Showing posts with label TGIF-News Review. Show all posts
Showing posts with label TGIF-News Review. Show all posts

Friday, October 20, 2017

TGIF HCV Rewind - Seasonal Flu, Liver Disease & Blog Updates Around The Web

Seasonal Flu & You
Welcome folks, the weather here in Michigan is quickly changing, soon we'll be enjoying our beautiful autumn foliage. The flu season is here as well, with experts tracking flu cases outside the US.

Australia is reporting more cases this year, far more than the last two flu seasons, according to the latest Australian Influenza Surveillance Report.

Australians over the age of 80 and children between the ages of 5 and 9, have been the hardest hit with A(H3N2). Experts say influenza A virus may cause complications for older people and those with weakened immune systems. How the flu season plays out in the southern hemisphere, may indicate what we see here in the northern hemisphere, a few months later.

Worldwide, the World Health Organization (WHO) reported that influenza A(H3N2) and B viruses accounted for the majority of influenza detections. Here in the US, the CDC found low influenza activity, with influenza A the most frequently identified strain reported.

The current seasonal influenza vaccine covers both A(H3N2) and B viruses.
Excerpt from the CDC web site:

What viruses will the 2017-2018 flu vaccines protect against?
There are many different flu viruses and they are constantly changing. The composition of U.S. flu vaccines is reviewed annually and updated as needed to match circulating flu viruses. Flu vaccines protect against the three or four viruses (depending on vaccine) that research suggests will be most common. For 2017-2018, three-component vaccines are recommended to contain:
  • an A/Michigan/45/2015 (H1N1)pdm09-like virus (updated)
  • an A/Hong Kong/4801/2014 (H3N2)-like virus
  • a B/Brisbane/60/2008-like (B/Victoria lineage) virus
Quadrivalent (four-component) vaccines, which protect against a second lineage of B viruses, are recommended to be produced using the same viruses recommended for the trivalent vaccines, as well as a B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

Watch - 2017-2018 Influenza Vaccination Recommendations
Medscape - CDC Expert Commentary
Lisa Grohskopf, MD, MPH
In this video, available online at Medscape, Dr Lisa Grohskopf, medical officer in the Influenza Division at the Centers for Disease Control and Prevention, will discuss CDC's influenza vaccination recommendations for the 2017-2018 influenza season.

People at High Risk of Developing Flu–Related Complications
People older than 65, those with certain chronic medical conditions, such as liver disease, COPD, diabetes, weakened immune systems, pregnant women and young children are most vulnerable for developing flu-related complications.

Liver Disease
Baby boomers, that is people born from 1945–1965, are 5 times more likely to have hepatitis C than other adults. Many baby boomers are over the age of 65, and living with chronic liver disease, for instance cirrhosis, making them more susceptible to complications related to the flu. Two reasons to protect yourself from the influenza virus.

Recently, a multicenter study published in the journal Eurosurveillance, concluded that people over the age of 65, who received influenza vaccination reduced their risk of being hospitalized for influenza-associated symptoms by 36 %. The study investigated hospitalization of the elderly in two influenza seasons (2013-2014 and 2014-2015).

So, if you’re over 65, you should absolutely get the flu shot. I feel compelled to add, the closer I get to that cut-off, 65, the more I hate the word elderly. Really. Hate it. Read more about the study here, or review the full-text article published in Eurosurveillance.

 How long is the flu contagious? What is the difference between a cold and the flu?
How long is a person with flu virus contagious?
The period when an infected person is contagious depends on the age and health of the person. You may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick. Most healthy adults may be able to infect others beginning 1 day before symptoms develop and 5 to 7 days after becoming sick. Some people, especially young children and people with weakened immune systems, might be able to infect others for an even longer time.

What is the difference between a cold and the flu?
The flu and the common cold are both respiratory illnesses but they are caused by different viruses. Because these two types of illnesses have similar symptoms, it can be difficult to tell the difference between them based on symptoms alone. In general, the flu is worse than the common cold, and symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense. Colds are usually milder than the flu. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.

How can you tell the difference between a cold and the flu?
Because colds and flu share many symptoms, it can be difficult (or even impossible) to tell the difference between them based on symptoms alone. Special tests that usually must be done within the first few days of illness can be carried out, when needed to tell if a person has the flu.

More information about Flu: The Disease.

In The News
British Liver Trust
Last year, fewer than half (46.9%) of people in clinical risk groups were protected against influenza, a virus, which can and does kill every year. People particularly ‘at risk’ of influenza, such as liver disease, and its complications are given the vaccine at no cost as part of NHS care. However last winter more than half (57.7%) of people under the age of 65 with a liver condition missed out on getting a free influenza (flu) vaccination in Wales.

Newly discovered viral marker could help predict flu severity in infected patients
Influenza is particularly dangerous for infants, the elderly, and people with underlying medical issues, but otherwise-healthy people sometimes experience severe infection, too. This suggests that, among the multiple strains that circulate yearly, some are more virulent than others. Markers of severity have been found for specific strains, but a general marker that applies to multiple strains would be more useful to inform treatment and policy

High-dose influenza vaccine better for solid organ transplant recipients
Transplant recipients are at particular risk of developing complications from an influenza virus, namely influenza-associated pneumonia. A study presented at IDWeek, held October 4, 2017 - October 8, 2017, reported that in adult solid organ transplant recipients, a high-dose influenza vaccine is preferable to a standard-dose vaccine. Read the summarized results published over at Healio, full-text study is available in Clinical Infectious Diseases.

The Infectious Diseases Society of America (IDSA) has published detailed guidance for the selection and timing of vaccines for persons with specific immunocompromising conditions, including solid organ transplant.

October 18, 2017
Patients with HIV receiving care at a hospital in Malawi were nearly three times more likely to have an influenza-like illness and five times more likely to develop severe influenza disease than patients without HIV, according to data from two recent observational studies.

October 9, 2017
With predictions calling for a potentially bad flu season this year, doctors are urging people -particularly those with diabetes - to get vaccinated

Cochrane Review Essay
In a new paper, experts in the field of Gastroenterology & Hepatology, expressed concern over the highly debated Cochrane systematic review which concluded that patients who achieved SVR (cure) using hepatitis C direct-acting antivirals (DAAs) showed no long term benefits. The new essay titled: Benefits of Direct-Acting Antivirals for Hepatitis C, was published in Annals of Internal Medicine this week.

Since June, when the Cochrane DAA review was published, updated in September with a somewhat "changed" conclusion, Henry E. Chang has tweeted out each rebuttal written about the misleading, failed, review. Read them all here, and make sure to follow Henry E. Chang for daily updates about viral hepatitis on Twitter. 

Conference Coverage - Coming Soon
The liver meeting starts today!

Oct 19, 2017
AASLD Liver Meeting Covers a Lot of Ground
New science could 'potentially change the field
There remains a great deal of interest in HCV, evidenced by dozens of posters and oral presentations on new therapeutics, as well as on other aspects of the disease..

Liver Meeting® 2017 - Gilead Announces Multiple Presentations Demonstrating High Cure Rates in Difficult-to-Cure HCV Patients
Gilead Sciences, Inc. (NASDAQ: GILD) today announced results from Phase 2 and Phase 3 studies of its approved medicines for chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infection, adding to the body of evidence supporting Gilead’s viral hepatitis therapies in diverse patient populations. These and other data from more than 25 abstracts will be presented this week at The Liver Meeting® 2017, which begins today in Washington, D.C.

The Liver Meeting® 2017 - The Frequency of Herbal and Dietary Supplement Mislabeling
Washington, D.C. – Herbal and dietary supplement mislabeling is common and should be evaluated as a potential cause for liver damage, according to research presented this week at The Liver Meeting® — held by the American Association for the Study of Liver Diseases.

Liver Meeting - Updates on this blog, if you are a patient in search of easy to understand information click on this (LINK) for a collection of great HCV sites covering this years Liver Meeting.

The Liver Meeting 2017: American Association for the Study of Liver Diseases (AASLD)
AASLD Website - The Liver Meeting
MedPage Today
Clinical Care Options
GI & Hepatology News
Updates on this blog

In The Journals
Alimentary Pharmacology & Therapeutics
Direct medical costs associated with the extrahepatic manifestations of hepatitis C virus infection in France
Cacoub,M. Vautier,A. C. Desbois,D. Saadoun,Z. Younossi
First published: 18 October 2017
The following extrahepatic manifestations of HCV infection were analysed: mixed cryoglobulinemia vasculitis, glomerulonephritis (increased creatininemia), end-stage renal disease, porphyria cutanea tarda, lichen planus, type 2 diabetes, depression, rheumatoid-like arthritis, lymphoma, Sjögren-like syndrome, stroke, heart failure and myocardial infarction.

On This Blog
Categorized article directory on the extrahepatic manifestations of hepatitis C.

Michael Carter / 16 October 2017

Blog Updates Around The Web
Hep Blogs
The Liver Disease That Threatens Us All
Lucinda K. Porter, RN
A few months ago, I reviewed Skinny Liver, a book about the most common liver disease in the United States—nonalcoholic fatty liver disease (NAFLD). Some studies estimate that up to 30 percent of Americans have fatty liver disease...

Daryl Luster
In recalling the early days of my hep C experience, I am reminded of just how awful I felt for years before I knew it was caused by hep C.

Hepatitis C and Breastfeeding
Carleen McGuffey
Did you also know that it’s perfectly safe and recommended for mothers with hepatitis C to breastfeed their infants? You need to know this, Mama. You probably even need to print this information from the CDC out to take with you to the delivery room and prenatal appointments, since many healthcare professionals are unaware regarding this science. HIV is different than HCV. HIV can be passed from mom to baby through breastfeeding and many providers falsely assume the same rules apply. They don’t.

The Weekly Bull
How HCV hides in the body; a new blood test to find liver cancer; rapid fibrosis in co-infected MSM, inadequate hospice care for people with chronic liver disease, efficacy of Maviret in chronic kidney disease ……..


HIV and ID Observations
Paul E. Sax, MD
Price’s “Quarantine” Comment a Startling Example of Remaining HIV Stigma and Ignorance
The stigma, fear, and ignorance associated with HIV are still very strong; those of us who do this work on a daily basis might forget this sad fact.

The Best Antiretroviral Therapy for Pregnant Women? The Controversy Continues
Paul E. Sax, MD
There’s considerable controversy in an area of HIV medicine that one would think should be all but solved by now. It’s what HIV treatment we should give pregnant women. The issue isn’t how to prevent the virus from being transmitted to the newborn — suppress the virus in mom, baby doesn’t get it — it’s what’s safest for the pregnancy outcome.

Harvard Health Publications
Robert H. Shmerling, MD
Statin drugs are among the most widely prescribed medications in the world. They lower cholesterol, reduce inflammation, and have been proven to reduce the risk of heart attack and stroke in those at high risk for these conditions. However, a limiting side effect is...

Dos and don’ts for patients who consult Dr. Google

Dear patient, I meet people several like you on a daily basis. It is always a pleasure to meet you since you come much more prepared compared to the average patient. I have seen you with several sheets of paper or even a notebook, a list of questions and an extra sheet of paper on which to write recommendations. You may even have printed research papers and articles off the Internet. I ...

Why are you seeing the gastroenterologist?
The decision to forego proven cancer treatment is an alarming trend, not unique to billionaire tech moguls. In fact, it’s a decision that I have witnessed with some frequency.  I’ve seen patients decline surgery, chemotherapy, and/or radiation — cancer therapies that have been proven to be beneficial. I have also witnessed these and other cancer patients return with cancers that had grown and spread because of a delay in evidence-based treatment.  This led our team to conduct a research study in order to determine whether the patients who chose alternative medicine in lieu of conventional cancer therapy were putting themselves at risk.

Healthy You
Drug-induced Liver Injury Remains Under-reported, Poorly Understood
Healio Gastroenterology, October 2017
Understanding of the causes and outcomes of drug-induced liver injury remains low not only among clinicians and patients, but also among the experts who study this phenomenon. There are emerging data showing that antibiotics and herbal and dietary supplements, or HDS, are the most important culprits of hepatotoxicity in the U.S. Beyond that, less frequent associations with other drug classes have been reported, but interesting and provocative genetic signals and immune factors are starting to emerge from ongoing studies that require further follow-up.

At the heart of the problem is that most clinicians still do not report DILI, according to Robert J. Fontana, MD, Medical Director of Liver Transplantation and professor of medicine at the University of Michigan. Fontana is co-chair of the Drug-Induced Liver Injury Network (DILIN), which aims to tackle the problem head-on. “Our network is important because these injuries are both under-recognized and under-reported,” he said. “We currently have six sites right now studying the problem in the U.S., but awareness is increasing.”...

Healio Gastroenterology, October 2017
Nancy S. Reau, MD, FAASLD, AGAF
Common medical perception of drug-induced liver injury, or DILI, associates it with stigmatized drugs and well-known injurious medications such as acetaminophen, but today, the picture can look quite different.

Fatty liver disease fastest-growing reason for transplants in young U.S. adults
By Carolyn Crist
About 18% of transplants were for acute liver failure, and other important causes were hepatitis C and B as well as liver cancers. Nonalcoholic steatohepatitis, also called NASH, accounted for just 3.3% of transplants across the entire study period, but it was the fastest-growing reason for transplant.

Harvard study: It’s not too late to start a healthy diet
Changing to one of three scientifically developed healthy eating programs is associated with improved longevity.

HEALTHbeat - Harvard University
If you're having the occasional twinge of joint pain when you go for a walk or climb stairs, or you're worried about arthritis because a parent had it, one step toward prevention is to check your weight.

Hope you get that flu shot, I'm not elderly, but I sure did get mine.
Enjoy the upcoming weekend everyone.

Friday, October 13, 2017

TGIF! HCV-related diseases and Coverage from the International Conference on Viral Hepatitis (ICVH) 2017

TGIF! Welcome to a review of this week's news, research and updates around the web.

New Online - HCV-related diseases
In case you haven't heard, HCV Advocate has launched a series of patient-friendly articles about the Extrahepatic Manifestations of Hepatitis C, written by Alan Franciscus.

Provided below is the latest articles in the series, make sure not to miss new articles published later this month, sign up here to receive updates, follow HCV Advocate on Twitter or connect on Facebook. Find out what's new, here!

HCV Advocate Index - Extrahepatic Manifestations of Hepatitis C
Oct 11
Hepatitis C and Porphyria Cutanea Tarda (PCT)
Oct 10
The Hepatitis C Connection – Fibromyalgia
Oct 5
Oct 3
Mixed Cryoglobulinemias

Just So You Know
Research has demonstrated that two-thirds of individuals with HCV infection experienced extrahepatic manifestations over the course of their disease. The good news is treating HCV early, and curing the virus, is shown to "reduce symptoms and mortality from severe extrahepatic manifestations."

Recommended Reading
Extrahepatic manifestations of HCV & Treatment

On This Blog
A collection of current research articles on ailments related to HCV
Categorized article directory on the extrahepatic manifestations of hepatitis C.

Coverage from the International Conference on Viral Hepatitis (ICVH) 2017
October 09 - 10, 2017
Chicago, Illinois
Medscape Gastroenterology
Hep C Treatment Increasingly Feasible in Primary Care
Oct 12
CHICAGO — With highly effective treatments for hepatitis C becoming less expensive, it is no longer necessary for subspecialists to treat most patients with this ...
Begin here.....

Oct 11
Medscape Gastroenterology - Hepatitis C Cure 'Difficult to Implement'
Medscape - Hepatitis C Virus Containing the Threat: The New Regimens  
This week episode 4 was added to Medscape's HCV six part video series: Hepatitis C Virus: Containing the Threat
The New Regimens
Liver specialists find that HCV patients who have comorbid conditions and treatment-resistant disease may still be candidates for combination therapies. 
View here....

October 11
MedPage Today - Sustained Response with HCV Combo Drug in chronic kidney disease (CKD)
Patients with both diseases had virologic response and no failure
MedPage Today reported on trial results from the phase III trial using Glecaprevir and Pibrentasvir (Mavyret) for 12 weeks in adults with chronic HCV genotype 1-6 and chronic renal impairment, published this week in the New England Journal of Medicine.
Begin here...

On Twitter
Collaborating with others on Twitter, Henry E. Chang tweets everyday about viral hepatitis, pointing us to full text articles using an online sharing platform. Check out the following articles, shared by Mr. Chang this week.

Long-term follow-up of clinical trial patients treated for chronic HCV infection with DCV-based regimens
Daclatasvir has achieved high sustained virologic response (SVR) rates in diverse hepatitis C virus (HCV) populations. This study evaluated the long-term efficacy and safety of daclatasvir-based regimens administered during clinical studies.

Resistance characterization of LDV & SOF in HCV genotype 4
Here we characterize the resistance profile of ledipasvir (LDV) and velpatasvir (VEL)inpatients with GT4 HCV infection.

Burden of primary liver cancer & underlying etiologies from 1990 to 2015: Results from GBD 2015 study
What is the burden of liver cancer globally, what are the major risk factors for liver cancer across countries, regions, and at the global level and how did these change between 1990and 2015?

Statins & liver disease: Is it time to recommend statins to prevent liver disease progression?
There is now mounting observational evidence of a beneficial effect, a limited number of randomized controlled trials demonstrating benefit, and laboratory studies supporting biologic plausibility of hepatic protection.

This study aimed to inform Hepatitis C (HCV) treatment by (1) better understanding the nexus of factors physicians consider when making HCV treatment decisions; (2) investigating the comparative influence and importance of specific factors and the trade-offs implicated in the decision making process; and (3)examining how much thrombocytopenia impacts treatment decisions and how it impacts treatment

Follow or view current Tweets; HenryEChang

Oct 7
Of Interest - Generic DAAs
Journal of Virus Eradication 
Mass treatment with generic DAAs is a feasible and economical alternative route of accessing curative DAAs, where the high prices for branded alternatives prevent access to treatment.

October 05
FixHepC - Blog
A site to help patients access affordable generic hepatitis C treatment. 
Just out of embargo for AASLD 2017 is the rather innocuous sounding Abstract 1078 which says, in brief, that these generic DAAs are inarguably proven the same as the originator DAAs....

Updates On This Blog
The Liver Meeting® 2017

Recommended Reading
September 2017 Volume 7, Issue 3, Pages 253–261
Chronic Hepatitis C: Do Generics Work as Well as Branded Drugs?

Today's News
Oct 13
How hepatitis C wages guerrilla warfare
Kari Williamson
How hepatitis C converts innocent cells into virus factories
The Hepatitis C (HCV) virus is a sly enemy to have in one’s body. Not only does it manage to make itself invisible to the immune system by breaking down communication between the immune cells, it also builds secret virus “factories” that quickly go into mass production.

It takes one to three months from infection to disease, and in the worst case scenario can lead to liver failure and death over time.

After an intense hunt, NTNU researchers can now describe an important part of the disease’s guerrilla tactics: how hepatitis C converts innocent cells into outright virus factories
Continue to article...

Oct 13
Cost, fear of side effects key barriers to HCV treatment
Cost, insurance and apprehension of side effects were the leading barriers to hepatitis C treatment, according to results from a recent survey of individuals either cured or not cured of HCV.

Oct 13
Optimizing Drug Plasma Levels Predicts SVR in Hepatitis C Patients
Specialty Pharmacy Times
The largest prospective study of ribavirin steady-state plasma levels in hepatitis C (HCV) patients in the current era of direct acting antiviral (DAA) treatment ...

Oct 12
"Compelling need" for HIV prevention in people over 50
NEW YORK (Reuters Health) - Given the rising incidence of HIV infection in people over age 50, more-targeted testing, educational and preventive interventions are needed, researchers say.

Dr. Lara Tavoschi from the European Centre for Disease Prevention and Control told Reuters Health, "The steady increase in the number of new HIV diagnoses among people over the age of 50 shows that the HIV epidemic in Europe is evolving in new directions."

"This increase is potentially a result of a lack of awareness of HIV and how it is transmitted in this group," she said by email. "This also means that they may underestimate their own risk of infection."
To investigate, Dr. Tavoschi and colleagues compared European HIV surveillance data from 2004 through 2015 between people age 50 or older and those ages 15 to 49, stratifying by age, sex, migration status, transmission route and CD4-cell count.

More than 54,000 new HIV diagnoses were reported in older adults, according to the study published online September 26 in The Lancet HIV.
Article -

Researchers: Hepatitis C virus control needs a public health approach
A public health approach is necessary to identify and treat hepatitis C virus (HCV)-infected individuals and prevent new infections, according to a new study. “We believe that the success of public health interventions, such as those for tuberculosis, can be translated to HCV infection,” lead author Fabienne Laraque, MD, MPH, medical director of the New York City Department of Homeless Services/Department of Social Services, told Medical Economics.

Oct 12
USC team finds a potentially better way to treat liver cancer
Keck School of Medicine researchers may have discovered a new way to remove drug-resistant "seed cells" for liver cancer therapy.

Oct 11
Duration of Hepatitis C Virus Therapy
Shorter duration therapy reduces treatment costs and may also improve adherence. How short can therapy be and who would qualify?

Blog Updates Around The Web
Hep B Blog
October is Liver Cancer Awareness Month! What’s the Hep B Connection?
According to the World Health Organization (WHO), liver cancer is the second most common cancer in the world, leading to 788,000 annual deaths worldwide.

Kevin MD
This is who’s to blame for the opioid crisis
It’s hard to imagine that law enforcement and the DEA were unable to recognize the difference between pill distributing centers and legitimate practices prescribing medications on a limited basis to individuals with documented needs. City, county and state governments gladly accepted the tax benefits, occupational license fees, and pharmaceutical license fees from these sham clinics while drug dealers drove in and out of our state to obtain prescription pain medications for sale in their hometowns. Of course, the blame for this was placed on the doctors and dentists.
The War on Hep C is Led by Veterans
With an enemy like hepatitis C, there is a continuous uphill struggle. For those who have served in the military, your time has come. The Veterans Administration (VA) has begun to launch.

The Dark Side of Stigma with Hepatitis C (Part 3)
By now, you may have already begun to recognize the voices that blame you for living with hep C virus. You can spot the accusations in your head. By catching yourself while in the middle of a self-induced tongue lashing and calling BS, you are coming out of the dark side of stigma with hepatitis C.

Hep Blogs
Living Beyond Hepatitis C with Faith and Trust
Living beyond hepatitis C is the hope for every hep C patient. Faith and trust when you have hepatitis C is not always easy. Dealing with hep C diagnosis, searching for treatment and holding onto to hope for a new life free from hep C, every patient has walked this road.

Moving Right Along
It has been so long since I posted that I don’t know where to begin. Changes! A lot of changes happened in the last 12 months. It seems as if I am a totally different person than I was last September. But here I am in the middle of Now with the wisdom that comes from shifting and adjusting… and the joy. Always gratitude and joy.

10 Proactive Steps for your Hep C Battle Plan
Do you feel like you’re battling something bigger than you? Hepatitis C can feel like that. There is hope for stopping Hep C in its tracks. First and foremost, you have to develop a good Hep C battle plan.

HIV and ID Observations
What Should We Do About Persistent Low-level Viremia?
Oh my, so much to unwrap here! Because when it comes to persistent low-level viremia in treated HIV patients, there’s much agony, gnashing of teeth, and confusion.

Health News Review
Review of article published by Health Day: Hate UTIs? One Simple Step Can Cut the risk
Drink more water to reduce UTI risk, urge researchers who work for Evian's manufacturer
Our Review Summary Urinary tract infections, or UTIs, are a common problem among women, and this story looks at a possible preventative technique: drinking more water. A study conducted in Bulgaria tracked women over a year, half of whom significantly increased the amount of water they drank. The story was strong on many points, providing …" Drink more water to reduce UTI risk, urge researchers who work for Evian’s manufacturer"
Read the review -

In Case You Missed It
Published in Gastroenterology
Journal Scan / Research · October 11, 2017
Influence of Metabolic Risk Factors on Risk of Hepatocellular Carcinoma and Liver-Related Death in Men With Chronic Hepatitis B
This study examined the association between metabolic risk factors and hepatocellular carcinoma in Asian males 40 to 65 years old with chronic hepatitis B virus infection

Clinical Cure of Hepatitis C Virus Is Possible Even With Detectable Viremia After Treatment Completion
Published in Gastroenterology
Journal Scan / Research October 13, 2017
This small case series reported that 5 patients with a detectable hepatitis C virus level after completing treatment with direct-acting antivirals, 1 with detectable viral levels 4 weeks after completion of therapy, went on to have a sustained virologic response.

Healthy You
The Lancet Volume 390, No. 10104, p1716, 14 October 2017
The link between cancer and obesity
The US Centers for Disease Control and Prevention released a new report on cancer and obesity last week, highlighting that cancers associated with overweight and obesity, including thyroid, liver, kidney, and ovarian cancer, constitute 40% of cancers diagnosed in the USA, with over 630 000 diagnoses in 2014 alone. The study looked at data from the United States Cancer Statistics for 2005-2014. Disparities between sexes in the rates of cancers associated with obesity are especially stark, with 55% of all cancers diagnosed in women being associated with overweight and obesity, compared with only 24% of cancers in men. Most of the disparity is due to endometrial, ovarian, and post-menopausal breast cancer, which together make up 42% of cases of obesity-related cancers. The report did not look at lifestyle factors, but the fact that women are less likely to use tobacco and alcohol makes the sharp burden for women-only overweight and obesity cancers especially confounding. Continue to Editorial @ Lancet ......

CDC Report
October Audio and Teleconference Transcript: Obesity and Cancer
CDC Telebriefing: New Vital Signs Report – Why is the overall cancer rate declining, while cancer rates associated with overweight and obesity are on the rise?

Fructose: A Dietary Sugar in Crosstalk with Microbiota Contributing to the Development and Progression of Non-Alcoholic Liver Disease
Fructose is one of the key dietary catalysts in the development of non-alcoholic fatty liver disease (NAFLD). NAFLD comprises a complex disease spectrum, including steatosis (fatty liver), non-alcoholic steatohepatitis, hepatocyte injury, inflammation, and fibrosis. It is also the hepatic manifestation of the metabolic syndrome, which covers abdominal obesity, insulin resistance, dyslipidemia, glucose intolerance, or type 2 diabetes mellitus.

Helpful Links
Premier Hepatitis C Websites, Blogs and Support Forums

Thanks for stopping by, check back for updates.

Friday, October 6, 2017

TGIF - HCV Headlines & Newsletters - Reuters Updated Article On The Cochrane Review of HCV Direct-acting Antivirals

HCV Headlines, Blog and Newsletter Updates 
Welcome to Friday! Check out today's news, along with recent journal and blog updates. Plus this months great index of October newsletters.

In The News
The Cochrane Review of HCV direct-acting antivirals is in the news again, yesterday an "updated article" from Reuters, noted the change in the authors conclusions, pointed out last month via Twitter by "Henry E. Chang."

An excerpt from the updated article; Do direct-acting antivirals curb the long-term effects of chronic HCV infection?
As reported in the Cochrane Database of Systematic Reviews, online September 18, the team stated they "could not reliably determine the effect of DAAs on the market or under development on (the) primary outcome of hepatitis C-related morbidity or all-cause mortality."
Full-text Cochrane Review with updated conclusions
Again thanks to Mr. Chang, "click here," to read the full-text Cochrane Review with updated conclusions. In addition, check out the backstory or follow the links to each rebuttal, written by HCV experts and devoted advocates.
Begin here...

Today's News
Is Birth Cohort Screening Effective for Identifying HCV Cases?
Yes; in three randomized trials, birth cohort screening was three to eight times more effective than risk-based screening...

California Works to Contain Deadly Hepatitis A Outbreaks - Medscape
"In our outbreak, 45% of the cases are illicit drug users, and nearly one in four had chronic hepatitis B or C yet had not been previously immunized," said Dr ...

Hundreds Hospitalized in San Diego as Hepatitis A Outbreak Spreads
Drug users, the homeless most affected; county has launched vaccination effort..

Denver VA nurse accused of swapping fentanyl syringes
DENVER – A former nurse at the Denver VA has been charged with stealing fentanyl. Investigators say it happened in 2016 and on several occasions Lisa Marie Jones allegedly removed fentanyl from a vial and replaced it with another substance.

How HCV Drug Makers Hit a Wall
There’s reason to believe the well for hepatitis C (HCV) treatments has dried up.

Liver Cancer Remains a Major Public Health Burden Globally
FRIDAY, Oct. 6, 2017 (HealthDay News) -- Causes of primary liver cancer differ widely among populations globally, but most cases can be prevented, according to a study published online Oct. 5 in JAMA Oncology.

Treating Hepatocellular Carcinoma: A Fight Against the Odds
Jasenka Piljac Žegarac, PhD
In an interview with Infectious Disease Advisor, Richard Burkhart, MD, assistant professor of surgery at Johns Hopkins Hospital, Baltimore, Maryland, and Amulya A. Nageswara Rao, associate professor of pediatrics and director of the Pediatric Brain Tumor Clinic at Mayo Clinic, Rochester, Minnesota, discussed the challenges associated with treating HCC.

Of Interest
October Audio and Teleconference Transcript: Obesity and Cancer

Seasonal Flu
Influenza Vaccine Good Match for Circulating Strains
Antigenic and genetic characterization of circulating influenza strains detected to date show few surprises, suggesting the 2017 to 2018 vaccine will offer good protection against this year's viruses.

Read all past and current Seasonal Flu Vaccine articles posted on this blog.

Journal Updates
Real-life results of sofosbuvir based therapy in chronic hepatitis C -naïve and -experienced patients in Egypt
In the real-life setting, Sofosbuvir based regimens for 24 weeks has established an efficacious and well tolerated treatment in naïve and experienced patients with chronic HCV genotype 4 infection; although shorter treatment durations may be possible. However, patient follow up should extent to at least 6 months post-treatment and verifying viral load on yearly basis is warranted to track any late relapse...

Incidence of DAA failure and the clinical impact of retreatment in real-life patients treated in the advanced stage of liver disease: Interim evaluations from the PITER network
Failure rate following the first DAA regimen in patients with advanced disease is similar to or lower than that reported in clinical trials, although the majority of patients were treated with suboptimal regimens. Interim findings showed that worsening of liver function after failure, in terms of Child Pugh class deterioration, was improved by successful retreatment in about one third of retreated patients within a short follow-up period; however, in some advanced liver disease patients, clinical outcomes (Child Pugh class, HCC development, liver failure and death) were independent of viral eradication...

Restrictions for reimbursement of interferon-free direct-acting antiviral drugs for HCV infection in Europe
All-oral direct-acting antiviral drugs (DAAs) for hepatitis C virus, which have response rates of 95% or more, represent a major clinical advance. However, the high list price of DAAs has led many governments to restrict their reimbursement. We reviewed the availability of, and national criteria for, interferon-free DAA reimbursement among countries in the European Union and European Economic Area, and Switzerland. Reimbursement documentation was reviewed between Nov 18, 2016, and Aug 1, 2017. Primary outcomes were fibrosis stage, drug or alcohol use, prescriber type, and HIV co-infection restrictions. Among the 35 European countries and jurisdictions included, the most commonly reimbursed DAA was ombitasvir, paritaprevir, and ritonavir, with dasabuvir, and with or without ribavirin (33 [94%] countries and jurisdictions). 16 (46%) countries and jurisdictions required patients to have fibrosis at stage F2 or higher, 29 (83%) had no listed restrictions based on drug or alcohol use, 33 (94%) required a specialist prescriber, and 34 (97%) had no additional restrictions for people co-infected with HIV and hepatitis C virus. These findings have implications for meeting WHO targets, with evidence of some countries not following the 2016 hepatitis C virus treatment guidelines by the European Association for the Study of Liver.

On Twitter
The following articles were shared on Twitter, by @HenryEChang

High sustained virological response rates using imported generic direct acting antiviral treatment for hepatitis C
This analysis assessed the efficacy of generic imported DAAs.

Treatment of HCV with 8 weeks of LDV/SOF: Highly effective in a predominately black male patient population
Reducing the duration of hepatitis C therapy may cut costs and improve adherence, but recent studies suggest that black men have lower cure rates than other patients when treatment durations are shortened. Here, we report high efficacy in a real world cohort of predominantly black male patients with hepatitis C.

Curing HCV infection: Best practices from the U.S. Department of Veterans Affairs
The widespread availability of curative oral DAA medications has made HCV epidemiologic control seem achievable. The VA is steadily approaching this goal and remains committed to diagnosing and treating all veterans with HCV infection who are willing and able to be treated.

Role of Age and Race in the Risk of HepatocellularCarcinoma in Veterans With HepatitisB Virus Infection
We conducted a retrospective cohort study using the national Veterans Administration data to identify patients with chronic HBV infection from 2001 through 2013. We examined the effect of race and age on HCC risk while adjusting for baseline clinical characteristics.

The cost of successful antiviral therapy in hepatitis C patients: a comparison of iFn-free versus iFn-based regimens at an individual patient level in Australia
We performed a retrospective chart review of 30 HCV-infected patients successfully treated with IFN-based therapy between 2013 and 2015. We also generated a model for a virtual group of 100 genotype 1 (GT1) and 100 genotype 3 (GT3) patients treated with IFN-free therapy derived from national guidelines and clinical trial data.

Blog Updates
By Rick Nash - October 5, 2017
When starting treatment, it’s an important question, how much can I work while on treatment? Of the six different treatments I’ve been on, I’ve worked part-time, full-time, some of the time, and...

The Dark Side of Stigma with Hepatitis C (Part 2) 
By Karen Hoyt - October 4, 2017
Click here to read Part 1 of The Dark Side of Stigma with Hepatitis C. Most of us have experienced stigma from having hep C. It’s easy to recognize the judgment that...

Staying Connected 
By Daryl Luster - October 3, 2017
Back in the day, when people were said to have connections it had nothing to do with the internet or the modern world of connectivity, where we are almost all involved in...

In Case You Missed It
The Physical and Emotional Toll of Hep C: Results from the Hepatitis C In America Survey

Hepatitis B Foundation
Who is Ted Slavin?
“Who is Ted Slavin? Why haven’t I heard about him before?” crept into my mind as I was reading The Immortal Life of Henrietta Lacks. Rebecca Skloot wrote a short snippet about Ted Slavin, detailing the story of a hemophiliac who sold his antibodies and aided Dr. Baruch Blumberg in the discovery of the link between the hepatitis B virus and liver cancer, which eventually led to the first hepatitis B vaccine..

Save The Date - October 12, 2017
On Thursday, Oct. 12, representatives from Hepatitis B Foundation, CDC’s Division of Viral Hepatitis, and NASTAD (the National Alliance of State and Territorial Aids Directors) will co-host a twitter chat at 2 p.m. EST using the hashtag #liverchat.

Creating a World Free of Hepatitis C
Improving Your Memory
October 5, 2017
Lucinda Porter

HEP - Blog Updates
Hepatitis C Treatment: Taking Care Physically
By Connie M. Welch        
Tips for how to take care of your health when living with hepatitis C..

HIV and ID Observations
With Several Wrong Predictions Behind Me, Here’s One I Got Right
Oct 1, 2017
Paul E. Sax, MD
However, when I wrote this summer that we might be at the end of HCV drug development, it turned out to be pretty spot-on. Since then, two companies have ended their HCV drug development programs, one in early September, then another last week. You can read more about the business reasons here, but the simple medical reason is that it would be an enormous challenge to improve on what we have now — which is good news for our patients, provided remaining access issues can be resolved...

MD Whistleblower
Does Secretary Tom Price Deserve Forgiveness?
Oct 1, 2017
Michael Kirsch, M.D.
What is the explanation for Tom Price, a physician and current Secretary of Health and Human Services, taking private charter flights costing taxpayers hundreds of thousands of dollars?

Weekly Bull
Read The Latest Issue: Weekly Bull

Hepatitis B & C Public Policy Association
October 2017 – Newsletter

HCV Advocate
October Newsletter

National Viral Hepatitis Roundtable
September/October 2017 NVHR Newsletter

The New York City Hepatitis C Task Force
Hep Free NYC Newsletters

GI & Hepatology
October Newsletter

Support Forums

Our goal is to be friendly, supportive, and most of all, informative about all aspects of transplantation. If we don't have an immediate answer to a question, we will search the Internet for information for you.

Hep Forum

Hep C Discussion Forum
Global Hepatitis C Support and Information

This message board will allow you to keep in touch with other patients, or caregivers, exchange ideas, as well as give and receive support. 

Helpful Links

Video Updates - Medscape
The Power to Protect: Vaccination Guidelines for Adults With Chronic Diseases
October 2017
CDC reviews the latest vaccine recommendations for adults, including patients with chronic medical conditions.

2017-2018 Influenza Vaccination Recommendations        
October 2017
The latest CDC influenza vaccination recommendations outline which vaccine products should--and which should not--be used to protect against flu this season.

Should You Recommend Coffee Drinking to Your Patients?
October 2017                         
(Video) Recent studies suggest that coffee drinking may be good for you, but more data replicating these studies are needed. Should you recommend coffee consumption to patients?
Free registration may be required to view videos

Happy Friday!

Friday, September 29, 2017

TGIF HCV Review - Merck Discontinues MK-3682B and MK-3682C Development Programs

Happy Friday! Here are a few updates on viral hepatitis you may have missed this week.

Quick Links
Weekly news recap at HepCBC.

In The News
Merck Discontinues MK-3682B and MK-3682C Development Programs
Sep 29, 2017
Company to Focus on Maximizing the Potential of ZEPATIER ® (Elbasvir and Grazoprevir)
Merck (NYSE:MRK), known as MSD outside of the United States and Canada, today announced its strategic decision to discontinue the development of the investigational combination regimens MK-3682B (grazoprevir/ruzasvir/ uprifosbuvir) and MK-3682C (ruzasvir/uprifosbuvir) for the treatment of chronic hepatitis C virus (HCV) infection. This decision was made based on a review of available Phase 2 efficacy data and in consideration of the evolving marketplace and the growing number of treatment options available for patients with chronic HCV infection, including ZEPATIER® (elbasvir and grazoprevir).

8 top stories on injection drug users, HIV/HCV coinfection
Sep 29, 2017
At the recent International Symposium on Hepatitis Care in Substance Users, researchers presented new data on injection drug users and their unique risk factors for hepatitis C infection and transmission, including younger age, and the critical need for HCV education among addiction clinic workers.

Flu Updates
Sept 29, 2017

Read all past and current Seasonal Flu Vaccine articles posted on this blog.

Sep 28,2017
by Liz Highleyman
The FDA recently approved two new combination regimens for hepatitis C, raising the question of whether further drug development is warranted in this area.
Gilead's Vosevi (sofosbuvir/velpatasvir/voxilaprevir) and AbbVie's Mavyret (glecaprevir/pibrentasvir) work against all hepatitis C virus (HCV) genotypes, with cure rates exceeding 95%. And Mavyret, which many patients will be able to take for just 8 weeks, brings a lower cost option to the market.
* Free registration required

Weekly / September 29, 2017 / 66(38);1031
QuickStats: Death Rates* for Chronic Liver Disease and Cirrhosis, by Sex and Age Group — National Vital Statistics System, United States, 2000 and 2015
From 2000 to 2015, death rates for chronic liver disease and cirrhosis in the United States increased 31% (from 20.1 per 100,000 to 26.4) among persons aged 45–64 years. Rates in that age group increased 21% for men (from 29.8 to 36.2) and 57% for women (from 10.8 to 17.0). Among persons aged 25–44 years, the death rate for men decreased 10% (from 6.1 to 5.5), and the rate for women increased 18% (from 2.8 to 3.3). Overall, among persons aged ≥65 years, rates increased 3% (from 29.4 to 30.2). Death rates for both men and women increased with age.

CDC - Mandating HCV Screening Increased Newly Diagnosed and Access to Care
Sept 28, 2017
Implementation of the New York law mandating health care providers to offer HCV testing to persons born during 1945–1965 was associated with an increase in HCV testing, and an increase in the percentage of persons with newly diagnosed HCV infections who were linked to care. Marked increases in the number of HCV tests performed and rates of testing were observed immediately after enactment of the law and remained steady over a 12-month period. Smaller increases were noted in the number of persons who accessed care after receiving a positive HCV screening test result....

Related: Does Mandating HCV Screening Among Baby Boomers Improve Outcomes?

Does Sustained Virologic Response Improve Glycemic Control in HCV?
Sept 29, 2017
Eradicating hepatitis C virus (HCV) infection with direct-acting antiviral (DAA) agents in patients with diabetes reduced the amount of diabetic medication needed and significantly reduced the need for insulin, according to a study in Diabetes Care.

Hepatitis C Formulary Choices for 2018: Will CVS Risk Looking Bad?
Sep 28, 2017
AbbVie’s aggressive list pricing for its new Hepatitis C Virus (HCV) drug Mavyret is disruptive to the current PBM business model.  It essentially asks PBMs to align with client interests by adding a cost-effective drug to their national formularies despite little to no possibility for retained rebates.
On September 15, 2017 Express Scripts (ESRX) chose to align with client interests by opening up the HCV therapeutic class to include Mavyret as well as other HCV drugs previously excluded.   If CVS chooses not to add Mavyret, it will be a sign that CVS is so desperate for rebate income that it is willing incur a very public case of misaligned interests.

FDA improves access to reports of adverse drug reactions
Sep 28, 2017
The U.S. Food and Drug Administration today launched a new user-friendly search tool that improves access to data on adverse events associated with drug and biologic products through the FDA’s Adverse Event Reporting System (FAERS). The tool is designed to make it easier for consumers, providers, and researchers to access this information.

Japan - AbbVie Announces Approval of MAVIRET™ (glecaprevir/pibrentasvir) of Chronic Hepatitis C in All Major Genotypes (GT1-6)
Sept. 27, 2017 /PRNewswire/ -- AbbVie (NYSE: ABBV), a global research and development-based biopharmaceutical company, today announced that the Japanese Ministry of Health, Labour and Welfare (MHLW) approved MAVIRET™ (glecaprevir/pibrentasvir), a once-daily, ribavirin-free treatment for adults with chronic hepatitis C virus (HCV) infection across all major genotypes
Sep 26,2017
Most patients with hepatitis C genotype 2, 4, 5 or 6 who received Mavyret for 8 weeks achieved sustained virologic response with a high safety profile, according to results from three phase 3 studies. The rate of virologic failure was less than 1%.

Communication of the Alcohol Guidelines ‘needs to be improved’
A study published today concludes that more needs to be done to communicate the drinking guidelines to the public. The study, published in the Journal …

September 28, 2017
There is a considerable burden of hepatitis C in Europe related to the lack of prompt diagnosis. We aimed to estimate the prevalence and related risk factors of HCV infections by the stages of liver fibrosis, using non-invasive methods, to understand testing needs in Poland.

Accepted manuscript online:
Article provided by @HenryEChang via Twitter

September 26, 2017
In a recent study, researchers examined whether muscle volume loss or portal hypertension were predictive of mortality among patients with liver cirrhosis.

Gut Health - Deaths from liver disease are soaring and people in deprived areas are at far higher risk. Now doctors are calling for more action to cut the death toll.

In case you missed it
Study of prevalence and pattern of peripheral neuropathy in patients with liver cirrhosis
Mahim Mittal, Pavan Kumar Singh, Sonu Kurian
Peripheral neuropathy is present in more than half of cirrhosis patients and is unrelated to etiology and nutritional status but related to the severity of cirrhosis.
LINK: Download Full Text - PDF

Liver Transplant
September 28, 2017
A recently published analysis of veterans with hepatocellular carcinoma showed that receipt of liver transplantation, Barcelona Clinic Liver Cancer stage and…

September 26, 2017
Patel and Su are among more than 16,000 Americans waiting for a liver transplant because of conditions such as hepatitis, cancer or cirrhosis. But only about 7,000 livers are donated each year. So they know their odds aren't great.

Rising Rates of Hepatocellular Carcinoma Leading to Liver Transplantation in Baby Boomer Generation with Chronic Hepatitis C
25 September 2017
We aim to study the impact of the baby boomer (BB) generation, a birth-specific cohort (born 1945–1965) on hepatocellular carcinoma (HCC)-related liver transplantation (LT) in patients with chronic hepatitis C virus (HCV), alcoholic liver disease (ALD), and non-alcoholic steatohepatitis (NASH).

Liver Cancer
Quantitative imaging predicts microvascular invasion in hepatocellular carcinoma
Last Updated: 2017-09-28
By Will Boggs MD
NEW YORK (Reuters Health) - Quantitative image analysis of preoperative CT scans can be used to predict microvascular invasion in patients with hepatocellular carcinoma (HCC), researchers report...

Reduce Liver Cancer Risk and Join a Liver Cancer Awareness Twitter Chat Oct. 12
October is Liver Cancer Awareness Month and it’s time to “chat” about reducing liver cancer, particularly in people living with hepatitis B and C. On Thursday, Oct. 12, representatives from Hepatitis B Foundation, CDC’s Division of Viral Hepatitis, and NASTAD (the National Alliance of State and Territorial Aids Directors) will co-host a twitter chat at 2 p.m. EST using the hashtag #liverchat.

Estrogen receptor expression in chronic hepatitis C and hepatocellular carcinoma pathogenesis
World J Gastroenterol. Oct 7, 2017
AIM - To investigate gender-specific liver estrogen receptor (ER) expression in normal subjects and patients with hepatitis C virus (HCV)-related cirrhosis and hepatocellular carcinoma (HCC). Various epidemiological studies around the globe have recognized the role of gender bias in the progression of HCV infection to chronic liver disease and cirrhosis due to poor therapeutic responses or further development of HCV-related HCC in these patients...

Environmental Contributions to Gastrointestinal and Liver Cancer in the Asia-Pacific Region
September 28, 2017
Liver cancer is the second most common digestive cancer in Asia. The high incidence of liver cancer in East Asia and South-East Asia is concordant with the high prevalence of hepatitis B virus and hepatitis C virus infection. Other important risk factors include alcohol use, smoking, and diabetes.

New At Clinical Care Options
* Free registration required
Downloadable Slides: Latest Developments in the Treatment of HCC in Veterans
Download this slideset to review the latest data on best practices for the care of patients with HCC across the disease spectrum and to address specific issues unique to treating veterans.   

Quick Reference Guide: HCV Screening and Testing
Download this practical guide to help you appropriately screen your patients for hepatitis C virus infection
Download this practical reference sheet on all the FDA-approved regimens for treating hepatitis C virus 
Start here.....

HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C
September 21, 2017
New Genotype 1 & 3 Treatment-Naïve & Treatment-Experienced
This version of the guidance has been updated to reflect several important developments, including the recent approvals of glecaprevir/pibrentasvir and sofosbuvir/velpatasvir/voxilaprevir. Updated recommendations reflecting these approvals are provided throughout the guidance.

Blog Updates From Around The Web
September 27, 2017
By Kimberly Morgan Bossley
Liver Disease can cause severe muscle loss and weakness..

September 27, 2017
By Connie M. Welch
Hepatitis C patients have many obstacles to fight and deal with, one of the first and biggest is stigma, the danger of labels...

September 25, 2017
By Lucinda K. Porter, RN
Before the Affordable Health Care Act (Obamacare), I was uninsurable. Hepatitis C marked me as having a preexisting condition.  This meant that insurance companies could deny me insurance...

By Kare Hoyt - September 28, 2017
It’s nearly impossible to get medical care without feeling judgment about Hepatitis C. You get used to it, but when you don’t feel good and need help, you expect professionals to show...

By Debra Walters - September 27, 2017
My first dance with Hepatitis C treatment was in 2008-2009. The only option was Ribavirin and peginterferon, so I signed up for a study at Baylor College of Medicine. I was randomized...

Living with PTSD and Hepatitis C (Part 3) 
By Karen Hoyt - September 25, 2017
Check out Part 1 and Part 2 of Karen’s series on PTSD. Post-Traumatic Stress Disorder or PTSD can come from a lot of little traumas and hepatitis C is one of them....

Off The Cuff
The British Liver Trust highlights the common causes of hepatitis A
Published in July, download it, here

In obese adults and children, the microbiome plays key role in one of the most common and serious liver diseases
September 29, 2017
BUFFALO, N.Y. — New clues to non-alcoholic fatty liver disease (NAFLD), which affects nearly all obese adults and a rising percentage of obese children, have been reported in a paper published earlier this month in the journal Gut.

The cost of drugs confounds this gastroenterologist
Michael Kirsch, MD | Meds | September 25, 2017
Most of us do not know the basics of economics, although we should. It impacts every one of us every day that we are alive. Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize. I can't explain fiscal or monetary policy. While I regard economics as a science, it seems that experts routinely interpret data differently, ...

Sep 2017
By Mollie Durkin
Internists can diagnose chronic abdominal wall pain with a simple physical exam and some savvy history taking, experts said, and reassure patients that their condition is not serious and may respond to treatment.... 

Posted September 28, 2017 
Monique Tello, MD, MPH, Contributing Editor Plenty of research supports the common-sense notion that a healthy lifestyle can prevent or treat many diseases. A diet high in fruits, veggies, whole grains, and plant protein and low in processed carbs, added sugars, saturated fats; regular physical activity; and emotional well-being are the potent treatments that can prevent the need for or even…

Enjoy the rest of your day!