Engagement in Care of High-Risk Hepatitis C Patients with Interferon-Free Direct-Acting Antiviral Therapies.

BACKGROUND AND AIMS: The extent to which hepatitis C (HCV) treatment uptake is improved following introduction of interferon-free direct-acting antiviral (DAA) treatments is unknown. The purpose of this study was to determine HCV patient engagement and barriers to care for accessing DAA treatments in a real-world setting. METHODS: Patients with HCV viremia at high risk for fibrosis were identified using the Veterans Affairs (VA) registry within San Diego's VA in October 2014. Patients not enrolled in HCV clinic were systematically contacted by letter and phone. Logistic regression was used to examine patient factors associated with subsequent engagement in care over 12-20 months. RESULTS: In the local registry of 2089 patients, 481 were identified with high-risk fibrosis scores. Of those, 380 (79%) were eligible for antiviral treatment, and 178/380 (47%) patients were actively followed in clinic. The remaining 202/380 (53%) patients were never seen by a HCV clinic provider or lost to follow-up. Of these, 114/380 (30%) of the treatment-eligible cohort remained non-engaged in care following outreach. Compared with patients engaged in care, non-engaged patients were significantly more likely to have homelessness, COPD comorbidity, or active alcohol or/and drug use. Overall 74.4% of patients engaged in HCV clinic received antiviral treatment. CONCLUSIONS: A significant portion of eligible HCV patients could not be engaged in treatment after a programmatic outreach effort. These data indicate that more sustained or innovative outreach efforts are needed in order to maximize treatment access, with specific interventions targeting those with unstable housing and active alcohol/substance use disorders.

Outcomes of interventional ERCP in hereditary pancreatitis.

GOALS: To clinically evaluate the patients with hereditary pancreatitis (HP) before the first, after the first and last interventional endoscopic retrograde cholangiopancreatography (ERCP), and at follow-up. BACKGROUND: There are limited data evaluating the outcomes and role of interventional ERCP in HP. STUDY: Between 1990 and 2008, 21 consecutive patients with HP were retrospectively assessed for response to therapeutic ERCP. Medical records were reviewed and a telephone survey was conducted to obtain information. RESULTS: Patients underwent a total of 87 interventional ERCPs (mean 4, range: 1 to 11) and were followed-up for a mean period of 5 years (2 to 212 mo) from the last ERCP. The mean age at diagnosis, first ERCP, and follow-up was 15, 19, and 27 years (2 to 39 y), respectively. Eleven of 12 patients (92%) who received surgical therapy required subsequent interventional ERCPs. Before and after first ERCP mean pain scores decreased from 8.3 to 3.2 (P=0.001) and after last ERCP scores decreased to 2.7 (P=0.001). Yearly hospital visits including urgent care and emergency room visits decreased from 5.7 to 1.9 (P<0.001) and then to 1.6 (P=0.001). Daily oxycodone equivalent usage decreased from 39 to 34 mg (P=0.7) and then to 9.4 mg (P=0.05). Complications included pancreatitis in 3% with no perforations, bleeding, or infection. CONCLUSIONS: Despite decompressive or resective surgeries in 12 of 21 patients, the majority (92%) developed subsequent complications and required endoscopic therapy. Endoscopic management for amenable lesions often requires multiple ERCPs. Interventional ERCPs in patients with HP is associated with decreased pain, analgesic usage, hospitalizations, and episodes of recurrent pancreatitis.

Phenotypic characteristics and diagnoses of patients referred to an iron overload clinic.

BACKGROUND: There are limited data on the phenotypic differences between patients with hereditary hemochromatosis (HH) and other forms of iron overload. AIMS: To describe and compare patients suspected of having iron overload disease. METHODS: Patients were evaluated at a university iron overload clinic over a 5-year period. Biochemical and clinical profiles of patients with HH and non-HH causes of suspected iron overload were retrospectively compared. RESULTS: A total of 270 patients were evaluated during the enrollment period, and 137 (51%) were diagnosed with HH. The most common reasons for referral were elevated serum iron markers (155 patients), followed by positive family history (40 patients), and known HH (75 patients). In patients without HH referred for suspected iron overload, the most common diagnoses were nonalcoholic fatty liver disease (NAFLD) (24%), chronic hepatitis C infection (14%), and alcohol related liver disease (9%). Of the patients with HH, 108 were C282Y homozygotes, 20 were compound heterozygotes (C282Y/H63D), and nine had neither mutation. The following clinical characteristics were significantly different (p < 0.05) between patients with HH and all other referred patients: arthralgia (42 vs. 16%) and decreased libido (11 vs. 4%). There was a non-significant trend towards increased fatigue (44 vs. 33%), diabetes (10 vs. 6%), impotence (8 vs. 4%), and hypothyroidism (10 vs. 6%) in the HH group. CONCLUSIONS: (1) A large proportion of patients referred for suspected iron overload have diagnoses other than HH. (2) NAFLD, chronic hepatitis C, and chronic alcohol use were the most common alternative diagnoses. (3) Arthralgia and fatigue are the most common symptoms among patients with HH.