Liver Transplantation for Severe Alcoholic Hepatitis: Report of a Single Center Pilot Program.

BACKGROUND: Liver transplantation (LT) can significantly improve mortality for severe alcoholic hepatitis (AH). However, this practice remains controversial. Our aim is to report the findings from our institution regarding outcomes for LT in severe AH and to discuss the results of a pilot program for discharging selected patients with close follow-up, in order to demonstrate sustained outpatient sobriety before listing. METHODS: Patient records were reviewed retrospectively from January 1, 2015 to January 17, 2018. The primary outcomes were patient and graft survival after LT. Secondary outcomes included relapse rates after LT, survival for those not transplanted, and reasons for denial among those not approved for transplant listing. RESULTS: A total of 18 patients with severe AH were considered for LT, of which 10 were transplanted and 8 were either denied transplantation or died before completing the evaluation. Patient and graft survival rates were 100% among those transplanted, and only 1 of the 10 patients (10%) returned to harmful drinking. In comparison, 6 of 8 (75%) of patients not transplanted died. Among the 10 patients transplanted, 4 were initially not approved for listing and were discharged with close follow-up, to demonstrate outpatient sobriety. All 4 of those patients demonstrated short-term abstinence and ultimately underwent transplantation, with no instances of relapse post-LT. CONCLUSIONS: Liver transplantation for AH can achieve excellent outcomes with low rates of relapse. Carefully selected patients can be discharged with close monitoring to demonstrate commitment to outpatient sobriety prior to transplant listing.

First Look: One Year Since Inception of Regional Share 35 Policy.

BACKGROUND: More than 10,000 patients are awaiting liver transplantation, and more than 1300 die waiting yearly. The Share 35 policy was implanted 1 year ago with expectations to decrease waitlist mortality. The purpose of our study was to look at waitlist outcomes and organ usage. METHODS: We compared data from the United Network of Organ Sharing before and after the initiation of Share 35, looking at waitlist mortality, organs shared with Model for End-Stage Liver Disease (MELD) score ≥ 35, organ discards, travel distance, cold ischemia time, MELD score at transplantation, donor characteristics, and waitlist times. The χ(2) test was used to compare the data from two time periods. RESULTS: Comparing the 1-year periods, we found no change in waitlist mortality rate; transplants in MELD score ≥ 35 increased from 19% to 27% and decreased in MELD score 15 to 34 from 74% to 67%; high-risk donors increased from 13% to 17%; and a 40% decrease in time on the waitlist before removal because of death from 58 to 35 days. CONCLUSIONS: One year since Share 35, there has been no change in waitlist mortality rate. Unfortunately, it will take several years to know the impact of Share 35 on changes in patient life-years saved.

Systematic review with meta-analysis: the proportion of chronic hepatitis B patients with normal alanine transaminase ≤ 40 IU/L and significant hepatic fibrosis.

BACKGROUND: Chronic hepatitis B (CHB) may lead to cirrhosis, hepatocellular carcinoma and premature death. Elevated alanine transaminase (ALT) levels ≥ the upper limit of normal (ULN) are a major determinant for initiating anti-viral therapy; however, ALT levels alone may not be predictive of hepatic fibrosis. AIM: To determine the proportion of CHB patients with ALT ≤ 40 IU/L and liver fibrosis stage ≥ 2. Secondary goals include subgroup analysis by hepatitis B e antigen (HBeAg) status, high hepatitis B virus (HBV) DNA levels, Asian ethnicity, lower ULN of ≤ 30 IU/L (males) and 19 IU/L (females), and advanced age. METHODS: Studies identified in EMBASE and MEDLINE (1/1990-6/2012) using the search criteria: "Hepatitis B"[Mesh] OR "Hepatitis B virus"[Mesh] OR "Hepatitis B, Chronic"[Mesh])) AND "Alanine Transaminase"[Mesh]) and abstracts containing the term 'hepatitis' from recent major U.S. gastroenterology and liver society meetings were considered. RESULTS: Among nine studies (N = 830 patients), a significant proportion (20.7%; 95% CI: 16.2-26.0%) of CHB patients with ALT levels ≤ 40 IU/L had significant fibrosis irrespective of HBeAg status, high HBV DNA levels, ethnicity or age, although this proportion may be higher in patients older than 30-40 years old. The corresponding proportion was 27.8% even when the newer ULN of 30 IU/L (males) and 19 IU/L (females) was applied. CONCLUSIONS: Approximately one fifth of CHB patients with ALT ≤ 40 IU/L may have significant hepatic fibrosis. The approach to such patients should be individualised, as further evaluation and treatment may be appropriate.

Prospective study of risk factors for hepatitis C virus acquisition by Caucasian, Hispanic, and Asian American patients.

Commonly known risk factors for infection with hepatitis C virus (HCV) include blood transfusion, injection drug use, intranasal cocaine use, and body tattoos. We hypothesized that Asian Americans infected with HCV may not identify with these established risk factors present in Caucasians and Hispanics, and our aim was to conduct a survey of risk factors in HCV-infected patients in these ethnic groups. In this prospective study, 494 patients infected with HCV completed a detailed risk assessment questionnaire at a liver centre in Northern California from 2001 to 2008. Among subjects participating in this study, 55% identified themselves as Caucasian, 20% as Hispanic, and 25% as Asian. Asian Americans were older, less likely to smoke or consume alcohol, and have a family history of cancer compared with Caucasians and Hispanics. The laboratory profiles were similar, and genotype 1 was the most common infection in all groups (74-75%). The great majority of Caucasians (94%) and Hispanics (86%) identified with commonly known risk factors, which was in contrast to 67% of Asians (P < 0.0001). The most common risk factors in Asians were blood transfusions (50%) and acupuncture (50%). Furthermore, 74% of Caucasians and 66% of Hispanics identified more than one major risk factor, while only 20% of Asians reported having more than one risk factor (P < 0.0001). Survey for established risk factors for acquisition of HCV may be more appropriate for risk assessment of Caucasians and Hispanics, but not for Asian Americans. These findings may guide the development of HCV screening in our increasingly diverse population.

Review article: current antiviral therapy of chronic hepatitis B.

BACKGROUND: The indications and endpoints for treatment of chronic hepatitis B continue to evolve. The aim of the therapy for chronic hepatitis B is to achieve a long-term continued suppression of the hepatitis B virus (HBV) DNA to prevent disease progression leading to the development of cirrhosis and hepatocellular carcinoma. AIM: To summarise current literature on therapy of chronic hepatitis B, with a focus on indications for therapy, preferred treatment options, and management of resistance and partial responders. METHODS: A systematic review of the literature, with a focus on international guidelines, was performed. RESULTS: Seven drugs are licensed for the treatment of chronic hepatitis B in many countries. The selection of a drug with high potency and low rate of resistance is essential to achieve rapid and long-term viral suppression. The prevention of the sequelae of antiviral drug resistance and appropriate management of viral breakthrough are major goals of current management. The addition or change to an antiviral agent that is not cross-resistant is critical to restore suppression of viral replication for patients with breakthrough resistance. Patient adherence to medication is essential to achieve adequate HBV DNA suppression. CONCLUSIONS: The current treatment strategy of chronic hepatitis B is now standard: initial selection of entecavir, tenofovir, or peginterferon alfa-2a. Future studies are required to determine if combination therapy using two oral agents or peginterferon with an oral agent with a high genetic barrier to resistance might be superior to standard current monotherapy.

Cannabis, tobacco and domestic fumes intake are associated with nasopharyngeal carcinoma in North Africa.

BACKGROUND: The lifestyle risk factors for nasopharyngeal carcinoma (NPC) in North Africa are not known. METHODS: From 2002 to 2005, we interviewed 636 patients and 615 controls from Algeria, Morocco and Tunisia, frequency-matched by centre, age, sex, and childhood household type (urban/rural). Conditional logistic regression was used to evaluate the association of lifestyles with NPC risk, controlling for socioeconomic status and dietary risk factors. RESULTS: Cigarette smoking and snuff (tobacco powder with additives) intake were significantly associated with differentiated NPC but not with undifferentiated carcinoma (UCNT), which is the major histological type of NPC in these populations. As demonstrated by a stratified permutation test and by conditional logistic regression, marijuana smoking significantly elevated NPC risk independently of cigarette smoking, suggesting dissimilar carcinogenic mechanisms between cannabis and tobacco. Domestic cooking fumes intake by using kanoun (compact charcoal oven) during childhood increased NPC risk, whereas exposure during adulthood had less effect. Neither alcohol nor shisha (water pipe) was associated with risk. CONCLUSION: Tobacco, cannabis and domestic cooking fumes intake are risk factors for NPC in western North Africa.

Transarterial chemoinfusion for hepatocellular carcinoma as downstaging therapy and a bridge toward liver transplantation.

Favorable outcomes after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are well described for patients who fall within defined tumor criteria. The effectiveness of tumor therapies to maintain tumor characteristics within these criteria or to downstage more advanced tumors to fall within these criteria is not well understood. The aim of this study was to examine the response to transcatheter arterial chemoinfusion (TACI) in HCC patients awaiting LT and its efficacy for downstaging or bridging to transplantation. We performed a retrospective study of 248 consecutive TACI cases in 122 HCC patients at a single U.S. medical center. Patients were divided into two groups: those who met the Milan criteria on initial HCC diagnosis (n = 95) and those with more advanced disease (n = 27). With TACI treatment, 87% of the Milan criteria group remained within the Milan criteria and 63% of patients with more advanced disease were successfully downstaged to fall within the Milan criteria. In conclusion, TACI appears to be an effective treatment as a bridge to LT for nearly 90% patients presenting within the Milan criteria and an effective downstaging modality for over half of those whose tumor burden was initially beyond the Milan criteria.

Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments.

UNLABELLED: To determine whether a process redesign could improve detection and treatment of osteoporosis, at-risk women over the age of 65 were identified using an electronic medical record and proactively contacted by letter and phone call. This resulted in a significant increase in testing for osteoporosis by DXA scan. The high-risk patients were then offered a shared medical appointment, which resulted in improved treatment outcomes compared to usual care. INTRODUCTION: Our objective was to determine if redesigning care through proactive contact with women 65 at-risk of osteoporosis increased BMD testing and to determine if a shared medical appointment (SMA) improved treatment for high-risk women. METHODS: Two primary care sites received the redesign intervention and two other sites served as the usual care controls. At the intervention sites, all women 65 who had not had a DXA scan performed in the prior 2 years were contacted by mail and phone calls. High-risk patients were invited to attend a SMA or follow-up visit with their primary physician. RESULTS: A significantly higher proportion of women at the intervention sites had a DXA (39.6% vs. 13.2%, p < 0.0001). Patients who attended the SMA were more likely to have calcium and vitamin D recommended, a vitamin D level checked, and receive a prescription medicine than those patients who had follow-up with their primary care physician. CONCLUSIONS: The redesigned process was highly effective in improving BMD testing for women 65. The SMA was shown to be a more effective method to make calcium and vitamin D recommendations, to evaluate secondary causes of low bone density, and to prescribe prescription medications, compared to usual care with the PCP.

[The tobacco cessation consultation of the Salah-Azeiz Tunis cancer center: one year results]. / La consultation d'aide au sevrage tabagique de l'institut de cancérologie Salah-Azeiz de Tunis : résultats à un an.

BACKGROUND: To reduce tobacco smoking is, in Tunisia, a public health priority. The tobacco cessation consultation is one of the interventions to fight against the tobacco epidemic; it is a new activity developed in the Salah-Azeiz Tunis cancer centre. The objective of this work is to evaluate the impact of the consultation on the smokers after one year of activities and to analyse the prognostic factors of tobacco cessation in order to improve the efficacy of such an activity in the future, in Tunisia. METHODS: The cessation methods were based on cognitive and behavioral therapies associated with nicotine patch, delivered free of charge. During one year (July 2003 to June 2004), 340 smokers were attended. Data on their smoking status and psychological characteristics were collected using a standardized questionnaire. RESULTS: The patients were mostly men (79%), these smokers did not present important anxiety-depressive troubles, 68% thought that they were able to quit easily. The majority (57%) smoked more than 20 cigarettes a day and was nicotine-dependent (Fagenström >7). Half of this population had already intended to stop, they declared to smoke mostly because of stress. The global cessation rate after a median follow-up of 32 weeks is 27%. The cessation rate lasting six months for 83 patients followed regularly was 23%. The good prognostic factors of cessation, after multivariate analysis, were (when taking out from the model the regular follow-up), to be confidant on the possibility to stop (OR=0.87 [0.78-0.97]). On the contrary, a high score (>7) for Fagerström test (OR=1.9 [1.1-3.4), the use of smoking to fight against stress (OR=1.08 [1.0-1.2) and a smoking environment at home (OR=4.5 [1.1-18.9]) were prognostic of a failure in quitting smoking. CONCLUSION: These results show that the cessation rate, which is still too low as compared with the literature, could be increased by a better follow-up of smokers associated with an information campaign on the existing possibilities to quit smoking in Tunisia.

Review article: current antiviral therapy of chronic hepatitis B.

BACKGROUND: The long-term goals of therapy for chronic hepatitis B are to reduce serum HBV DNA to low or undetectable levels and ultimately reduce or prevent the development of cirrhosis and hepatocellular carcinoma. AIM: To review the current treatment of chronic hepatitis B, with a focus on diagnosis and management of resistance and active management of suboptimal responses. METHODS: A systematic review of the literature, with a focus on recent guidelines, was undertaken. RESULTS: Among the six drugs licensed for the treatment of chronic hepatitis B in the US, the preferred agents in 2008 will include entecavir, peginterferon alfa-2a, possibly telbivudine, and tenofovir following licensure. When using an oral agent, a major focus of management is on the selection of a drug with high potency and low rate of resistance, and active on-treatment management to optimize therapy. Preventing the sequelae of antiviral drug resistance and appropriate management when resistance is initially detected are also the major focus of current management. The addition of an antiviral agent that is not cross-resistant is critical to restore suppression of viral replication. CONCLUSIONS: Newer agents and modified treatment strategies, especially using combination therapy, hold promise to optimize the management of patients with chronic hepatitis B by achieving the high potency and the lowest rate of resistance.

Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years.

A 5 year observational study is reported which reviews the implementation of the Geisinger Health System Osteoporosis Disease Management Program. This program includes Osteoporosis Clinical Practice Guidelines, physician and allied health care provider education, community education, and a bone density testing program. All women over the age of 55 years enrolled in the Geisinger Health Plan (GHP) from 1996 to 2000 were included in this analysis. The guidelines led health care providers to increase the evaluation of osteoporosis via bone density measurements and to increase the prescription treatment of osteoporosis. Most importantly, the age-adjusted incidence of hip fractures fell significantly in the entire group as well as in several age strata (65-74, 75-84 and 85+ years). Compared with a predictive model of no intervention, there was an overall reduction in health care costs to GHP estimated to be US$7.8 million over a 5 year period. This report is the first to suggest that an organized Osteoporosis Disease Management Program delivered by a health care system can result in increased evaluation and treatment of osteoporosis with a resultant significant decrease in hip fractures while decreasing the total direct costs of care to a health plan.

Polymyalgia rheumatica. Duration of therapy and long-term outcome.

The duration of therapy and outcome were examined in 76 patients with polymyalgia rheumatica without evidence of temporal arteritis at presentation. Seventy-five patients received corticosteroids, with a mean prednisone dosage of 22.8 mg per day initially. Duration of therapy was assessed using life-table methods. No significant difference could be ascertained between groups segregated on the basis of age, sex, or initial steroid dosage. The median duration of therapy was 37.3 months. It was estimated that 40 percent of patients will require therapy longer than four years. Corticosteroids were permanently discontinued in 31 patients after a mean of 23.7 months of therapy. The data support the concept of two patient populations--one with limited disease and another requiring long-term therapy. Relapses were frequent, occurring in 56 percent of patients. Evolution of arteritis during the course of therapy was infrequent, occurring in only one patient. Steroid-related adverse effects occurred in 22.7 percent of patients and were more common in females. The data suggest that, although corticosteroids may be discontinued in some patients with polymyalgia rheumatica, prolonged therapy is required in a significant number.