Wednesday, September 21, 2011

HCV News; Early virologic responses increases levels of adherence to Hepatitis C therapy

Early virologic responses increases levels of adherence to Hep C therapy
This month's issue of the Annals of Internal Medicine examines the relationship between adherence to Hepatitis C virus therapy and virologic outcomes.

Adherence to therapy with pegylated interferon and ribavirin for hepatitis C virus (HCV) infection has been incompletely examined.

Dr Vincent Lo Re and colleagues from Pennsylvania, USA evaluated the relationship between adherence to HCV therapy and early and sustained virologic response, assess changes in adherence over time, and examine risk factors for nonadherence.

The team performed a retrospective cohort study of the National Veterans Affairs Hepatitis C Clinical Case Registry.

Early virologic response increased with higher levels of adherence to ribavirin
Annals of Internal Medicine
The team assessed 5706 HCV-infected patients with at least 1 prescription for both pegylated interferon and ribavirin between 2003 and 2006 and HCV RNA results before and after treatment initiation.

The research team calculated adherence over 12-week intervals by using pharmacy refill data.

End points included early virologic response and sustained virologic response.

Early virologic response increased with higher levels of adherence to ribavirin therapy over the initial 12 weeks.

Among patients with HCV genotype 1 or 4, sustained response increased with higher adherence to ribavirin therapy over the second, third, and fourth 12-week intervals. Results were similar for adherence to interferon therapy.

The team noted that mean adherence to therapy with interferon and ribavirin decreased by 3.4 and 6.6 percentage points per 12-week interval, respectively.

Patients who received growth factors or thyroid medications during treatment had higher mean adherence to antiviral therapy.

Dr Lo Re and colleagues commented, "Early and sustained virologic responses increased with higher levels of adherence to interferon and ribavirin therapy."
"Adherence to therapy with both antivirals decreased over time, but more so for ribavirin."
Ann Int Med 2011: 155(6): 353-360
21 September 2011

Burden of cirrhosis and hepatic encephalopathy on patients and caregivers
The most recent issue of the American Journal of Gastroenterology evaluates multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers.

Cirrhosis and hepatic encephalopathy can adversely affect survival, but their effect on socioeconomic and emotional burden on the family is not clear.

Dr Jasmohan Bajaj and colleagues from Virginia, USA studied the emotional and socioeconomic burden of cirrhosis and hepatic encephalopathy on patients and informal caregivers.

A cross-sectional study in 2 transplant centers of cirrhotic patients and their informal caregiver was performed.

Demographics for patient/caregivers, model-for-end-stage liver disease (MELD) score, and cirrhosis complications were recorded.

Patients underwent a cognitive battery, sociodemographic, and financial questionnaires.

Cirrhosis-related expenses impact the family unit's daily functioning
American Journal of Gastroenterology
Caregivers were given the perceived caregiver burden and Zarit Burden Interview (ZBI)-Short Form, and questionnaires for depression, anxiety, and social support.

A total of 104 cirrhotics and their caregivers were included.

Cirrhosis severely impacted the family unit with respect to work, finances, and adherence.

Those with previous hepatic encephalopathy had worse unemployment and financial status, and posed a higher caregiver burden.

The research team observed that cognitive performance and MELD score were significantly correlated with employment and caregiver burden.

Veterans and non-veterans were equally affected.

On regression, depression score, MELD, and cognitive tests predicted both PCB and Zarit Burden Interview score.

Dr Bajaj's team comments, "Previous hepatic encephalopathy and cognitive dysfunction are associated with worse employment, financial status, and caregiver burden."
"Cirrhosis-related expenses impact the family unit's daily functioning and medical adherence."
"A multidisciplinary approach to address this burden is required."
Am J Gastroenterol 2011; 106: 1646–1653
21 September 2011

Fatty Liver Ups Risk of Cardiovascular Disease
By: SARA FREEMAN, Internal Medicine News Digital Network
LISBON – Increasing accumulation of fat, inflammation, and fibrosis of the liver appears tied to corresponding increases in the risk of cardiovascular disease, especially in patients with diabetes, according to the findings of a small retrospective study presented at the annual meeting of the European Society for the Study of Diabetes.
"What we are realizing is that [nonalcoholic fatty liver disease] is adding extra cardiovascular risk to people with diabetes, and to those without, on top of that which is already existing," Dr. Christopher Byrne, one of the lead study investigators, said in an interview.
Dr. Byrne, professor of endocrinology and metabolism at the University of Southampton (England), suggested that patients with documented liver disease perhaps require more aggressive therapies to address the additional risk. Such therapies need to target the liver as much as the heart.
In the study of 112 patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD), Kleiner scores – a histologic measure of NAFLD severity – were shown to be highly correlated with both Framingham Risk Score (FRS) and QRISK2, two cardiovascular risk calculators.
"Nonalcoholic fatty liver disease represents a spectrum of fat-mediated liver conditions causing progressive hepatocellular damage," said Sarah Hudson, a 5th-year medical student at the University of Southampton.
"There is increasing evidence of an increased cardiovascular risk associated with progression of nonalcoholic fatty liver disease," Ms. Hudson explained, noting that the preferred method of determining NAFLD severity was via histopathologic assessment.
The aim of the study was to see if a histopathologic marker – Kleiner score – correlated with cardiovascular risk, and if scores were higher in people already known to have a high cardiovascular risk, namely those with diabetes.
Kleiner scores assess the degree of steatosis, lobular inflammation, hepatocyte "ballooning," and fibrosis, with higher scores indicating more severe liver disease (Hepatology 2005;41:1313-21).
The mean age of the study cohort was 48 years and the mean Kleiner score was 5.3. The median FRS was 13 and the median QRISK2 score was 8. The mean body mass index of participants was approximately 34 kg/m2.
Kleiner scores were not only found to be highly correlated with both cardiovascular risk models used, but they were also higher in a subgroup of 32 patients with diabetes when compared with those without diabetes (6.4 vs. 4.7, P less than .001).
The increased risk of cardiovascular disease in correlation with increasing NAFLD severity was found to be independent of both hyperglycemia and increasing body weight.
"We need more prospective studies to see what markers may be used to help stratify who requires biopsy and how best to manage people who have got NAFLD." Nonalcoholic steatohepatitis was associated with the highest cardiovascular risk estimates in the study.
"Up until now we’ve been very poor in providing cardiovascular risk reduction treatments for patients with NAFLD," Dr. Byrne said. Currently the only treatment strategy proven to work for NAFLD is lifestyle changes.
"We know that losing weight and increasing activity levels are very effective at decreasing liver fat," Dr. Byrne explained. "But what we don’t know is whether those lifestyle changes are good at decreasing liver inflammation, or decreasing liver fibrosis."
Treatment to decrease liver fat and prevent progression to fibrosis is thus urgently needed, and Dr. Byrne is part of a team now looking at the use of a high concentration of highly purified omega-3 fatty acid ethyl esters in the treatment of NAFLD.
The highly purified fish oil being used in the trial has been available commercially in Europe for at least a decade (Omacor) and in the United States since 2004 (Lovaza), and is currently licensed to treat hypertriglyceridemia.
The study is not due to be completed until December 2012. Until then, clinicians need to optimize the treatments they have at their disposal, including antihypertensive and lipid-lowering medicines commonly used to lower cardiovascular risk in conjunction with lifestyle modifications.
The study was funded by the National Institute for Health Research and Diabetes UK. Dr. Byrne and Ms. Hudson said they had no relevant financial disclosures. Dr. Byrne said he has given lectures on behalf of pharmaceutical companies in the past, including Pfizer

Couple sues hospital after he gets her infected kidney
Pa. pair say doctors missed positive test for hepatitis C before life-saving transplant
A Pennsylvania couple is suing a prominent medical center after doctors transplanted the woman’s kidney into her boyfriend’s body despite a test that showed she was infected with hepatitis C.
Christina L. Mecannic, 40, and Michael J. Yocabet, 50, of Greene County, Pa., said he’s now got the potentially fatal liver disease after the April 6 transplant at the University of Pittsburgh Medical Center that was meant to save his life.
“He did need it very badly,” Mecannic told “The dialysis was not working well for him. He was not doing well. I just wanted to do whatever I could to help.”..continue 

CDC Moves to Make Organ Transplantation Safer
Proposed guideline would screen more aggressively for hepatitis B and C
WEDNESDAY, Sept. 21 HealthDay.-- More thorough donor screening and more advanced organ testing to help protect transplant patients from infectious diseases are recommended in a draft of an updated organ transplant guideline released Wednesday by the U.S. Centers for Disease Control and Prevention.
The goal of the new guideline is to reduce infections such as HIV (the virus that causes AIDS), hepatitis B virus (HBV), and hepatitis C virus (HCV). Screening is already done for HIV, but HBV and HCV should be added to the screening process, the CDC said.
From 2007 to 2010, the CDC was involved in more than 200 investigations of suspected, unexpected transmission of HIV, hepatitis B and hepatitis C through transplants. In some of the confirmed cases, the transplant recipient died due to the infection.
The existing guideline was created in 1994. Other major proposed changes to the guideline include updated and more sensitive tests for donor organs, and a revised set of donor risk factors that can help doctors get a better idea of possible problems with donors' organs.
The new draft guideline focuses on organ safety because the U.S. Food and Drug Administration has already implemented tighter regulations for tissue and semen donors.
"Our first priority must be patient safety. These recommendations will save lives and reduce unintended disease in organ recipients," Dr. Matthew J. Kuehnert, director of the CDC's Office of Blood, Organ and Other Tissue Safety Office, said in a CDC news release. "The guideline will help patients and their doctors have information they need to fully weigh risks and benefits of transplanting a particular organ."
The Draft 2011 Public Health Service Guideline for Reducing Transmission of HIV, HBV, and HCV through Solid Organ Transplantation can be found at The review-and-comment period will last 60 days.
More information
The United Network for Organ Sharing has more about organ transplantation.
Copyright © 2011 HealthDay. All rights reserved

Complementary and Alternative Medicine

Released: 9/21/2011 9:00 AM EDT
Source: Thomas Jefferson University
Newswise — (PHILADELPHIA) – Mood disorders are among the most prevalent mental health issues today. While medication is available, more and more people are turning to complementary and alternative medicine (CAM), including herbal remedies, acupuncture, and meditation to help manage their mood disorders.
Andrew Newberg, MD, director of Research, Daniel Monti, MD, medical and executive director and Aleeze Moss, PhD, instructor of the Mindfulness-Based Art Therapy program at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital review the most commonly used CAM practices in the management of patients with mood disorders and the available data on CAM use for mood disorders in the recent issue of the Expert Reviews in Neurotherapeutics.
Mood and anxiety disorders include a broad range of diagnoses such as major depression; dysthymia, a type of mild depression, and others.
A 2007 National Health Interview Survey (NHIS) showed that almost 40 percent of adults use CAM, with Americans with depression more likely to use CAM remedies than conventional antidepressants or psychotherapy.
Newberg, Monti and Moss evaluated CAM modalities across four categories: natural products; mind-body medicine and manipulative and body-based practices; and other CAM practices. A snapshot of their findings is outlined here:
Natural Products
Botanical medicines, vitamins, minerals and natural products found to positively impact patients with mood disorders, include: Hypericum (St. John’s Wort); S-adenosyl-methionine- an amino acid essential in production and delivery of dopamine, serotonin and norepenephrine throughout the brain; Omega-3 fatty acids- essential fatty acids (EFAs) play a role in maintaining brain structure and function. Research shows that reduced levels of EFAs may be associated with depression. The most common source of EFAs is fish oil.
Mind-body practices
Meditation, yoga, qi-gong, tai-chi and acupuncture are among the most commonly used.
Yoga is effective in improving anxiety and depression, suggests a growing body of research; Meditation-based practices such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have supporting data suggesting therapeutic benefit, including decreases in depression, anxiety and distress for a variety of health conditions, including mood disorders; Acupuncture- inconclusive evidence shows acupuncture can be a beneficial treatment modality for mood disorders.
Other CAM products
There are several CAM products that are used for mood disorders, but many have little supporting data. A few that do include: TRP and 5-HTP, amino acid precursors of serotonin, and the botanical Rhodiola rosea.
The popularity of CAM interventions within the general Western population continues to grow as does the body of rigorous research into the effects and mechanisms of CAM interventions for mood disorders.

“As the field grows, we anticipate that the data will be able to provide a more detailed evaluation of CAM interventions with more practical applications regarding potential benefit effects and helping to avoid adverse effects,” conclude Drs. Newberg and Monti and Moss.
Editor’s Note: Click here to view today’s Jefferson University Hospital The Daily Dose blog post on this topic.
# # #
The Jefferson-Myrna Brind Center of Integrative Medicine has been providing professional education programs in integrative medicine for physicians, medical students, nurses and other health providers since 1995. The Center promotes research and educational activities related to integrative medicine. Collaborative study protocols are developed with Jefferson clinical investigators and basic scientists.
Thomas Jefferson University Hospitals
Thomas Jefferson University Hospitals (TJUH) are dedicated to excellence in patient care, patient safety and the quality of the healthcare experience. Consistently ranked by U.S. News & World Report among the nation's top hospitals, Thomas Jefferson University Hospital, established in 1825, has over 900 licensed acute care beds with major programs in a wide range of clinical specialties. TJUH is one of the few hospitals in the U.S. that is both a Level 1 Trauma Center and a federally-designated regional spinal cord injury center. TJUH patient care facilities include Jefferson Hospital for Neuroscience, the region’s only dedicated hospital for neuroscience, Methodist Hospital in South Philadelphia, and additional patient care facilities throughout Pennsylvania and New Jersey. TJUH partners with its education affiliate, Thomas Jefferson University.


FDA Confirms Source of Listeriosis
By Cole Petrochko, Associate Staff Writer, MedPage Today
WASHINGTON -- The FDA confirmed Tuesday that the source of a multi-state listeriosis outbreak that started in Colorado was Jensen Farms' Rocky Ford brand cantaloupes.
The agency found traces of Listeria monocytogenes in company cantaloupe samples from a store and a packing facility, as well as on equipment at the facility, the FDA said in a statement. The infectious traces match one of the three strains involved in the multi-state outbreak of listeriosis.
Jensen Farms recalled its Rocky Ford brand cantaloupes as a precautionary measure following the outbreak announcement in mid-September. The affected produce was shipped from July 29 to Sept. 10 to at least 17 states, which may have distributed them further, the statement said.
Since that announcement, the number of patients affected by the bug has grown to 35, while the number of deaths has risen to four.
Listeriosis can be fatal to some high-risk patients, such as patients ages 60 and older and those with compromised immune systems, in addition to the offspring of pregnant mothers with the disease.
Listeria bacteria are commonly found in water, soil, some farm animals, raw meat, raw sprouts, raw milk and raw milk products, and some processed meat products. They can survive and grow in the cold of a refrigerator.
The FDA added that customers should throw out any Rocky Ford brand cantaloupe, as bacteria may be on the cantaloupe's skin, and that cutting it may transfer bacteria from the outside to fruit inside.
The agency noted that it is working with Colorado state health officials to determine how the produce became contaminated and to develop potential controls to prevent future outbreaks.


10 Rules to Expose Medical Junk News

For Your Reading Pleasure

Grand Rounds is a weekly summary of the best health blog posts on the Internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week.

This Weeks Host Is Suture for a Living
I am a plastic surgeon in Little Rock, AR. I may "suture for a living", but I "live to sew". When I can, I sew. These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

Grand Rounds Volume 7 Number 52

A few submissions from this weeks grand rounds below, to read more click here
OK, I can get behind those as non-emergency ER conditions. I'd quite like to see those folks re-routed to clinics or PCPs. But wait, there's more! Other "Non-emergent conditions" for which the state will not pay include:
Chest Pain
Abdominal Pain
There are many others -- these are just the most ridiculous "non-emergency" conditions that jumped out at me. It's also manifestly arbitrary and haphazard what made it onto the list and what did not. The HCA considers "Cholelithiasis with acute Cholecystitis" an emergency condition worth paying for, but "Acute Cholecystitis" is not. The state will pay for hand cellulitis, but not for the more dangerous foot cellulitis……...

Do you use black humor in your workplace? 
Do you keep it there or do you use it in public places, including Facebook and Twitter? There has been much discussion of this over the past week and Laika, Laika's MedLibLog, writes a post “about the inappropriate use of black humor by doctors (using terms like "labia-ward") at Facebook & Twitter”: Medical Black Humor, that is Neither Funny nor Appropriate. Please, go read it all.

Jordan, In My Humble Opinion, writes a lovely piece on a time when he had A Moment Of Clarity
Although the name on the chart was oddly familiar I couldn't place her. I was covering for apartner who was on vacation. It felt like my day would never end.
When she bopped into the office I knew immediately. We went to school together. Years ago. She sat down quietly on the exam table typing away on her mobile phone. I approached cautiously my mind musing on occupational hazards. I wondered if she would recognize me. ……….

Visit  this weeks host @ Suture for a Living

 New On The Blog

European approval for hepatitis C drug, Telaprevir-Incivek "called Incivo in Europe."

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