Medicine Internal Medicine. Clinical Gastroenterology Free Preview. Show next edition. Buy eBook. FAQ Policy. About this book Around the world hepatitis has infected more than 2 billion people 10 million in the US and is, in its chronic form, the leading factor in end-stage liver disease and the rising incidence of hepatocellular carcinoma. Show all. Pages Show next xx. A prospective, multicenter pilot of HealthElink across primary care services in South Australia, Victoria, and the Northern Territory, as well as prison services in South Australia and the Northern Territory, is scheduled to begin in June The primary outcome is SVR at 12 weeks.
Secondary outcomes include patient, doctor and nurse satisfaction; cost analysis; and number of treatment initiations per practitioner. Additional data regarding time spent on the portal by each person and usage statistics will be gathered. We anticipate preliminary results to be presented in mid , followed by a qualitative analysis at the completion of the study to further elicit the clinician and patient experience of using the portal. This includes qualitative analysis of the user experience and measurement of time taken to complete a specialist referral via HealthElink compared with current practice the remote consultation form.
The HealthELink HCV treatment algorithm provided appropriate treatment options to prison medical officers for all seven patients based on viral and host characteristics. One patient was excluded from remote treatment initiation and referred for further investigation via the portal based on a low platelet count, despite an aspartate aminotransferase to platelet index of less than 1. Recruitment for the formal pilot study is expected to commence in June We anticipate preliminary results to be presented in mid Australia represents one of the first countries to be granted unrestricted access to these medications.
Additional retrospective data, including biochemistry, FibroScan score, and comorbidities, were collected, and outpatient letters were reviewed for treatment failures. The median age was 56 years range, 36—63 years. Treatment failure was not significantly associated with age, sex, rurality, APRI, linguistically diverse background, prior treatment experience, or incarceration.
These were both Child—Pugh B cirrhotics, with genotypes 2 and 3.
Consideration may be made for a longer treatment course for genotype 3 patients who display markers suggestive of advanced fibrosis or who are borderline in their assessment. Australia is one of the first countries to provide unrestricted access to these medications, as of 1 March While much focus has remained on the trial success of these medications, minimal outcome data are available from an unrestricted access population. We aimed to document efficacy and failure rates from a large South Australian tertiary cohort. Additional retrospective data, including biochemistry and FibroScan scores, were collected.
There was a marked decline in new treatment initiations in the second 6 months of this period vs patients. Mean age at treatment initiation was 52 years range, 21—85 years. There was no significant difference in SVR12 between 8 or 12 weeks of sofosbuvir—ledipasvir in genotype 1 with low viral load. The State Hepatitis Program based at St Vincent's Hospital Melbourne has assessed prisoners and commenced treatment on to date.
Given the limited resources of the prison system, it is important that simple, inexpensive, and available methods of disease state assessment be evaluated. Methods : We performed a prospective comparison of the accuracy of the APRI score for excluding the presence of cirrhosis, such that elastography is avoided.
Results : Data on patients were included in the current analysis. Of these, the mean age was The average body mass index was Of these prisoners, The failure rate for FibroScan was The predictive accuracy of APRI scores of 0. Data collection is ongoing and focused on unbiased sampling of all prisoners assessed, including both treated and untreated prisoners. Background : Despite major advances in the care of patients with chronic hepatitis C CHC in recent years, the provision of outpatient mental health care to this cohort remains grossly inadequate.
Aims : To assess the need of our local CHC population for outpatient mental health services, using a validated psychological assessment scale; utilization of community mental health care services; and correlation with demographic data. Methods : We conducted a prospective cohort study surveying 96 consecutive patients with CHC attending an outer metropolitan hepatology clinic between October and February On the K10 scale, No hospital outpatient service was available; thus, the main source of support was a Mental Health Care Plan psychologist or psychiatrist.
Conclusion : Using a psychological assessment scale that has been validated for use in Australia to estimate the needs of a population for mental health services, 2 we have formally documented an important unmet need in our CHC population. We propose that this is currently an unrecognized deficit in service provision in the new era of antiviral treatment. Furthermore, it is highly likely to be mirrored in our local metropolitan liver centers due to their parallel absence of outpatient mental health facilities and the predisposition of this population to mental health disorders, due to premorbid psychosocial disadvantage and potential direct neurocognitive effects of the virus itself.
Public health strategies have been developed to meet treatment demand, with the ultimate goal of HCV eradication. Aim : To describe characteristics of patients undergoing HCV treatment with DAAs, methods of facilitating treatment, and treatment outcomes. Methods : This was a prospective cohort study of patients whose treatment was initiated or supervised by Cairns Hospital.
Demographics, clinical features cirrhosis, prior antiviral treatment , DAA regimens, and outcomes sustained virological response at 12 weeks [SVR12] were recorded.
No patients were prescribed interferon. SVR12 results were available for treated patients There were patients No patients ceased treatment due to adverse effects. Presence of cirrhosis Most prescribers were gastroenterologists Diverse models of care facilitate treatment delivery in regional and remote settings. Additionally, it is unknown what proportion of those patients in phase 4a progress to 4b and if there are clinical markers that may predict this.
Aim : To determine the natural history of CHB in patients in phase 4 through analysis of demographics and clinical indices that may predict progression to phase 4b. Methods : A total of patients with CHB managed at the liver clinics of a large Australian health care network between 25 October and 25 November were included in the study. Baseline characteristics were collected from medical records, including age, sex, body mass index BMI , VL, and liver stiffness measurement.
As this did not reach statistical significance, a larger sample size may be needed to indicate the use of maximum recorded VL as a marker for future ALT flares. The median time to flare was 1. On analysis, age, sex, BMI, and liver stiffness provided no prognostic information. Deferral of antiviral therapy using this approach has obvious patient, health care and cost advantages. Even in patients with VL greater than this threshold, there is adequate time to observe for biochemical flare rather than treating on the basis of VL alone.
Introduction : Newer antivirals used in the management of chronic hepatitis B have been associated with high barriers to resistance and strong safety profiles. The number of patients with chronic hepatitis B is expected to increase annually, thus posing more pressure on tertiary centers.
Given the safety profiles of the newer antiviral agents, we are testing the feasibility and potential cost savings with the transition of care of chronic hepatitis B patients from tertiary to primary care settings. Medical records and outpatient clinic letters were reviewed, and patients with a change in management were identified. A change in management was defined as an increased frequency of clinic encounters compared with what was decided in previous consultations, any changes in antiviral therapy, or additional imaging studies ordered to investigate complications or progression of the patient's liver disease.
Results : A total of patients with chronic hepatitis B mean age, Patients were followed up for a mean period of Overall, Of these changes, In the remaining 20 patients, changes in management were attributed to new liver lesions discovered on ultrasound The need for interpreter use OR, 2. A change in management was predictable in In the 87 patients without a change in management, the total number of clinic encounters and cost incurred were calculated on a yearly basis from to This showed a With this new model of care, potential cost savings in the tertiary care setting can be achieved, in view of a growing demand for outpatient clinic encounters.
The primary endpoint was a sustained virological response 12 weeks after treatment cessation SVR The majority were genotypes 1a Reasons for treatment failure included relapse 4. SVR12 rates were lower in patients with genotype 3 Data collection is continuing, and SVR12 results will be presented at the conference. Lower SVR12 rates are observed in patients with genotype 3 and cirrhosis. Although a rare complication of HCV, PCT causes a significant deterioration in a patient's quality of life, with implications for daily manual activities and going outdoors.
Results : Ten patients median age, Five had genotype 1, one had genotype 2, one had genotype 3, and three patients' genotypes were unknown at the time of submission. One patient had cirrhosis. Six patients had completed DAA therapy, while the remaining four were on therapy or being worked up. All six patients who completed therapy achieved sustained virological response at 12 weeks.
No adverse outcomes were reported. Porphyrin levels were available in three of six patients at time of submission, with two of three achieving reductions in both plasma and urinary porphyrins. Patients reported improvement in blistering and fragility after DAA therapy. This study presents important lessons for other jurisdictions where access to DAAs is limited by degree of fibrosis without consideration of associated conditions.
Recently, conflicting data have come to light with regards to the safety of DAAs in terms of their effect on hepatocellular carcinoma HCC. HCC patients were excluded if previous imaging demonstrated a lack of complete locoregional response to HCC treatment, or if indeterminate nodules were present before DAA commencement. Demographic data, markers of liver synthetic function, and HCV infection characteristics were all recorded.
Results : A total of patients met the inclusion criteria. Sustained virological response SVR was achieved in 93 of 95 treated patients None of these de novo HCC cases had aggressive characteristics. Median time to HCC recurrence was These risk factors were not significant on multivariate analysis. This suggests that further work needs to be undertaken to confirm these findings and identify which patients are at highest risk.
Remote support to general practitioners to prescribe DAA therapy was established in our tertiary center in April Our aim was to investigate the impact of this change on hepatology clinic referrals. Methods : We performed a retrospective analysis of all outpatient clinic referrals to our liver service 1 year before and after the introduction of our HCV remote consultation program, from 1 April to 31 March , inclusive. Demographic and etiological data were extracted from referral letters. Results : A total of referrals were received before and after April Conclusions : An increasing proportion of patients have a higher clinical urgency, and there are shorter waiting times to first review, enabling patients to be seen promptly.
Planning for the ongoing changes of increasing treatment in primary care and adapting services to meet needs will be crucial. Remote support for primary care will continue to play a part for those unfamiliar with prescribing DAAs.
Clinical Gastroenterology In Chronic Viral Hepatitis: Diagnosis and Therapeutics, leading scientists, clinicians, and clinical investigators comprehensively. In Chronic Viral Hepatitis, Second Edition, a panel of distinguished clinicians and clinical Clinical Gastroenterology Provides a concise, well illustrated guide to all aspects of chronic viral hepatitis, including diagnostic and therapeutic.
An update of this dataset in 12 months, once GPs are more familiar with our remote consultation program, is planned. Data were collected from patient flowcharts, laboratory results through the iSoft patient management database, and case notes. Results : There were a total of patients treated in Royal Perth Hospital liver service from to Record numbers of patients accessed treatment, with predictably high success rates.
SVR was not ordered or found in the remaining 70 patients. Of those with treatment failure, five had genotype 1, and three had genotype 3. Conclusion : The Northern Liver Clinic has achieved significant progress in the uptake and treatment of HCV in the region, with a low rate of treatment failure. However, documenting SVR rates was problematic, and further analysis will need to be undertaken to elucidate the factors accounting for this low SVR testing rate. We have evaluated the efficacy of antiviral therapy delivered in the prison system using this model. Methods : All prisoners are offered screening for viral hepatitis on prison entry and when moving between prison sites.
CNCs conduct interviews, clinical assessments, liver stiffness measurement using transient elastography FibroScan , and organize blood tests with participants in their local prisons. Patients are triaged for consultation by supervising hepatologists via telemedicine or F2F at a central prison. To be eligible for DAA therapy, treatment must be able to be completed within the expected sentence duration.
We report the results of the first 17 months of the program—clinical assessments commenced in October , and the treatment program commenced in March A total of prisoners have been assessed in the first 17 months of the program, of whom have been eligible for treatment as per the treatment protocol. There were prisoners who commenced treatment, and have reached the sustained virological response at 12 weeks SVR12 time point. The SVR12 results for all prisoners completing treatment before 1 August will be presented at the conference.
Prisoner uptake and treatment response rates have been excellent. Amino acid substitutions in the NS5A region have been described that reduce sensitivity to NS5A inhibitors and are selected in patients who relapse after therapy. To date, there are no Australian data describing clinical or virological predictors of DAA treatment failure. Clinical features and treatment history were extracted from the hepatitis database. Data were compared with the larger cohort of patients treated with DAAs during this time.
The rate of novel hepatoma diagnosis was also higher among the relapse cohort. Salvage therapies should be designed to include at least two DAAs active against any specific resistance variant.
Our aim was to determine the prevalence of depressive symptoms, genetic polymorphisms, mRNA and protein expression linked with major depression in a CHC cohort at two teaching hospitals in metropolitan Victoria. Look for cutaneous complications of long-term HCV infection, such as palpable purpura associated with cryoglobulinemia or blisters and vesicles porphyria cutanea tarda.
Elevated levels indicate ongoing hepatocellular necrosis; however, AST and ALT are not good markers of the degree of fibrosis. Pegylated interferon may cause leukopenia and thrombocytopenia, and ribavirin may cause anemia. Pre-existing leukopenia or thrombocytopenia is a relative contraindication to treatment of HCV infection. Iron deficiency anemia should be corrected before treatment is initiated. Immunity to hepatitis A and hepatitis B should be established by reliable documentation of previous immunization or the presence of hepatitis A and B surface antibodies.
If the patient is not immune, vaccination is recommended whether or not the patient is a candidate for treatment of HCV infection. In patients with significant iron overload, hemochromatosis should be ruled out, and these patients should be considered for treatment with phlebotomy. Iron overload is a negative predictor for successful therapy, but iron reduction does not necessarily improve outcome. Infections with HCV genotypes 2 and 3 have a better prognosis cure rates of 70 to 80 percent and require only six months of treatment, whereas infections with HCV genotype 1 have a cure rate of 40 to 50 percent and require 12 months of treatment.
Information from references 5 , 11 , 12 , and The liver biopsy provides the most direct information about the current status of the liver and is recommended in most patients with active HCV infection. The two central pieces of information from the biopsy are the degree of inflammation and the degree of fibrosis.
Inflammation is scored from zero no inflammation to 4 severe inflammation.
The degree of inflammation correlates roughly with the amount of ongoing hepatic injury and the natural history of the disease. Fibrosis is the replacement of functional hepatic tissue with nonfunctional connective tissue. It is triggered by ongoing inflammation and cytokine-related stimulation of hepatic stellate cells. In chronic HCV infection, fibrosis begins to develop in and around the portal triad and then extends to the periportal area; next, it bridges from one portal triad to an adjacent one, and finally proceeds to a complete circle of fibrosis or cirrhosis connecting all adjacent portal units.
Therefore, fibrosis is scored on a four-point scale: zero no fibrosis , 1 portal fibrosis , 2 periportal fibrosis , 3 bridging fibrosis , and 4 cirrhosis. Liver fibrosis correlates with the natural history of the disease. Patients who have already progressed to cirrhosis have a lower response rate to treatment and a higher rate of hepatic complications during treatment. The liver biopsy also may detect the presence of other liver diseases that may require separate treatments and could affect the timing of the treatment of HCV infection.
For example, evidence of fatty liver, alcoholic liver disease, or hemochromatosis would require consideration of weight loss, alcohol cessation measures, and phlebotomy, respectively. Patients with HCV infection should be educated about the natural history of the disease and the negative impact of alcohol consumption. They should be reassured that there is no evidence of HCV transmission via casual household contact, including the sharing of utensils or food, hugging, kissing, or breastfeeding. The lifetime risk for sexual transmission of HCV in monogamous couples appears to be less than 1 percent.
Patients who are considering treatment for HCV infection with pegylated interferon and ribavirin should be made aware of potential side effects. Patients should be directed to reliable sources of information so they can learn more about their condition see accompanying patient information handout. The NIH consensus statement 5 on the management of HCV infection states that all patients with chronic infection are potential candidates for therapy.
This is a marked change from the NIH consensus statement 26 and reflects the availability of more effective treatment regimens and more established treatment expertise. Important factors to consider include the presence of comorbid conditions that would make treatment dangerous or more difficult, patient motivation and reliability, and HCV viral genotype. Treatment of HCV genotype 1 has a success rate of only 40 to 50 percent, whereas treatment of genotypes 2 or 3 has a success rate of 70 to 80 percent. After a complete evaluation, most patients clearly will be candidates for treatment or have contraindications that preclude treatment.
In some patients, however, the decision to treat is not clear based on the work-up alone and must be made on an individual basis. The online version of this article contains a table that presents three clinical scenarios highlighting several factors that must be considered in deciding whether to treat a patient who has chronic HCV infection. Providing treatment for patients with HCV requires that the physician and office personnel be familiar with the side effects of the medications and able to provide close follow-up during therapy.
Currently, most patients with HCV infection who are candidates for treatment are referred to a subspecialist. However, with the increasing prevalence of HCV infection, more family physicians may be treating uncomplicated cases, with adequate back-up from an appropriate subspecialist. Already a member or subscriber? Log in. WARD, M. Ward received his medical degree and a graduate degree in pharmacology from the University of Washington School of Medicine, Seattle.
Kugelmas received his medical degree from the University of Buenos Aires Facultad de Medicina and completed a gastroenterology and hepatology fellowship at the Cleveland Clinic, Cleveland, Ohio. Address correspondence to Raymond P. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. The prevalence of hepatitis C virus infection in the United States, through N Engl J Med. Alter MJ. Epidemiology of hepatitis C.
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