels to the hypotheses of some of the classical dose-response models, such as independent action (single-hit model) and individual effective dose (probit model). The findings of this study support experimental evidence and postulations from other investigations that response is, in fact, influenced by both in-host and between-host variability.

A survey of training in pediatric flexible bronchoscopy.

OBJECTIVE: There is currently no evidence-based method for defining competency in pediatric flexible bronchoscopy (FB). Based on expert opinion, guidelines using numbers of procedures have been published in defining competency for pediatric FB. The purpose of this study was to formally survey the opinion of USA pediatric pulmonology training directors about the assessment of competency and training experiences in pediatric FB in their programs. METHODS: An Internet-based Survey Monkey™ of the Pediatric Pulmonary Training Directors Association (PEPTDA) was administered 10/12/10 through 11/1/10 with a supplemental survey 6/1/11-6/30/11. RESULTS: This survey of US pediatric pulmonology training directors about competency and training in pediatric FB showed that a majority (86%) felt there was a minimum threshold of procedures for developing competency that could be defined, with a median of 50 and an average of 56.4 (SD = 33.0). The actual number of FBs performed by fellows during their 3-year fellowship averaged 89.4 (SD = 45.3) with a range of 10-200. The survey also revealed a variety of teaching techniques used for FB, including simulation technology. Finally many differences were reported in skill assessment, locations for performance of FB, and the range of underlying indications and patient populations. The apprenticeship model is the predominant method of learning FB in the surveyed programs. CONCLUSIONS: A majority of US pediatric pulmonology training directors felt that a minimum number of procedures could be defined for developing competency in pediatric FB. There was variability in the numbers of procedures performed, training techniques and assessment, and application of FB. This survey represents an initial step in assessing training and defining competency in pediatric FB.

Moving from a universal to targeted child health programme: which children receive enhanced care? A population-based study using routinely available data.

BACKGROUND: There is a current emphasis on 'progressive universal' delivery of the UK child health programme, with a core universal service complemented by enhanced support provided according to need. In Scotland, a three-category indicator of need, the 'Health Plan Indicator' (HPI) is used to identify children requiring enhanced support from the child health programme to facilitate this. METHODS: Routine child health programme and hospital delivery records for a cohort of 36 871 Scottish children were used to explore the factors associated with being identified as requiring enhanced child health programme support using multilevel logistic regression modelling. RESULTS: The following factors were all independently associated with an increased likelihood of being assessed as requiring enhanced support: (i) deprivation; (ii) young maternal age, maternal smoking and drug misuse; (iii) a previous stillbirth; (iv) prematurity; (v) being small for gestational age; (vi) no breastfeeding, admission to a special care baby unit; and (vii) medical, social or developmental concerns about the baby. There was a tendency for children living in areas with higher Health Visitor staffing levels to be more likely to be assessed as requiring enhanced support but this effect was not statistically significant. There was significant residual variation between areas in the likelihood of children being assessed as requiring enhanced support. DISCUSSION: This study suggests Health Visitors take a complex range of factors into account when assessing which children require enhanced support from the child health programme. Health Visitors' workload may influence the likelihood of them identifying children as requiring enhanced support but this requires further clarification. There are clear differences between areas in allocation of the different HPI categories. Further work is required to explore the relationship between being identified as in need of enhanced support, the care actually provided to children, and their outcomes.

Catastrophe risk models for evaluating disaster risk reduction investments in developing countries.

Major natural disasters in recent years have had high human and economic costs, and triggered record high postdisaster relief from governments and international donors. Given the current economic situation worldwide, selecting the most effective disaster risk reduction (DRR) measures is critical. This is especially the case for low- and middle-income countries, which have suffered disproportionally more economic and human losses from disasters. This article discusses a methodology that makes use of advanced probabilistic catastrophe models to estimate benefits of DRR measures. We apply such newly developed models to generate estimates for hurricane risk on residential structures on the island of St. Lucia, and earthquake risk on residential structures in Istanbul, Turkey, as two illustrative case studies. The costs and economic benefits for selected risk reduction measures are estimated taking account of hazard, exposure, and vulnerability. We conclude by emphasizing the advantages and challenges of catastrophe model-based cost-benefit analyses for DRR in developing countries.

The importance of understanding epidemiology in order to inform financial decisions: a lesson from the Scottish Home Oxygen Service.

OBJECTIVES: To ensure that decisions on the future planning of the Scottish Home Oxygen Service reflect population needs by examining the epidemiology of the main conditions that require home oxygen therapy and trends in their management. STUDY DESIGN: Analysis of routinely available vital event and health service data supplemented by published literature. Use of linked data to provide person-based analyses. METHODS: Consideration of trends in key risk factors, disease incidence, prevalence and mortality for chronic neonatal lung disease, cystic fibrosis, chronic interstitial lung disease in adults and chronic obstructive pulmonary disease. Examination of trends in management of these conditions including hospital admissions, length of stay and re-admissions. RESULTS: The prevalence of all the conditions studied has increased in Scotland over recent years due to a combination of increased incidence, increased survival, more active case finding and demographic changes. There have been changes in management with trends towards shorter hospital stays. CONCLUSIONS: The clinical need for home oxygen therapy is likely to continue to increase over the next 10-20 years. It will encompass all age groups and a complex range of conditions. Public health needs to be proactive in providing relevant needs assessment information to ensure that planning within financial constraints is appropriately informed on population needs.

Incentivized recruitment of a population sample to a mobile HIV testing service increases the yield of newly diagnosed cases, including those in need of antiretroviral therapy.

OBJECTIVE: The aim of the study was to compare the yields of newly diagnosed cases of HIV infection and advanced immunodeficiency between individuals attending a mobile HIV counselling and testing (HCT) service as participants in a population-based HIV seroprevalence survey and those accessing the same service as volunteers for routine testing. METHODS: The study was conducted in a peri-urban township within the Cape Metropolitan Region, South Africa. Survey participants (recruited testers) were randomly selected, visited at home and invited to attend the mobile HCT service. They received 70 South African Rand food vouchers for participating in the survey, but could choose to test anonymously. The yield of HIV diagnoses was compared with that detected in members of the community who voluntarily attended the same HIV testing facility prior to the survey and did not receive incentives (voluntary testers). RESULTS: A total of 1813 individuals were included in the analysis (936 recruited and 877 voluntary testers). The prevalence of newly diagnosed HIV infection was 10.9% [95% confidence interval (CI) 9.0-13.1%] among recruited testers and 5.0% (3.7-6.7%) among voluntary testers. The prevalence of severe immune deficiency (CD4 count ≤ 200 cells/ µL) among recruited and voluntary testers was 17.8% (10.9-26.7%) and 4.6% (0.0-15.4%), respectively. Linkage to HIV care in recruited testers with CD4 counts ≤ 350 cells/ µL was 78.8%. CONCLUSION: Compared with routine voluntary HCT, selection and invitation in combination with incentives doubled the yield of newly diagnosed HIV infections and increased the yield almost fourfold of individuals needing antiretroviral therapy. This may be an important strategy to increase community-based HIV diagnosis and access to care.

A qualitative assessment of perspectives on the inclusion of adolescents in HIV vaccine trials in South Africa.

Adolescents are at high risk for HIV acquisition, and thus need to be included in HIV vaccine trials. In preparation for inclusion of adolescents in HIV vaccine trials in an urban community in Cape Town with a high antenatal HIV prevalence, the study assessed the attitudes towards the inclusion of adolescents in HIV vaccine trials. A total of 18 focus group discussions were conducted using a semistructured interview guide. The participants (n = 200) were adolescents, young adults, parents and other key informants. Participants from all groups welcomed the inclusion of adolescents in HIV vaccine trials due to their high-risk status. There were, however, concerns about sexual disinhibition, fear of side-effects, fear of HIV testing and disclosure of HIV status, mistrust of nurses and clinics. The study highlighted a number of ethical and social issues that need to be addressed before the trials.

Morphological features of advanced hepatocellular carcinoma as a predictor of downstaging and liver transplantation: an intention-to-treat analysis.

In selected patients, locoregional therapy (LRT) has been successful in downstaging advanced hepatocellular carcinoma (HCC) so that the conventional criteria for liver transplantation (LT) can be met. However, the factors that predict successful treatment are largely unidentified. To determine these factors, we analyzed our experience with multimodal LRT in downstaging advanced HCC before LT in a retrospective cohort study. Thirty-two patients with advanced HCC exceeding conventional and expanded criteria for LT underwent therapy, but only those patients whose tumors were successfully downstaged were considered for LT. Eighteen patients (56%) had their tumors successfully downstaged; 14 patients (44%) did not. No intergroup differences existed with respect to patient characteristics or the types and number of treatments. However, mean alpha-fetoprotein levels were significantly higher in the non-downstaged group than in the downstaged group (P < 0.048), and significantly more patients in the non-downstaged group had infiltrative tumors (P = 0.0001). The median survival time was 42 and 7 months for the downstaged and non-downstaged groups, respectively (P = 0.0006). Fourteen patients (43.3%) underwent LT. After a median follow-up period of 35 months (range, 1.5-50 months) after LT, 2 patients (14.2%) developed tumor recurrence. The Kaplan-Meier survival rates after LT were 92% at 1 year and 75% at 2 years. The noninfiltrative expanding tumor type was the sole predictor of successful downstaging and improved outcome on univariate and multivariate analyses. Our study suggests that, in patients with advanced HCC, morphological characteristics of the tumor may predict a good response to downstaging and an improved outcome after LT.

Fertility needs and funding in couples with blood-borne viral infection.

BACKGROUND: Couples infected with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are increasingly seeking assisted conception. These couples avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for safe conception. For many couples, access to such services is restricted on ethical, geographical and financial grounds. OBJECTIVE: The aim of the study was to assess the fertility needs, geographical origin and state funding of patients with blood-borne viral infection. METHODS: A retrospective review of the medical records of couples referred for fertility treatment between January 1999 and December 2006, where one or both partners were infected with HIV, HBV and/or HCV, was carried out. RESULTS: Of the 205 couples included in the study, 44% lived in London, 51% came from elsewhere in the United Kingdom and 5% travelled from outside the United Kingdom to seek treatment. Genitourinary medicine clinics were the main source of referral. 85.8% of couples had HIV infection, 15.1% were infected with HBV and 13.6% had HCV infection. Fertility screening identified a high incidence of male factor infertility (33.3%) in HIV-infected men and tubal disease (40.8%) in HIV-infected women. Only 23.6% of HIV-infected couples, 20% of HBV-infected couples and 12.5% of HCV-infected couples obtained state funding for assisted conception. CONCLUSION: Fertility screening identified a high incidence of male and tubal factor subfertility among couples living with HIV, HBV and HCV. Limited access to specialist clinics equipped to cater for these couples and restricted funding may impact negatively on couples obtaining risk-reducing assisted reproduction treatment. This may have long-term public health implications as individuals attempt to conceive through unprotected intercourse.