Overcome Health Inequities to Eliminate Viral Hepatitis.

This Viewpoint outlines the progress made toward eliminating hepatitis B and C but emphasizes the work that remains to prioritize diagnosis and treatment of populations disproportionately affected by viral hepatitis, including ensuring that there are systems in place to treat those infected and care for those at risk.

Aspectos que fragilizam o acesso das pessoas com hepatites virais aos serviços de saúde / Aspectos que debilitan el acceso de la persona com hepatitis virales a la atención em servicios de salud / Aspects that weaken access of people with viral hepatitis to healthcare services

Resumo Objetivo analisar os aspectos que fragilizam o acesso à atenção às hepatites virais. Método pesquisa avaliativa, desenvolvida no Estado de Mato Grosso, com os gestores da Secretaria de Estado de Saúde e os profissionais dos serviços de referência. Para a coleta de dados realizaram-se entrevistas, utilizou-se a Análise de Conteúdo, na vertente temática e, para a discussão as dimensões do modelo de análise de acesso universal aos serviços de saúde. Resultados a dimensão política apresenta pouca participação da gestão federal e estadual na proposição de diretrizes, coordenação e pactuação. Na dimensão econômico-social o baixo investimento na rede pública e a dificuldade de fixação de profissionais especialistas. Na dimensão organizacional a regulação do acesso, da assistência e a logística do tratamento sofrem com as barreiras geográficas, além do baixo uso do monitoramento e a avaliação. Na dimensão técnica a pouca formação profissional e a ausência de projeto compartilhado em rede. Na dimensão simbólica os fatores culturais, de crença, valores e subjetividade interferem no acesso. Conclusão e implicações para a prática os resultados colaboram para direcionar ações de enfrentamento, almejando alcançar as metas pactuadas para a Agenda 2030.

Resumen Objetivo analizar los aspectos que debilitan el acceso a la atención a las hepatitis virales. Método investigación evaluativa, desarrollada en el Estado de Mato Grosso, con los gestores del Departamento de Salud del Estado y los profesionales de los servicios de referencia. Para la recolección de datos fueron realizadas entrevistas, se utilizó el Análisis de Contenido, en el aspecto temático, y para discutir las dimensiones del modelo de análisis de acceso universal a los servicios de salud. Resultados la dimensión política presenta poca participación de la administración federal y estatal en la propuesta de lineamientos, coordinación y acuerdo. En la dimensión económico-social la baja inversión en la red pública y dificultad para fijar profesionales especializados. En la dimensión organizacional, la regulación de la logística de acceso, asistencia y tratamiento sufren con las barreras geográficas, además del bajo uso de monitoreo y evaluación. En la dimensión técnica poca formación y ausencia de proyecto compartido en red. En la dimensión simbólica los factores culturales, la creencia, los valores y la subjetividad interfieren en el acceso. Conclusión e implicaciones para la práctica los hallazgos colaboran para reflejar las acciones de afrontamiento destinadas a alcanzar los objetivos acordados para la Agenda 2030.

Abstract Objective to analyze the aspects that weaken the access to viral hepatitis care. Method evaluative research, developed in the State of Mato Grosso, with managers of the State Health Department and professionals from reference services. For data collection, interviews were conducted. Content analysis was used in a theme-based approach and, for the discussion, the dimensions of the analysis model of universal access to health services. Results The political dimension presents little participation of federal and state management in the proposition of guidelines, coordination, and pacts. In the economic-social dimension, the low investment in the public network and the difficulty in hiring specialist professionals were identified. In the organizational dimension, the regulation of access, assistance, and the logistics of treatment suffers from geographic barriers, besides the low use of monitoring and evaluation. In the technical dimension, the little professional training and the absence of a shared network project were noticed. In the symbolic dimension, cultural factors, beliefs, values, and subjectivity interfere with access. Conclusion and implications for the practice the results collaborate to direct confrontation actions, aiming to reach the goals agreed upon for the 2030 Agenda

Effects of COVID-19 Pandemic Response on Service Provision for Sexually Transmitted Infections, HIV, and Viral Hepatitis, England.

Since the coronavirus disease pandemic response began in March 2020, tests, vaccinations, diagnoses, and treatment initiations for sexual health, HIV, and viral hepatitis in England have declined. The shift towards online and outreach services happened rapidly during 2020 and highlights the need to evaluate the effects of these strategies on health inequalities.

T and NK Cell-Based Immunotherapy in Chronic Viral Hepatitis and Hepatocellular Carcinoma.

In chronic viral hepatitis and in hepatocarcinoma (HCC), antigen-specific T cells are deeply exhausted, and evidence of dysfunction has also been observed for NK cells, which can play a pathogenetic role, exerting a regulatory activity on adaptive immune responses [...].

Repercussões da pandemia por Covid-19 nos serviços de referência para atenção às hepatites virais / Repercussions of the Covid-19 pandemic on referral services for viral hepatitis care

Resumo Estudo com objetivo de analisar, segundo a perspectiva de gestores e profissionais de saúde, as repercussões da pandemia por Covid-19 para os serviços de referência às hepatites virais no estado de Mato Grosso. Trata-se de pesquisa avaliativa, em abordagem descritiva de dados qualitativos, coletados por meio de entrevistas semiestruturada. A análise temática resultou em duas categorias: "Pandemia de Covid-19 e fragilidades na atenção às hepatites virais" e "Desafios da gestão na atenção às hepatites virais agravados pela pandemia". Constatou-se dificuldades de organização e implementação de estratégias para favorecer o cuidado, durante a pandemia, por ter redução no serviço administrativo na gestão estadual, ausência de diretrizes para os serviços e limitação no quantitativo de profissional, além da necessidade de remanejamento para atendimento a Covid-19. Os desafios postos pela gestão incluem a prioridade de ações estratégicas para aumentar a testagem e oportunizar acesso aos serviços de referência. Entretanto, a rotatividade de gestores e quantitativo de profissionais repercute no enfrentamento às hepatites. A organização da rede de atenção precisa avançar na governança das ações e serviços e em rearranjos organizacionais capazes de permitir respostas mais rápidas nos fluxos da atenção.

Abstract Study carried out with the objective of analyzing the repercussions of the Covid 19 pandemic on reference services for viral hepatitides in the state of Mato Grosso from the perspective of managers and health professionals. This is an evaluative research with a descriptive approach of qualitative data through semi-structured interviews. The thematic analysis resulted in two categories: "Covid-19 pandemic and weaknesses in viral hepatitis care" and "Management challenges in viral hepatitis care aggravated by the pandemic". The study found difficulties in organizing and implementing care strategies during the pandemic due to the reduction in the state administrative service, in addition to the absence of guidelines to perform the services and limitation in the number of professionals; also, due to the need for relocation to face the Covid 19 pandemic. Management challenges include prioritizing strategic actions in order to increase testing and provide access to reference services. The turnover of managers and the number of professionals have repercussions on coping with hepatitides. It is necessary to organize the care network with the objective of advancing actions and services that allow faster responses in care flows.

Advanced Nanotheranostics of CRISPR/Cas for Viral Hepatitis and Hepatocellular Carcinoma.

Liver disease, particularly viral hepatitis and hepatocellular carcinoma (HCC), is a global healthcare burden and leads to more than 2 million deaths per year worldwide. Despite some success in diagnosis and vaccine development, there are still unmet needs to improve diagnostics and therapeutics for viral hepatitis and HCC. The emerging clustered regularly interspaced short palindromic repeat/associated proteins (CRISPR/Cas) technology may open up a unique avenue to tackle these two diseases at the genetic level in a precise manner. Especially, liver is a more accessible organ over others from the delivery point of view, and many advanced strategies applied for nanotheranostics can be adapted in CRISPR-mediated diagnostics or liver gene editing. In this review, the focus is on these two aspects of viral hepatitis and HCC applications. An overview on CRISPR editor development and current progress in clinical trials is first given, followed by highlighting the recent advances integrating the merits of gene editing and nanotheranostics. The promising systems that are used in other applications but may hold potentials in liver gene editing are also discussed. This review concludes with the perspectives on rationally designing the next-generation CRISPR approaches and improving the editing performance.

La hepatitis viral y los métodos dialíticos / Viral hepatitis and the dialytic methods

RESUMEN Se realizó un acercamiento teórico al problema actual de la hepatitis viral y los métodos dialíticos -desde el enfoque de la ciencia, la tecnología y la sociedad-, con el objetivo de resaltar la importancia de su prevención en los pacientes de riesgo. Se analizó cómo el desarrollo alcanzado por la ciencia, en particular en el campo de la Medicina, y el enorme avance tecnológico, permiten el empleo de medidas de soporte vital, como los métodos dialíticos de depuración extrarrenal. Pero, con ello, existe el alto riesgo de transmisión de la hepatitis como infección nosocomial, problema social al que urge buscar soluciones (AU).

ABSTRACT The authors theoretically approached the current problem of viral hepatitis and the dialytic methods -from the point of view of science, technology and society-, with the objective of pointing up the importance of its prevention in risk patients. They analyzed how the great development of the science, particularly in the field of medicine, and the enormous technological advance allow the usage of life support measures, like the dialytic methods of extra renal depuration. But, it involves a high risk of hepatitis transmission as nosocomial infection, a social problem that has to be urgently solved (AU).

Capacity building of healthcare workers: Key step towards elimination of viral hepatitis in developing countries.

BACKGROUND: Lack of awareness about viral hepatitis (VH) potentially predisposes the healthcare workers (HCWs) to a higher risk of infection and may in turn increase the risk of transmission of the infection to their families and in the community. Thus, combating VH, requires adequate and updated training to the HCWs. With this objective, Project PRAKASH designed a meticulously planned training program, aimed to assess the effect of a one-day training on VH among in-service nurses. METHODS AND MATERIAL: The content and schedule of scientific sessions of the training program were decided by subject experts to improve knowledge, attitude and practice(KAP) related to VH among in-service nurses. A 54-item questionnaire divided into four domains: Transmission and Risk Factors; Prevention; Treatment; Pathophysiology and Disease Progression were used to assess the KAP related to VH. The questionnaire consisted of four sections: demographic details, knowledge(30-items), attitude(12-items) and practice(12-itmes) with a total score of 30, 60 and 24 respectively in each section. The pre-post knowledge assessment was done and impact assessment survey was undertaken among the participants who completed six months post-training period. Paired-t-test was used to assess the effect of training on knowledge using SPSSv-22. RESULTS: A total of 5253 HCWs were trained through 32 one-day trainings, however data for 4474 HCWs was included in final pre-post knowledge analysis after removing the missing/incomplete data. Mean age of participants was 33.7±8.4 with median experience of 8(IQR: 3-13). Mean improvement in knowledge score was found to be significant (p<0.001) with mean knowledge score of 19.3±4.4 in pre-test and 25.7±3.9 in the post-test out of 30. Impact assessment survey suggested change in attitude and practice of HCWs. CONCLUSION: The one-day training programs helped the in-service nurses to enhance their knowledge related to viral hepatitis. The study provided a roadmap to combating viral hepatitis through health education among HCWs about viral hepatitis.

Natural Killer Cells and T Cells in Hepatocellular Carcinoma and Viral Hepatitis: Current Status and Perspectives for Future Immunotherapeutic Approaches.

Natural killer (NK) cells account for 25-50% of the total number of hepatic lymphocytes, which implicates that NK cells play an important role in liver immunity. The frequencies of both circulating and tumor infiltrating NK cells are positively correlated with survival benefit in hepatocellular cancer (HCC) and have prognostic implications, which suggests that functional impairment in NK cells and HCC progression are strongly associated. In HCC, T cell exhaustion is accompanied by the interaction between immune checkpoint ligands and their receptors on tumor cells and antigen presenting cells (APC). Immune checkpoint inhibitors (ICIs) have been shown to interfere with this interaction and have altered the therapeutic landscape of multiple cancer types including HCC. Immunotherapy with check-point inhibitors, aimed at rescuing T-cells from exhaustion, has been applied as first-line therapy for HCC. NK cells are the first line effectors in viral hepatitis and play an important role by directly eliminating virus infected cells or by activating antigen specific T cells through IFN-γ production. Furthermore, chimeric antigen receptor (CAR)-engineered NK cells and T cells offer unique opportunities to create CAR-NK with multiple specificities learning from the experience gained with CAR-T cells with potentially less adverse effects. This review focus on the abnormalities of NK cells, T cells, and their functional impairment in patients with chronic viral hepatitis, which contributes to progression to hepatic malignancy. Furthermore, we discuss and summarize recent advances in the NK cell and T cell based immunotherapeutic approaches in HCC.

Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid enhanced magnetic resonance imaging-guided risk assessment in living donor liver transplant patients with postoperative complications: a pilot study.

OBJECTIVE: To evaluate whether gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (MRI), the measurements of quantitative and qualitative parameters on hepatobiliary phase images can predict the risk of postoperative complications in patients underwent living donor liver transplantation (LDLT) PATIENTS AND METHODS: We obtained Gd-EOB-DTPA-enhanced 3 Tesla MRI before living donor hepatectomy in donors (donor group; n=30) and after LDLT in their recipients (recipient group; n=30). MRIs were evaluated in terms of quantitative and qualitative variables. Quantitative parameters included relative liver enhancement value, biliary signal intensity value, and muscle signal index value. Qualitative parameters included visual evaluation of the liver and biliary enhancement on hepatobiliary phase images. Patients were followed up for postoperative biliary and vascular complications and divided according to the presence and absence of complications. The relationship between MRI parameters and postoperative complications was statistically analyzed. RESULTS: The mean relative liver enhancement values, mean biliary signal values, and muscle signal index were significantly lower in recipients with postoperative complications than those in donors and recipients without complications (p < 0.001). Visual assessments of liver enhancement and biliary signal were also significantly different in recipients with postoperative complications than that in donors and recipients without complications (p < 0.001). CONCLUSIONS: Quantitative and qualitative MRI parameters obtained by Gd-EOB-DTPA-enhanced MRI on hepatobiliary phase images may potentially become a reliable tool for the assessment of the risk for postoperative complications after LDLT.

Blood exchange transfusion in viral hepatitis in a small infant: a case report.

We report a case of blood exchange transfusion to treat acute liver failure following hepatitis B infection at the Infectious Disease Department of Children's Hospital No.2 in Ho Chi Minh City, Vietnam. A 3.5-month old baby boy was admitted to the hospital with a presentation of progressively worsening jaundice for the past one month. The patient was diagnosed with hepatitis B infection with a positive HBV DNA quantitative assay. Plasma exchange was indicated in view of progressive liver failure and gradually increasing hepatic coma. However, it was impossible to perform plasmapheresis in this case because the patient was small (in terms of age and weight) and there was no suitable plasma exchange filter. Accordingly, the patient was treated with 3 times of blood exchange transfusion in combination with an antiviral drug, lamivudine. After each blood exchange transfusion, the biochemical values (bilirubin, liver enzymes, and coagulation profile) gradually improved and he was discharged after 1 month of treatment. Blood exchange transfusion is an effective procedure for managing acute liver failure, where plasma exchange is not possible while waiting for the recovery of liver functions or liver transplantation.

Role of Microbiota in Pathogenesis and Management of Viral Hepatitis.

Hepatitis is a condition that can be self-limiting or can progress to fibrosis (scarring), cirrhosis, or liver cancer. These days, gut microbiota becomes an important part of our immune system, which is important for disease progression or recovery. Translocation of gut microbial and metabolic products causes intestinal inflammation by modulating immune cells leading to impairment of the primary barrier. But there are limited studies discussing pathogenesis and management of hepatitis with gut microbiota. In this review, we have discussed the role of gut microbiota in pathogenesis and management of various hepatitis, especially hepatitis B and C. We have discussed the role of bacterial products, LPS-TLR4 pathway, and unmethylated CpG DNA, which ultimately affects downstream NF-kB signaling in hepatitis. Finally, we have discussed the role of fecal microbiota transplantation in the management of hepatitis.

Principles of Care for Patients with Liver Disease During the Coronavirus Disease 2019 (COVID-19) Pandemic: Position Statement of the Saudi Association for the Study of Liver Disease and Transplantation.

In December 2019, a novel coronavirus was identified in patients in Wuhan, China. The virus, subsequently named severe acute respiratory syndrome coronavirus-2, spread worldwide and the disease (coronavirus disease 2019 or COVID-19) was declared a global pandemic by the World Health Organization in March 2020. Older adults and individuals with comorbidities have been reported as being more vulnerable to COVID-19. Patients with chronic liver disease (CLD) have compromised immune function due to cirrhosis and are more susceptible to infection. However, it is unclear if patients with CLD are more vulnerable to COVID-19 and its complications than other populations. The high number of severe cases of COVID-19 has placed an unusual burden on health systems, compromising their capacity to provide the regular care that patients with CLD require. Hence, it is incredibly crucial at this juncture to provide a set of interim recommendations on the management of patients with CLD during the current COVID-19 outbreak.

Epstein-Barr Virus and Cytomegalovirus Infections of the Liver.

Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections are common and are associated with a variety of liver manifestations. EBV and CMV infections, in immunocompetent hosts, commonly manifest as acute hepatitis, with severity varying from asymptomatic, self-limited icteric hepatitis to acute liver failure. Atypical manifestations, such as cholestasis, chronic hepatitis, precipitation of acute-on-chronic liver failure, and autoimmune hepatitis, are reported with EBV infection, whereas cholestasis, portal vein thrombosis, and Budd-Chiari syndrome are reported with CMV infection. In the setting of liver transplantation, CMV is the most common infectious complication and carries significant morbidity; EBV is the major cause of post-transplant lymphoproliferative disorders.

[Hepatobiliary complications following allogeneic hematopoietic cell transplantation: Recommendations of the Francophone Society of Bone Marrow transplantation and cellular Therapy (SFGM-TC)]. / Complications hépatobiliaires dans le contexte de l'allogreffe de cellules hématopoïétiques : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC).

Hepatobiliary complications are frequent in the context of allogeneic hematopoietic cell transplantation (allo-HCT) and contribute largely to the morbidity and mortality after transplantation. Within the framework of the ninth workshops of practice harmonization of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held in Lille in September 2018, diagnostic approaches and treatments of hepatobiliary dysfunctions prior to and following transplantation were reviewed according to the analysis of published studies.