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Talal AH, Markatou M, Liu A, Perumalswami PV, Dinani AM, Tobin JN, Brown LS. Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial. JAMA 2024; 331:1369-1378. [PMID: 38568601 PMCID: PMC10993166 DOI: 10.1001/jama.2024.2452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/13/2024] [Indexed: 04/06/2024]
Abstract
Importance Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration ClinicalTrials.gov Identifier: NCT02933970.
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Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | | | - Anran Liu
- Department of Biostatistics, University at Buffalo, Buffalo, New York
| | - Ponni V. Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Amreen M. Dinani
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan N. Tobin
- Clinical Directors Network, Inc (CDN), New York, New York
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Lawrence S. Brown
- START Treatment & Recovery Centers, Brooklyn, New York
- Weill Cornell Medicine, New York, New York
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Winder GS, Fernandez AC, Perumalswami PV, Mellinger JL, Clifton EG. Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation. Liver Transpl 2024; 30:431-442. [PMID: 38009890 DOI: 10.1097/lvt.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Ponni V Perumalswami
- Department of Internal Medicine, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Perumalswami PV, Winder GS, Fernandez AC, Mellinger JL. Practical Considerations to Optimize Care for Patients With Alcohol-Associated Liver Disease in General Gastroenterology Practice. Am J Gastroenterol 2024; 119:591-595. [PMID: 37725695 DOI: 10.14309/ajg.0000000000002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Ponni V Perumalswami
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica L Mellinger
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Perumalswami PV, Adams MA, Frost MC, Holleman R, Kim HM, Zhang L, Lin LA. Telehealth and delivery of alcohol use disorder treatment in the Veterans Health Administration. Alcohol Clin Exp Res (Hoboken) 2024. [PMID: 38529689 DOI: 10.1111/acer.15305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 02/09/2024] [Accepted: 03/06/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The use of telehealth treatment of alcohol use disorder (AUD) has increased since the start of the COVID-19 pandemic. However, it is unclear which patients are using telehealth and how telehealth visits are associated with treatment duration. This study examined characteristics associated with telehealth use among Veterans Health Administration patients receiving AUD treatment. METHODS Using a national retrospective cohort study, we examined data from March 01, 2020 to February 28, 2021 to: First, identify patient characteristics associated with (a) any telehealth versus only in-person care for AUD treatment, and (b) video (≥1 video visit) versus only telephone visits for AUD treatment (≥1 telephone visit, no video) among any telehealth users. This analysis used mixed-effects logistic regression models to adjust for potential correlation across patients treated at the same facility. Second, we assessed whether visit modality was associated with the amount of AUD treatment received (number of AUD psychotherapy visits or medication coverage days). This analysis used mixed-effects negative binomial regression models. RESULTS Among 138,619 patients who received AUD treatment, 52.8% had ≥1 video visit, 38.1% had ≥1 telephone but no video visits, and 9.1% had only in-person visits. In the regression analyses, patients who were male or had an opioid or stimulant use disorder (compared to having no non-AUD substance use disorder) were less likely to receive any telehealth-delivered AUD treatment compared to only in-person AUD treatment. Among patients who received any telehealth-delivered AUD treatment, those who were ≥45 years old (compared to 18-29 years old), Black (compared to White), diagnosed with a cannabis or stimulant use disorder, or diagnosed with a serious mental illness were less likely to receive a video visit than only telephone visits. Receiving any AUD telehealth was associated with receiving more psychotherapy visits and medication coverage days than only in-person care. CONCLUSIONS Telehealth, a common modality for AUD treatment, supported a greater number of psychotherapy visits and a longer duration of medication treatment for AUD. However, some groups were less likely to receive any video telehealth than telephone visits, suggesting that multiple treatment modalities should remain available to ensure treatment access.
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Affiliation(s)
- Ponni V Perumalswami
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
| | - Megan A Adams
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Rob Holleman
- Health Services Research & Development, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Hyungjin Myra Kim
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Consulting for Statistics, Computing & Analytics Research (CSCAR), University of Michigan, Ann Arbor, Michigan, USA
| | - Lan Zhang
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Psychiatry, Addiction Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lewei Allison Lin
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
- Department of Psychiatry, Addiction Center, University of Michigan, Ann Arbor, Michigan, USA
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Winder GS, Clifton EG, Denysenko L, DiChiara AM, Hathaway D, Perumalswami PV, Shenoy A, Suzuki J, Tareen K, Mellinger JL, Fernandez AC. "But I didn't drink!": What to do with discordant phosphatidylethanol results. Liver Transpl 2024; 30:213-222. [PMID: 37486958 DOI: 10.1097/lvt.0000000000000223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023]
Abstract
Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Lex Denysenko
- Department of Psychiatry, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alex M DiChiara
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - David Hathaway
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ponni V Perumalswami
- Department of Internal Medicine, Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akhil Shenoy
- Department of Psychiatry, Columbia University, New York City, New York, USA
| | - Joji Suzuki
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kinza Tareen
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Talal AH, George SJ, Talal LA, Dharia A, Ventuneac A, Baciewicz G, Perumalswami PV, Dickerson SS. Engaging people who use drugs in clinical research: integrating facilitated telemedicine for HCV into substance use treatment. Res Involv Engagem 2023; 9:63. [PMID: 37533127 PMCID: PMC10399008 DOI: 10.1186/s40900-023-00474-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND People who use drugs (PWUD) have difficulty participating in clinical research. We evaluated approaches to engage PWUD in clinical research, using facilitated telemedicine for hepatitis C virus (HCV) care as an example. METHODS We analyzed stakeholder interview transcripts and study-related data (i.e., progress reports, meeting minutes) from interrelated studies to understand engagement experiences at the patient, site, and organizational levels. Stakeholders include patient-participants, opioid treatment program (OTP) staff and administrators, and research team members involved in HCV management through facilitated telemedicine integrated into OTPs. RESULTS Three themes emerged. Initially, the research team sought understanding of the unique culture and community of each OTP (Theme 1). The team built trusting relationships through education, communication, and feedback (Theme 2). Finally, the research team enhanced collaborative care and incorporated the patients' voice to improve health outcomes (Theme 3). Patient-participants and OTP staff endorsed the integrated HCV care approach. Engagement practices are summarized as the CREATE framework (C = culture, R = respect, E = educate, A = advantage, T = trust, E = endorse). CONCLUSIONS PWUD engagement in clinical research is maximized by building trusting relationships with open communication channels. Understanding the community, demonstrating respect, and augmenting knowledge are foundational for engaging PWUD in clinical research. These practices are transferable to engagement of PWUD in clinical research broadly.
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Affiliation(s)
- Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, State University of New York, 875 Ellicott Street, Suite 6090, Buffalo, NY, 14203, USA.
| | - Saliyah J George
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Arpan Dharia
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, State University of New York, 875 Ellicott Street, Suite 6090, Buffalo, NY, 14203, USA
| | - Ana Ventuneac
- START Treatment and Recovery Centers, Brooklyn, NY, USA
| | | | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suzanne S Dickerson
- Division of Biobehavioral Health and Clinical Sciences, School of Nursing, University at Buffalo, Buffalo, NY, USA
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Perumalswami PV, Belemkoabga A, Joseph L, Erblich J, Jandorf L. HBV screening among West Africans living in the US: Influences of stigma, health literacy, and self-efficacy. Hepatol Commun 2023; 7:02009842-202306010-00030. [PMID: 37267200 DOI: 10.1097/hc9.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/13/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Applying theoretically informed constructs using an adaptation of the "Theory of Planned Behavior," this study assessed social-cognitive and sociocultural determinants of HBV screening among West Africans living in the US to inform solutions to testing gaps. METHODS We developed and administered a theory-based survey in both English (41%) and French (59%) from September 2021 to April 2022 to a sample of West African-born individuals (n = 162). Predictors of HBV screening included: attitudes, perceived behavioral control or self-efficacy, and subjective norms along with health literacy (HL), language proficiency, and stigma of HBV infection. We hypothesized that these constructs would predict HBV testing. We also conducted path analytic modeling to better understand both direct and indirect effects of key factors on HBV screening status. RESULTS West Africans who completed the survey in English were younger with less education and lower income, whereas those who completed the survey in French reported higher HBV-related stigma. In a bivariate analysis of factors associated with HBV screening by language, less education was associated with lower HBV screening in English speakers. Adequate HL, higher self-efficacy, and higher English language proficiency were independently associated with HBV screening. Path analysis to better understand the interplay between social-cognitive and sociocultural factors revealed HL and stigma both had indirect effects on screening, mediated by differences in self-efficacy. CONCLUSIONS This study identified HL and stigma as key indirect factors that influence HBV screening by way of self-efficacy in West Africans in the US. This work is a first step to identifying barriers that can lead to the development of an evidence-based intervention aimed at increasing HBV screening of West Africans to address health disparities.
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Affiliation(s)
- Ponni V Perumalswami
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Assita Belemkoabga
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lovely Joseph
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joel Erblich
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Psychology, Hunter College and The Graduate Center, City University of New York, New York, USA
| | - Lina Jandorf
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rocha C, Doyle EH, Bowman CA, Fiel M, Stueck AE, Goossens N, Bichoupan K, Patel N, Crismale JF, Makkar J, Lewis S, Perumalswami PV, Schiano TD, Hoshida Y, Schwartz M, Branch AD. Hepatocellular carcinoma in patients cured of chronic hepatitis C: Minimal steatosis. Cancer Med 2023; 12:10175-10186. [PMID: 37078924 PMCID: PMC10225173 DOI: 10.1002/cam4.5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 01/06/2023] [Accepted: 02/07/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Successful treatment of hepatitis C reduces liver inflammation and fibrosis; however, patients remain at risk of developing hepatocellular carcinoma (HCC). AIMS To identify risk factors for new-onset HCC in patients cured of hepatitis C. METHODS Imaging, histological, and clinical data on patients whose first HCC was diagnosed >12 months of post-SVR were analyzed. Histology of 20 nontumor tissues was analyzed in a blinded manner using the Knodel/Ishak/HAI system for necroinflammation and fibrosis/cirrhosis stage and the Brunt system for steatosis/steatohepatitis. Factors associated with post-SVR HCC were identified by comparison with HALT-C participants who did not develop post-SVR HCC. RESULTS Hepatocellular carcinoma was diagnosed in 54 patients (45 M/9F), a median of 6 years of post-SVR [interquartile range (IQR) =1.4-10y] at a median age of 61 years (IQR, 59-67). Approximately one-third lacked cirrhosis, and only 11% had steatosis on imaging. The majority (60%) had no steatosis/steatohepatitis in histopathology. The median HAI score was 3 (1.25-4), indicating mild necroinflammation. In a multivariable logistic regression model, post-SVR HCC was positively associated with non-Caucasian race (p = 0.03), smoking (p = 0.03), age > 60 years at HCC diagnosis (p = 0.03), albumin<3.5 g/dL (p = 0.02), AST/ALT>1 (p = 0.05), and platelets <100 × 103 cells/μL (p < 0.001). Alpha fetoprotein ≥4.75 ng/mL had 90% specificity and 71% sensitivity for HCC occurrence. Noncirrhotic patients had larger tumors (p = 0.002) and a higher prevalence of vascular invasion (p = 0.016) than cirrhotic patients. CONCLUSIONS One-third of patients with post-SVR HCC did not have liver cirrhosis; most had no steatosis/steatohepatitis. Hepatocellular carcinomas were more advanced in noncirrhotic patients. Results support AFP as a promising marker of post-SVR HCC risk.
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Affiliation(s)
- Chiara Rocha
- Department of Surgery—Transplant DivisionIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Erin H. Doyle
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount Sinai SchoolNew YorkNew YorkUSA
| | - Chip A. Bowman
- Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - M‐Isabel Fiel
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Ashley E. Stueck
- Department of PathologyDalhousie UniversityHalifaxNova ScotiaCanada
| | - Nicolas Goossens
- Division of Liver Diseases, Department of MedicineTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Kian Bichoupan
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Neal Patel
- Division of GastroenterologyDepartment of Medicine, Nuvance Health Danbury HospitalDanburyCTUSA
| | - James F. Crismale
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Jasnit Makkar
- Department of RadiologyColumbia UniversityNew YorkNew YorkUSA
| | - Sara Lewis
- Department of RadiologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Thomas D. Schiano
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Yujin Hoshida
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Myron Schwartz
- Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrea D. Branch
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Perumalswami PV, Kilpatrick S, Frost MC, Adams MA, Kim HM, Zhang L, Lin L. The impact of COVID-19 on trends in alcohol use disorder treatment in Veterans Health Administration. Addiction 2023; 118:1062-1071. [PMID: 36738085 DOI: 10.1111/add.16156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The COVID-19 pandemic disrupted health-care provision in the United States and prompted increases in telehealth-delivery of care. This study measured alcohol use disorder (AUD) treatment trends across visit modalities before and during COVID-19. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS We conducted a national, retrospective cohort study with interrupted time-series models to estimate the impact of COVID-19 on AUD treatment in the Veterans Health Administration (VHA) in the United States during pre-COVID-19 (March 2019 to February 2020) and COVID-19 (March 2020 to February 2021) periods. We analyzed monthly trends in telephone, video and in-person visits for AUD treatment and compared patient and treatment characteristics of patients receiving AUD treatment between the pre-COVID-19 and COVID-19 periods. AUD was defined using International Classification of Diseases, 10th revision (ICD-10) codes for alcohol abuse (F10.1) and alcohol dependence (F10.2), which have previously been used to study AUD in VHA. FINDINGS The predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the beginning of the pre-COVID period was 13.8% (n = 49 494). The predicted percentage decreased by 4.3% (P = 0.001) immediately at the start of the COVID-19 period due to a decline in AUD psychotherapy. Despite an increase of 0.3% per month (P = 0.026) following the start of COVID-19, the predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the end of the study period remained below the pre-COVID-19 period. In February 2021, AUD psychotherapy visits were primarily delivered by video (50%, 58 748), followed by in-person (36.6%, 43 251) and telephone (13.8%, 16 299), while AUD pharmacotherapy visits were delivered by telephone (38.9%, 3623) followed by in-person (34.3%, 3193) and video (26.8%, 2498) modalities. Characteristics of VHA patients receiving AUD treatment were largely similar between pre-COVID-19 and COVID-19 periods. CONCLUSIONS Despite increased telehealth use, the percentage of United States Veterans Health Administration patients with an alcohol use disorder (AUD) diagnosis receiving AUD treatment declined during COVID-19 (March 2020 to February 2021) mainly due to a decrease in psychotherapy.
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Affiliation(s)
- Ponni V Perumalswami
- Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Sidonie Kilpatrick
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA.,Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Megan A Adams
- Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor, MI, USA
| | - Lan Zhang
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Lewei Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor, MI, USA
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10
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Hershman M, Torbjornsen K, Pang D, Wyatt B, Dieterich DT, Perumalswami PV, Branch AD, Dinani AM. Modification of the Diabetes Prevention Program for the Treatment of Nonalcoholic Fatty Liver Disease: A Pilot Study. Obes Sci Pract 2022. [DOI: 10.1002/osp4.637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Melissa Hershman
- Division of Gastroenterology Oregon Health & Science University Portland OR97329 United States of America
- Department of Gastroenterology and Hepatology Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Karen Torbjornsen
- Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Daniel Pang
- Department of Medicine Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Brooke Wyatt
- Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Douglas T Dieterich
- Division of Liver Diseases Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Ponni V Perumalswami
- Division of Liver Diseases Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
- Division of Gastroenterology and Liver Diseases University of Michigan Ann Arbor MI48109 United States of America
| | - Andrea D Branch
- Division of Liver Diseases Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
| | - Amreen M Dinani
- Division of Liver Diseases Icahn School of Medicine at Mount Sinai New York NY10029 United States of America
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11
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Perumalswami PV, Wyatt B, Bowman CA, Patel K, Mageras A, Lewis SC, Branch AD. Hepatocellular carcinoma surveillance, incidence, and tumor doubling times in patients cured of hepatitis C. Cancer Med 2022; 11:1995-2005. [PMID: 35261196 PMCID: PMC9089228 DOI: 10.1002/cam4.4508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) incidence and mortality vary by race/ethnicity and both are higher in Black patients than in Whites. For HCC surveillance, all cirrhotic patients are advised to undergo lifelong twice‐annual abdominal imaging. We investigated factors associated with surveillance and HCC incidence in a diverse HCC risk group, cirrhotic patients recently cured of hepatitis C virus (HCV) infection. Methods In this observational cohort study, all participants (n = 357) had advanced fibrosis/cirrhosis and were cured of HCV with antiviral treatment. None had Liver Imaging Reporting and Data System (LI‐RADS) 2–5 lesions prior to HCV cure. Ultrasound, computed tomography, and/or magnetic resonance imaging were used for surveillance. Results At a median follow‐up of 40 months [interquartile range (IQR) = 28–48], the median percentage of time up‐to‐date with surveillance was 49% (IQR) = 30%–71%. The likelihood of receiving a first surveillance examination was not significantly associated with race/ethnicity, but was higher for patients with more advanced cirrhosis, for example, bilirubin [odds ratio (OR) = 3.8/mg/dL, p = 0.002], private insurance (OR = 3.4, p = 0.006), and women (OR = 2.3, p = 0.008). The likelihood of receiving two or three examinations was significantly lower for non‐Hispanic Blacks and Hispanics versus non‐Hispanic Whites (OR = 0.39, and OR = 0.40, respectively, p < 0.005 for both) and for patients with higher platelet counts (OR = 0.99/10,000 cells/µl, p = 0.01), but higher for patients with private insurance (OR = 2.8, p < 0.001). Incident HCC was associated with higher bilirubin (OR = 1.7, p = 0.02) and lower lymphocyte counts (OR = 0.16, p = 0.01). Conclusions Contrary to best practices, HCC surveillance was associated with sociodemographic factors (insurance status and race/ethnicity) among patients cured of HCV. Guideline‐concordant surveillance is needed to address healthcare disparities.
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Affiliation(s)
- Ponni V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brooke Wyatt
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chip A Bowman
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krupa Patel
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna Mageras
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara C Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrea D Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Yip TCF, Lee HW, Chan WK, Wong GLH, Wong VWS, Armstrong MJ, Pose E, Brenner EJ, Cargill T, Catana MA, Dhanasekaran R, Eshraghian A, García-Juárez I, Gill US, Jones PD, Kennedy J, Marshall A, Matthews C, Mells G, Mercer C, Perumalswami PV, Avitabile E, Qi X, Su F, Ufere NN, Wong YJ, Zheng MH, Barnes E, Barritt AS, Webb GJ. Asian perspective on NAFLD-associated HCC. J Hepatol 2022; 76:726-734. [PMID: 34619251 DOI: 10.1016/j.jhep.2021.09.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/10/2021] [Accepted: 09/18/2021] [Indexed: 12/18/2022]
Abstract
Recent data suggest that non-alcoholic fatty liver disease (NAFLD) has become a major public health problem in Asia, with an updated population prevalence of 34%. In parallel, NAFLD-associated hepatocellular carcinoma (HCC) is also on the rise. In this review, we describe the changing epidemiology of HCC in Asia over the past 30 years. While traditional risk factors for HCC (older age, male sex and metabolic factors) are also important in Asia, the PNPLA3 gene polymorphism is particularly prevalent in East Asia and may increase the risk of HCC. NAFLD among non-obese individuals is also commonly described in Asia. Because NAFLD is often undiagnosed, few patients receive HCC surveillance, and the target surveillance population beyond patients with cirrhosis remains poorly defined. As a result, NAFLD-associated HCC is often diagnosed at an advanced stage, rendering curative treatment impossible. Finally, despite around 20-30 years of universal vaccination, chronic HBV infection remains prevalent in Asia, and emerging evidence highlights the importance of metabolic factors and concomitant hepatic steatosis on HCC development in infected patients. Future studies should explore the role of metabolic treatments in HCC prevention among patients with hepatic steatosis and concomitant liver diseases.
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Affiliation(s)
- Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Wah Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong; State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
| | | | - Elisa Pose
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Erica J Brenner
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Maria-Andreea Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ahad Eshraghian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz, Iran
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Upkar S Gill
- Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, QMUL, London, UK
| | - Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James Kennedy
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Charmaine Matthews
- Department of Gastroenterology and Hepatology, Royal Liverpool Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - George Mells
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Carolyn Mercer
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain
| | - Xialong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Feng Su
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease, Zhejiang Province, Wenzhou, Zhejiang, China
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gwilym J Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK; Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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13
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Wyatt B, Perumalswami PV, Mageras A, Miller M, Harty A, Ma N, Bowman CA, Collado F, Jeon J, Paulino L, Dinani A, Dieterich D, Li L, Vandromme M, Branch AD. A Digital Case-Finding Algorithm for Diagnosed but Untreated Hepatitis C: A Tool for Increasing Linkage to Treatment and Cure. Hepatology 2021; 74:2974-2987. [PMID: 34333777 PMCID: PMC9299620 DOI: 10.1002/hep.32086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/29/2021] [Accepted: 07/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Although chronic HCV infection increases mortality, thousands of patients remain diagnosed-but-untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment. APPROACH AND RESULTS We developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV-RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm-defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV-related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P < 0.001) and to have a verified sustained virological response (67% vs. 46%; P < 0.001) than other patients. Forty-eight percent (n = 2,992) of DBU patients could not be reached by phone, which was a major barrier to engagement. Nearly half of these patients had Fibrosis-4 scores ≥ 2.67, indicating significant fibrosis. Multivariable logistic regression showed that DBUs who could not be contacted were less likely to have private insurance than those who could (18% vs. 50%; P < 0.001). CONCLUSIONS The digital DBU case-finding algorithm efficiently identified potential HCV treatment candidates, freeing resources for navigation and coordination. The algorithm is portable and accelerated HCV elimination when incorporated in our comprehensive program.
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Affiliation(s)
- Brooke Wyatt
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Ponni V. Perumalswami
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY,Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI,Gastroenterology SectionVeterans AffairsAnn Arbor Healthcare SystemAnn ArborMI
| | - Anna Mageras
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Mark Miller
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Alyson Harty
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Ning Ma
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Chip A. Bowman
- Department of MedicineIcahn School of Medicine Mount SinaiNew YorkNY
| | - Francina Collado
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Jihae Jeon
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Lismeiry Paulino
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Amreen Dinani
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Douglas Dieterich
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Li Li
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Maxence Vandromme
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Andrea D. Branch
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
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14
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Talal AH, Jaanimägi U, Davis K, Bailey J, Bauer BM, Dharia A, George S, McLeod A, Morton K, Nugent A, Zeremski M, Dinani A, Des Jarlais DC, Perumalswami PV, Tobin JN, Dickerson SS. Facilitating engagement of persons with opioid use disorder in treatment for hepatitis C virus infection via telemedicine: Stories of onsite case managers. J Subst Abuse Treat 2021; 127:108421. [PMID: 34134875 DOI: 10.1016/j.jsat.2021.108421] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 02/07/2023]
Abstract
Although hepatitis C virus (HCV) infection has high prevalence and incidence in persons with opioid use disorder (PWOUD), their engagement in HCV care has been limited due to a variety of factors. In an ongoing multisite study at 12 opioid treatment programs (OTPs) throughout New York State (NYS), we have been evaluating telemedicine accompanied by onsite administration of direct acting antiviral (DAA) medications compared with usual care including offsite referral to a liver specialist for HCV management. Each site has a case manager (CM) who is responsible for all study-related activities including participant recruitment, facilitating telemedicine interactions, retention in care, and data collection. Our overall objective is to analyze CM experiences of clients' stories and events to understand how the telemedicine model facilitates HCV treatment. Hermeneutic phenomenology was used to interpret and to explicate common meanings and shared practices of the phenomena of case management, and a focus group with CMs was conducted to reinforce and expand on key themes identified from the CMs' stories. We identified three themes: (1) building trust, (2) identification of multiple competing priorities, and (3) development of personalized care approaches. Our results illustrate that trust is a fundamental pillar on which the telemedicine system can be based. Participants' experiences at the OTP can reinforce trust. Understanding the specific competing priorities and routinizing dedicated personalized approaches to overcome them are key to increasing participation in HCV care among PWOUD.
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Affiliation(s)
- Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, United States of America.
| | - Urmo Jaanimägi
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, United States of America
| | - Kathleen Davis
- Department of Psychiatry, University of Rochester, Rochester, NY, United States of America
| | - Jordan Bailey
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Barbara M Bauer
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, United States of America
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, United States of America
| | - Saliyah George
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Anthony McLeod
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Karen Morton
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Ann Nugent
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Marija Zeremski
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Amreen Dinani
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Don C Des Jarlais
- School of Global Public Health, New York University, New York, NY, United States of America
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Suzanne S Dickerson
- School of Nursing, University at Buffalo, Buffalo, NY 14203, United States of America
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15
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Marjot T, Moon AM, Cook JA, Abd-Elsalam S, Aloman C, Armstrong MJ, Pose E, Brenner EJ, Cargill T, Catana MA, Dhanasekaran R, Eshraghian A, García-Juárez I, Gill US, Jones PD, Kennedy J, Marshall A, Matthews C, Mells G, Mercer C, Perumalswami PV, Avitabile E, Qi X, Su F, Ufere NN, Wong YJ, Zheng MH, Barnes E, Barritt AS, Webb GJ. Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: An international registry study. J Hepatol 2021; 74:567-577. [PMID: 33035628 PMCID: PMC7536538 DOI: 10.1016/j.jhep.2020.09.024] [Citation(s) in RCA: 330] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease (CLD) and cirrhosis are associated with immune dysregulation, leading to concerns that affected patients may be at risk of adverse outcomes following SARS-CoV-2 infection. We aimed to determine the impact of COVID-19 on patients with pre-existing liver disease, which currently remains ill-defined. METHODS Between 25th March and 8th July 2020, data on 745 patients with CLD and SARS-CoV-2 (including 386 with and 359 without cirrhosis) were collected by 2 international registries and compared to data on non-CLD patients with SARS-CoV-2 from a UK hospital network. RESULTS Mortality was 32% in patients with cirrhosis compared to 8% in those without (p <0.001). Mortality in patients with cirrhosis increased according to Child-Pugh class (A [19%], B [35%], C [51%]) and the main cause of death was from respiratory failure (71%). After adjusting for baseline characteristics, factors associated with death in the total CLD cohort were age (odds ratio [OR] 1.02; 1.01-1.04), Child-Pugh A (OR 1.90; 1.03-3.52), B (OR 4.14; 2.4-7.65), or C (OR 9.32; 4.80-18.08) cirrhosis and alcohol-related liver disease (OR 1.79; 1.03-3.13). Compared to patients without CLD (n = 620), propensity-score-matched analysis revealed significant increases in mortality in those with Child-Pugh B (+20.0% [8.8%-31.3%]) and C (+38.1% [27.1%-49.2%]) cirrhosis. Acute hepatic decompensation occurred in 46% of patients with cirrhosis, of whom 21% had no respiratory symptoms. Half of those with hepatic decompensation had acute-on-chronic liver failure. CONCLUSIONS In the largest such cohort to date, we demonstrate that baseline liver disease stage and alcohol-related liver disease are independent risk factors for death from COVID-19. These data have important implications for the risk stratification of patients with CLD across the globe during the COVID-19 pandemic. LAY SUMMARY This international registry study demonstrates that patients with cirrhosis are at increased risk of death from COVID-19. Mortality from COVID-19 was particularly high among patients with more advanced cirrhosis and those with alcohol-related liver disease.
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Affiliation(s)
- Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Jonathan A Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious diseases Department, Tanta University, Tanta, Egypt
| | - Costica Aloman
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Elisa Pose
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Erica J Brenner
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Maria-Andreea Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ahad Eshraghian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz, Iran
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Upkar S Gill
- Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, QMUL, London, UK
| | - Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James Kennedy
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Charmaine Matthews
- Department of Gastroenterology and Hepatology, Royal Liverpool Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - George Mells
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Carolyn Mercer
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain
| | - Xialong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Feng Su
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease, Zhejiang Province, Wenzhou, Zhejiang, China
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gwilym J Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK; Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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16
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Patel AA, Bui A, Prohl E, Bhattacharya D, Wang S, Branch AD, Perumalswami PV. Innovations in Hepatitis C Screening and Treatment. Hepatol Commun 2021; 5:371-386. [PMID: 33681673 PMCID: PMC7917266 DOI: 10.1002/hep4.1646] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 12/11/2022] Open
Abstract
New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.
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Affiliation(s)
- Arpan A. Patel
- Division of Digestive DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
| | - Aileen Bui
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Eian Prohl
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Debika Bhattacharya
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
- Division of Infectious DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Su Wang
- Saint Barnabas Medical CenterLivingstonNJUSA
- World Hepatitis AllianceLondonUnited Kingdom
| | - Andrea D. Branch
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ponni V. Perumalswami
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
- Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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17
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Da BL, Kushner T, El Halabi M, Paka P, Khalid M, Uberoi A, Lee BT, Perumalswami PV, Rutledge SM, Schiano TD, Friedman SL, Saberi B. Liver Injury in Patients Hospitalized with Coronavirus Disease 2019 Correlates with Hyperinflammatory Response and Elevated Interleukin-6. Hepatol Commun 2021; 5:177-188. [PMID: 33230491 PMCID: PMC7675519 DOI: 10.1002/hep4.1631] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injury is commonly seen in coronavirus disease 2019 (COVID-19); however, the mechanism behind liver injury, particularly in patients with severe and critical COVID-19, remains unclear, and the clinical course is poorly described. We conducted a single-center retrospective cohort study of consecutive patients hospitalized with severe and critical COVID-19 with or without liver injury and who underwent immunologic testing (interleukin [IL]-6, IL-8, tumor necrosis factor alpha [TNF-α], and IL-1β). Liver injury was defined as peak aminotransferases ≥3 times the upper limit of normal (40 U/L) or ≥120 U/L. Patients with liver injury were compared to those who had normal aminotransferases throughout the hospital course. We studied 176 patients: 109 with liver injury and 67 controls. Patients with liver injury were more likely to be men (71.6% vs. 37.3%, P < 0.001). Peak inflammatory markers and IL-6 were higher in the liver injury group: C-reactive protein (CRP), 247 vs. 168 mg/L, P < 0.001; lactate dehydrogenase (LDH), 706 vs. 421 U/L; ferritin, 2,973 vs. 751 ng/mL, P < 0.001; IL-6, 121.0 vs. 71.8 pg/mL, P < 0.001. There was no difference in the levels of IL-8, TNF-α, and IL-1β. The liver injury group had a longer length of stay in the hospital and more severe COVID-19 despite having less diabetes and chronic kidney disease. Conclusion: An exaggerated hyperinflammatory response (cytokine storm) characterized by significantly elevated CRP, LDH, ferritin, and IL-6 levels and increasing severity of COVID-19 appears to be associated with the occurrence of liver injury in patients with severe/critical COVID-19.
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Affiliation(s)
- Ben L Da
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA.,Sandra Atlas Bass Center for Liver Diseases & Transplantation, Division of Hepatology, Department of Internal MedicineDonald and Barabara Zucker School of Medicine for Hofstra/Northwell HealthManhasset, New YorkNYUSA
| | - Tatyana Kushner
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Maan El Halabi
- Department of Internal MedicineMount Sinai Saint Luke's and Mount Sinai WestNew YorkNYUSA
| | - Pavan Paka
- Department of Internal MedicineMount Sinai Saint Luke's and Mount Sinai WestNew YorkNYUSA
| | - Mian Khalid
- Department of Internal MedicineIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Angad Uberoi
- Department of Internal MedicineMount Sinai Saint Luke's and Mount Sinai WestNew YorkNYUSA
| | - Brian T Lee
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | - Stephanie M Rutledge
- Division of GastroenterologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Thomas D Schiano
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Scott L Friedman
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Behnam Saberi
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA.,Division of Gastroenterology and HepatologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMAUSA
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18
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Sung JC, Wyatt BE, Perumalswami PV, Branch AD. Response to 'hepatitis C cure improved patient-reported outcomes in patients with and without liver fibrosis in a prospective study at a large urban medical center'. J Viral Hepat 2020; 27:1502-1503. [PMID: 32841428 DOI: 10.1111/jvh.13381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/10/2020] [Indexed: 12/09/2022]
Abstract
Patient-reported outcomes (PROs) are important measures of quality of life. Direct-acting antiviral (DAA) drugs for hepatitis C virus (HCV) improved PROs in clinical trials. We prospectively evaluated the impact of DAA-based HCV cure on PROs and liver-related outcomes in real-world patients at a large urban medical centre. The Short Form (SF)-36 and three additional validated instruments were used. F3-4 fibrosis was defined as >9.6 kPa by transient elastography (TE); S2-3 steatosis was defined as >270 dB/m by TE-controlled attenuation parameter (CAP). Data were analysed by paired and unpaired t tests. Patients (n = 16) who did not achieve a sustained virologic response at 12 weeks (SVR12) were excluded. The study achieved its primary endpoint and showed a significant 30% improvement in the SF-36 vitality score, measured baseline to SVR12: 63 vs 82, P < .001 (n = 111). Scores in 24 of 25 PRO domains improved at SVR12 (P < .05). Nearly all gains exceeded 5%, indicating their clinical significance. Transaminase values and liver stiffness improved (decreased) significantly, baseline to SVR12 (p<0.005), but steatosis was unchanged (p=0.58). Patients with baseline F0-2 fibrosis and those with F3-F4 fibrosis both improved in 22 domains. Patients with baseline S0-S1 steatosis improved in more domains (23) than patients with S2-S3 steatosis (19). At baseline, patients with F3-F4 fibrosis and patients with S2-3 steatosis had worse scores in certain PRO domains than patients with F0-2 fibrosis or S0-S1 steatosis, but this difference resolved by SVR12. HCV cure led to meaningful gains in PROs, and these findings may encourage patients to seek treatment.
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Affiliation(s)
- Julie C Sung
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brooke E Wyatt
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Andrea D Branch
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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19
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Rabiee A, Sadowski B, Adeniji N, Perumalswami PV, Nguyen V, Moghe A, Latt NL, Kumar S, Aloman C, Catana AM, Bloom PP, Chavin KD, Carr RM, Dunn W, Chen VL, Aby ES, Debes JD, Dhanasekaran R, Roytman M, Viveiros K, Chan W, Li M, Vogel A, Wegerman K, Lee T, Zhou K. Liver Injury in Liver Transplant Recipients With Coronavirus Disease 2019 (COVID-19): U.S. Multicenter Experience. Hepatology 2020; 72:1900-1911. [PMID: 32964510 PMCID: PMC7537191 DOI: 10.1002/hep.31574] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/19/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19) is associated with liver injury, but the prevalence and patterns of liver injury in liver transplantation (LT) recipients with COVID-19 are open for study. APPROACH AND RESULTS We conducted a multicenter study in the United States of 112 adult LT recipients with COVID-19. Median age was 61 years (interquartile range, 20), 54.5% (n = 61) were male, and 39.3% (n = 44) Hispanic. Mortality rate was 22.3% (n = 25); 72.3% (n = 81) were hospitalized and 26.8% (n = 30) admitted to the intensive care unit (ICU). Analysis of peak values of alanine aminotransferase (ALT) during COVID-19 showed moderate liver injury (ALT 2-5× upper limit of normal [ULN]) in 22.2% (n = 18) and severe liver injury (ALT > 5× ULN) in 12.3% (n = 10). Compared to age- and sex-matched nontransplant patients with chronic liver disease and COVID-19 (n = 375), incidence of acute liver injury was lower in LT recipients (47.5% vs. 34.6%; P = 0.037). Variables associated with liver injury in LT recipients were younger age (P = 0.009; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.20-3.54), Hispanic ethnicity (P = 0.011; OR, 6.01; 95% CI, 1.51-23.9), metabolic syndrome (P = 0.016; OR, 5.87; 95% CI, 1.38-24.99), vasopressor use (P = 0.018; OR, 7.34; 95% CI, 1.39-38.52), and antibiotic use (P = 0.046; OR, 6.93; 95% CI, 1.04-46.26). Reduction in immunosuppression (49.4%) was not associated with liver injury (P = 0.156) or mortality (P = 0.084). Liver injury during COVID-19 was significantly associated with mortality (P = 0.007; OR, 6.91; 95% CI, 1.68-28.48) and ICU admission (P = 0.007; OR, 7.93; 95% CI, 1.75-35.69) in LT recipients. CONCLUSIONS Liver injury is associated with higher mortality and ICU admission in LT recipients with COVID-19. Hence, monitoring liver enzymes closely can help in early identification of patients at risk for adverse outcomes. Reduction of immunosuppression during COVID-19 did not increase risk for mortality or graft failure.
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Affiliation(s)
- Atoosa Rabiee
- Division of GastroenterologyVA Medical CenterWashingtonDC
| | - Brett Sadowski
- Division of GastroenterologyGeorgetown UniversityWashingtonDC
| | - Nia Adeniji
- Division of GastroenterologyStanford UniversityStanfordCA
| | | | | | - Akshata Moghe
- Division of GastroenterologyUniversity of Pittsburgh Medical CenterPA
| | - Nyan L. Latt
- Division of GastroenterologyOchsner Medical CenterLA
| | - Sonal Kumar
- Division of GastroenterologyWeill Cornell MedicineNY
| | - Costica Aloman
- Division of GastroenterologyRush University Medical CenterIL
| | | | | | - Kenneth D. Chavin
- Division of Transplant and Hepatobiliary SurgeryUniversity Hospitals Cleveland Medical CenterOH
| | | | - Winston Dunn
- Division of GastroenterologyKansas University Medical CenterKS
| | | | - Elizabeth S. Aby
- Division of GastroenterologyUniversity of MinnesotaMN,Division of GastroenterologyHennepin County Medical CenterMN
| | - Jose D. Debes
- Division of GastroenterologyUniversity of MinnesotaMN,Division of GastroenterologyHennepin County Medical CenterMN
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20
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Lee BT, Perumalswami PV, Im GY, Florman S, Schiano TD. COVID-19 in Liver Transplant Recipients: An Initial Experience From the US Epicenter. Gastroenterology 2020; 159:1176-1178.e2. [PMID: 32442561 PMCID: PMC7237372 DOI: 10.1053/j.gastro.2020.05.050] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/13/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Brian T. Lee
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ponni V. Perumalswami
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gene Y. Im
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Division of Abdominal Transplantation, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas D. Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York,Correspondence Address correspondence to: Thomas D. Schiano, MD, One Gustave Levy Place, Box 1104, New York, NY 10029; fax: (212) 241-2138
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21
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Moon AM, Webb GJ, Aloman C, Armstrong MJ, Cargill T, Dhanasekaran R, Genescà J, Gill US, James TW, Jones PD, Marshall A, Mells G, Perumalswami PV, Qi X, Su F, Ufere NN, Barnes E, Barritt AS, Marjot T. High mortality rates for SARS-CoV-2 infection in patients with pre-existing chronic liver disease and cirrhosis: Preliminary results from an international registry. J Hepatol 2020; 73:705-708. [PMID: 32446714 PMCID: PMC7241346 DOI: 10.1016/j.jhep.2020.05.013] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Gwilym J. Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Costica Aloman
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | | | - Joan Genescà
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Upkar S. Gill
- Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, Queen Mary University of London, UK
| | - Theodore W. James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Patricia D. Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - George Mells
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ponni V. Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Feng Su
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nneka N. Ufere
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK.
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22
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Webb GJ, Marjot T, Cook JA, Aloman C, Armstrong MJ, Brenner EJ, Catana MA, Cargill T, Dhanasekaran R, García-Juárez I, Hagström H, Kennedy JM, Marshall A, Masson S, Mercer CJ, Perumalswami PV, Ruiz I, Thaker S, Ufere NN, Barnes E, Barritt AS, Moon AM. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. Lancet Gastroenterol Hepatol 2020; 5:1008-1016. [PMID: 32866433 PMCID: PMC7455160 DOI: 10.1016/s2468-1253(20)30271-5] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
Background Despite concerns that patients with liver transplants might be at increased risk of adverse outcomes from COVID-19 because of coexisting comorbidities and use of immunosuppressants, the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on this patient group remains unclear. We aimed to assess the clinical outcomes in these patients. Methods In this multicentre cohort study, we collected data on patients with laboratory-confirmed SARS-CoV-2 infection, who were older than 18 years, who had previously received a liver transplant, and for whom data had been submitted by clinicians to one of two international registries (COVID-Hep and SECURE-Cirrhosis) at the end of the patient's disease course. Patients without a known hospitalisation status or mortality outcome were excluded. For comparison, data from a contemporaneous cohort of consecutive patients with SARS-CoV-2 infection who had not received a liver transplant were collected from the electronic patient records of the Oxford University Hospitals National Health Service Foundation Trust. We compared the cohorts with regard to several outcomes (including death, hospitalisation, intensive care unit [ICU] admission, requirement for intensive care, and need for invasive ventilation). A propensity score-matched analysis was done to test for an association between liver transplant and death. Findings Between March 25 and June 26, 2020, data were collected for 151 adult liver transplant recipients from 18 countries (median age 60 years [IQR 47–66], 102 [68%] men, 49 [32%] women) and 627 patients who had not undergone liver transplantation (median age 73 years [44–84], 329 [52%] men, 298 [48%] women). The groups did not differ with regard to the proportion of patients hospitalised (124 [82%] patients in the liver transplant cohort vs 474 [76%] in the comparison cohort, p=0·106), or who required intensive care (47 [31%] vs 185 [30%], p=0·837). However, ICU admission (43 [28%] vs 52 [8%], p<0·0001) and invasive ventilation (30 [20%] vs 32 [5%], p<0·0001) were more frequent in the liver transplant cohort. 28 (19%) patients in the liver transplant cohort died, compared with 167 (27%) in the comparison cohort (p=0·046). In the propensity score-matched analysis (adjusting for age, sex, creatinine concentration, obesity, hypertension, diabetes, and ethnicity), liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection (absolute risk difference 1·4% [95% CI −7·7 to 10·4]). Multivariable logistic regression analysis showed that age (odds ratio 1·06 [95% CI 1·01 to 1·11] per 1 year increase), serum creatinine concentration (1·57 [1·05 to 2·36] per 1 mg/dL increase), and non-liver cancer (18·30 [1·96 to 170·75]) were associated with death among liver transplant recipients. Interpretation Liver transplantation was not independently associated with death, whereas increased age and presence of comorbidities were. Factors other than transplantation should be preferentially considered in relation to physical distancing and provision of medical care for patients with liver transplants during the COVID-19 pandemic. Funding European Association for the Study of the Liver, US National Institutes of Health, UK National Institute for Health Research.
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Affiliation(s)
- Gwilym J Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Costica Aloman
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, IL, USA
| | | | - Erica J Brenner
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Maria-Andreea Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hannes Hagström
- Division of Hepatology, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - James M Kennedy
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Steven Masson
- Liver Transplant Unit, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Carolyn J Mercer
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Isaac Ruiz
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Sarang Thaker
- Division of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, IL, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
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23
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Sung JC, Bosh C, Wyatt B, Miller M, Harty A, Del Bello D, Knight S, Dieterich DT, Perumalswami PV, Branch AD. Hepatitis C cure improved patient-reported outcomes in patients with and without liver fibrosis in a prospective study at a large urban medical center. J Viral Hepat 2020; 27:350-359. [PMID: 31742821 DOI: 10.1111/jvh.13234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Abstract
Patient-reported outcomes (PROs) are important measures of quality of life. Direct-acting antiviral (DAA) drugs for hepatitis C virus (HCV) improved PROs in clinical trials. We prospectively evaluated the impact of DAA-based HCV cure on PROs and liver-related outcomes in real-world patients at a large urban medical center. The short form (SF)-36 and three additional validated instruments were used. F3-4 fibrosis was defined as > 9.6 kPa by transient elastography (TE); S2-3 steatosis was defined as > 270 dB/m by TE-controlled attenuation parameter (CAP). Data were analysed by paired and unpaired t tests. Patients (n = 16) who did not achieve a sustained virologic response at 12 weeks (SVR12) were excluded. The study achieved its primary endpoint and showed a significant 30% improvement in the SF-36 vitality score, measured baseline to SVR12: 63 versus 82, P < .001 (n = 111). Scores in 24 of 25 PRO domains improved at SVR12 (P < .05). Nearly all gains exceeded 5%, indicating their clinical significance. Transaminase values and liver stiffness improved (decreased) significantly, baseline to SVR12 (P < .005), but steatosis was unchanged (P = .58). Patients with baseline F0-2 fibrosis and those with F3-F4 fibrosis both improved in 22 domains. Patients with baseline S0-S1 steatosis improved in more domains (23) than patients with S2-S3 steatosis (19). At baseline, patients with F3-F4 fibrosis and patients with S2-3 steatosis had worse scores in certain PRO domains than patients with F0-2 fibrosis or S0-S1 steatosis, but this difference resolved by SVR12. HCV cure led to meaningful gains in PROs, and these findings may encourage patients to seek treatment.
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Affiliation(s)
- Julie C Sung
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Ciara Bosh
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Brooke Wyatt
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Mark Miller
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Alyson Harty
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - David Del Bello
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Sterling Knight
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Douglas T Dieterich
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Ponni V Perumalswami
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
| | - Andrea D Branch
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York
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Rich NE, Yang JD, Perumalswami PV, Alkhouri N, Jackson W, Parikh ND, Mehta N, Salgia R, Duarte-Rojo A, Kulik L, Rakoski M, Said A, Oloruntoba O, Ioannou GN, Hoteit MA, Moon AM, Rangnekar AS, Eswaran SL, Zheng E, Jou JH, Hanje J, Pillai A, Hernaez R, Wong R, Scaglione S, Samant H, Kapuria D, Chandna S, Rosenblatt R, Ajmera V, Frenette CT, Satapathy SK, Mantry P, Jalal P, John BV, Fix OK, Leise M, Lindenmeyer CC, Flores A, Patel N, Jiang ZG, Latt N, Dhanasekaran R, Odewole M, Kagan S, Marrero JA, Singal AG. Provider Attitudes and Practice Patterns for Direct-Acting Antiviral Therapy for Patients With Hepatocellular Carcinoma. Clin Gastroenterol Hepatol 2020; 18:974-983. [PMID: 31357028 PMCID: PMC8174017 DOI: 10.1016/j.cgh.2019.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/13/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC. METHODS We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses (58.6%). RESULTS Provider beliefs about risk of HCC recurrence after DAA therapy varied: 48% responded that DAAs reduce risk, 36% responded that DAAs do not change risk, and 16% responded that DAAs increase risk of HCC recurrence. However, most providers believed DAAs to be beneficial to and reduce mortality of patients with complete response to HCC treatment. Accordingly, nearly all providers (94.9%) reported recommending DAA therapy to patients with early-stage HCC who received curative treatment. However, fewer providers recommended DAA therapy for patients with intermediate (72.9%) or advanced (57.5%) HCC undergoing palliative therapies. Timing of DAA initiation varied among providers based on HCC treatment modality: 49.1% of providers reported they would initiate DAA therapy within 3 months of surgical resection whereas 45.9% and 5.0% would delay DAA initiation for 3-12 months and >1 year post-surgery, respectively. For patients undergoing transarterial chemoembolization (TACE), 42.0% of providers would provide DAAs within 3 months of the procedure, 46.7% would delay DAAs until 3-12 months afterward, and 11.3% would delay DAAs more than 1 year after TACE. CONCLUSIONS Based on a survey sent to hepatology providers, there is variation in provider attitudes and practice patterns regarding use and timing of DAAs for patients with HCC. Further studies are needed to characterize the risks and benefits of DAA therapy in this patient population.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
| | - Ju Dong Yang
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center and Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Ponni V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Naim Alkhouri
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, Texas
| | - Whitney Jackson
- Division of Gastroenterology and Hepatology, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Neil Mehta
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Reena Salgia
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - Andres Duarte-Rojo
- T.E. Starzl Transplantation Institute and Center for Liver Disease, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Kulik
- Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Mina Rakoski
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California
| | - Adnan Said
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Omobonike Oloruntoba
- Division of Gastroenterology and Hepatology, Duke University Health Center, Durham, North Carolina
| | - George N Ioannou
- Division of Gastroenterology and Research and Development, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington
| | - Maarouf A Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Amol S Rangnekar
- Division of Gastroenterology, Georgetown University Hospital, Washington, DC
| | - Sheila L Eswaran
- Division of Gastroenterology, Rush Medical College, Chicago, Illinois
| | - Elizabeth Zheng
- Division of Digestive and Liver Diseases, Columbia University, New York, New York
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Oakland, California
| | - Steven Scaglione
- Division of Hepatology, Loyola University Medical Center and Edward Hines Veterans Affairs, Chicago, Illinois
| | - Hrishikesh Samant
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Devika Kapuria
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
| | - Shaun Chandna
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine - New York-Presbyterian Hospital, New York, New York
| | - Veeral Ajmera
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Catherine T Frenette
- Division of Organ Transplantation, Scripps Green Hospital, San Diego, California
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Prasun Jalal
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas
| | - Binu V John
- Division of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Oren K Fix
- Organ Transplant Department, Swedish Medical Center, Seattle, Washington
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Nayan Patel
- Banner Transplant Institute, Banner - University Medical Center Phoenix, Phoenix, Arizona
| | - Z Gordon Jiang
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nyan Latt
- Oschner Multi-Organ Transplant Institute, Oschner Health System, New Orleans, Louisiana
| | | | - Mobolaji Odewole
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Sofia Kagan
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
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Chen X, Ma T, Yip R, Perumalswami PV, Branch AD, Lewis S, Crane M, Yankelevitz DF, Henschke CI. Elevated prevalence of moderate-to-severe hepatic steatosis in World Trade Center General Responder Cohort in a program of CT lung screening. Clin Imaging 2019; 60:237-243. [PMID: 31945662 DOI: 10.1016/j.clinimag.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/19/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS To determine the prevalence of moderate-to-severe hepatic steatosis (HS) and associated risk factors in members of the World Trade Center (WTC) General Responder Cohort (GRC) who qualify for low-dose non-contrast computed tomography for lung cancer screening and compare them to non-WTC participants in the same screening program. METHODS All participants gave written informed consent before participating in this IRB-approved study. Clinical variables and laboratory values were recorded. Hepatic attenuation measurement (Hounsfield unit; HU) was measured on low-dose computed tomography (LDCT) and a threshold attenuation value <40HU indicated moderate-to-severe HS. Bivariate and multivariable linear and logistic regression analyses were performed. Propensity scores (PS) were calculated and inverse probability weighting (IPW) was used to adjust for potential confounders when comparing the WTC with non-WTC participants. RESULTS The prevalence of moderate-to-severe HS was 16.2% among 154 WTC participants compared to 5.3% among 170 non-WTC participants. In WTC members, moderate-to-severe HS was associated with higher BMI, higher laboratory liver function tests, and former smoking status. Using PS analysis and IPW to account for potential confounders, the odds ratio for moderate-to-severe HS was 3.4-fold higher (95% confidence interval: 1.7-6.7) in the WTC participants compared with non-WTC participants. Moderate-to-severe HS was also associated with higher BMI and former smoker status. CONCLUSION Prevalence of moderate-to-severe HS was >3-fold higher in the WTC-GRC group than in other participants.
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Affiliation(s)
- Xiangmeng Chen
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States; Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou 510630, China; Department of Radiology, Jiangmen Central Hospital, Jiangmen 529030, China
| | - Teng Ma
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States; Department of Radiology, Tong Ren Hospital, Capital Medical University, Beijing 100730, China
| | - Rowena Yip
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Andrea D Branch
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Sara Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Michael Crane
- Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Jirapatnakul A, Reeves AP, Lewis S, Chen X, Ma T, Yip R, Chin X, Liu S, Perumalswami PV, Yankelevitz DF, Crane M, Branch AD, Henschke CI. Automated measurement of liver attenuation to identify moderate-to-severe hepatic steatosis from chest CT scans. Eur J Radiol 2019; 122:108723. [PMID: 31778964 DOI: 10.1016/j.ejrad.2019.108723] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Develop and validate an automated method for measuring liver attenuation in non-contrast low-dose chest CT (LDCT) scans and compare it to the standard manual method for identifying moderate-to-severe hepatic steatosis (HS). METHOD The automated method identifies a region below the right lung within the liver and uses statistical sampling techniques to exclude non-liver parenchyma. The method was used to assess moderate-to-severe HS on two IRB-approved cohorts: 1) 24 patients with liver disease examined between 1/2013-1/2017 with non-contrast chest CT and abdominal MRI scans obtained within three months of liver biopsy, and 2) 319 lung screening participants with baseline LDCT performed between 8/2011-1/2017. Agreement between the manual and automated CT methods, the manual MRI method, and pathology for determining moderate-to-severe HS was assessed using Cohen's Kappa by applying a 40 HU threshold to the CT method and 17.4% fat fraction to MRI. Agreement between the manual and automated CT methods was assessed using the intraclass correlation coefficient (ICC). Variability was assessed using Bland-Altman limits of agreement (LoA). RESULTS In the first cohort, the manual and automated CT methods had almost perfect agreement (ICC = 0.97, κ = 1.00) with LoA of -7.6 to 4.7 HU. Both manual and automated CT methods had almost perfect agreement with MRI (κ = 0.90) and substantial agreement with pathology (κ = 0.77). In the second cohort, the manual and automated CT methods had almost perfect agreement (ICC = 0.94, κ = 0.87). LoA were -10.6 to 5.2 HU. CONCLUSION Automated measurements of liver attenuation from LDCT scans can be used to identify moderate-to-severe HS on LDCT.
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Affiliation(s)
- Artit Jirapatnakul
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States
| | - Anthony P Reeves
- School of Electrical and Computer Engineering, Cornell University, 392 Rhodes Hall, Ithaca, NY 14853, United States
| | - Sara Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States
| | - Xiangmeng Chen
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States; Department of Radiology, The First Affiliated Hospital of Jinan University, Huangpu West Ave No. 613, Guangzhou, Guangdong, China; Department of Radiology, Jiangmen Central Hospital, No. 18 Zicha Road, Jiangmen, Guangdong, China
| | - Teng Ma
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States; Department of Radiology, Jiangmen Central Hospital, No. 18 Zicha Road, Jiangmen, Guangdong, China
| | - Rowena Yip
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States
| | - Xing Chin
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States
| | - Shuang Liu
- School of Electrical and Computer Engineering, Cornell University, 392 Rhodes Hall, Ithaca, NY 14853, United States
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1123, New York, NY 10029, United States
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States
| | - Michael Crane
- Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY 10029, United States
| | - Andrea D Branch
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1123, New York, NY 10029, United States
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, Box 1234, New York, NY 10029, United States.
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Fluegge K, Bresnahan MP, Laraque F, Litwin AH, Perumalswami PV, Shukla SJ, Weiss JJ, Winters A. Evaluating reimbursement of integrated support services using chronic care management (CCM) codes for treatment of hepatitis C among Medicare beneficiaries. J Healthc Risk Manag 2019; 39:31-40. [PMID: 31469484 DOI: 10.1002/jhrm.21389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The New York City Department of Health and Mental Hygiene (DOHMH) implemented Project INSPIRE, an integrated model of hepatitis C care coordination and telementoring services, from 2014 to 2017. We evaluated the use of chronic care management (CCM) codes to sustain the intervention. DOHMH data were collected as part of a Healthcare Innovation Award from the Centers for Medicare & Medicaid Services (CMS). A retrospective cohort medical billing study was conducted by assigning INSPIRE activities to procedure codes in both facility and nonfacility settings. Rates for procedures were extracted from the CMS's 2018 fee schedules and added across the eligibility periods for Medicare enrollees. Reimbursement was adjusted on the basis of expected patient attrition and compared to costs. The minimum number needed to treat (NNT) to break even was calculated in each setting. Facility reimbursement was higher than costs, whereas nonfacility reimbursement was lower (both P < .01). The NNT was 23 patients in facilities and 33 patients in nonfacilities; 24 patients per care coordinator were treated annually in INSPIRE. CCM fees alone were insufficient to fully reimburse the costs in either setting. Implementation of an appropriate risk financing strategy is necessary to mitigate financial shortfalls when providing CCM services in facility settings.
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Wei L, Kumada H, Perumalswami PV, Tanwandee T, Cheng W, Heo J, Cheng PN, Hwang P, Mu SM, Zhao XM, Asante-Appiah E, Caro L, Hanna GJ, Robertson MN, Haber BA, Talwani R. Safety and efficacy of elbasvir/grazoprevir in Asian participants with hepatitis C virus genotypes 1 and 4 infection. J Gastroenterol Hepatol 2019; 34:1597-1603. [PMID: 30779220 DOI: 10.1111/jgh.14636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Estimates suggest that in Asia, more than 31 million individuals have hepatitis C virus infection. The present analysis was conducted to assess the efficacy and safety of elbasvir/grazoprevir in Asian participants enrolled in the elbasvir/grazoprevir phase 2/3 clinical trials. METHODS This is an integrated analysis of data from 12 international phase 2/3 clinical trials. Asian participants with chronic hepatitis C virus genotype 1 or 4 infection who received elbasvir 50 mg/grazoprevir 100 mg once daily for 12 weeks or elbasvir/grazoprevir plus ribavirin for 16 weeks were included in this analysis. The primary end point was sustained virologic response at 12 weeks after completion of therapy (SVR12). RESULTS Seven hundred eighty Asian participants from 15 countries were included in this analysis. SVR12 was achieved by 756/780 (96.9%) of all participants, including 748/772 (96.9%) of those who received elbasvir/grazoprevir for 12 weeks and 8/8 (100%) of those who received elbasvir/grazoprevir plus ribavirin for 16 weeks. In the genotype 1b-infected population, the SVR12 rate was 691/709 (97.5%), and there was no impact of age, high baseline viral load, or presence of cirrhosis. The most frequently reported adverse events were nasopharyngitis (8.0%), upper respiratory tract infection (5.4%), and diarrhea (5.2%). Twenty participants receiving elbasvir/grazoprevir for 12 weeks reported a total of 25 serious adverse events, and 7 (0.9%) discontinued treatment because of an adverse event. CONCLUSION Elbasvir/grazoprevir administered for 12 weeks is an effective and generally well-tolerated treatment option for Asian individuals with hepatitis C virus genotype 1b infection.
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Affiliation(s)
- Lai Wei
- Peking University People's Hospital, Beijing, China
| | | | | | | | - Wendy Cheng
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jeong Heo
- College of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Pin-Nan Cheng
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Peggy Hwang
- Merck & Co., Inc., Kenilworth, New Jersey, USA
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Bolutayo K, van Manh AL, Cohen N, Ndiaye D, Jandorf L, Perumalswami PV. Reducing Liver Cancer Risk in African-Born Immigrants Through Culturally Targeted Hepatitis B Group Education Programs. J Cancer Educ 2018; 33:1201-1205. [PMID: 28526938 DOI: 10.1007/s13187-017-1231-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Of 900 West African-born immigrants living in New York City who were tested for hepatitis B virus (HBV), over 9% were found to have the infection (Shankar H et al. Clin Infectious Dis 62(S4):S289-s297, 2016). Community targeted group education programs (EP) have been shown to improve immigrant population's health (Bailey E et al. J Natl Med Assoc 92(3):136-42, 2000). Our aim is to enhance HBV screening in at-risk West African immigrants through the development of a group EP as a first critical step to reducing liver cancer risk. The framework for an HBV group EP was created based on our prior work to identify barriers and facilitators for HBV screening in this community (Sriphanlop, P et al. Am J Health Behav 5(10):745-754, 2014). The framework was then refined with input from community "gatekeepers" or leaders (n = 57) through four focus groups. After refining the group EP, we then pilot tested the EP with 154 participants from eight different West African communities with a pre-/post-test HBV knowledge survey assessment to determine the impact of the group EP. Results from the pre-/post-test survey assessment demonstrated a significant increase in HBV knowledge after the EP (70% pre-test vs. 88% post-test, p value <.01). Through a community-based participatory approach, a group EP could be effective in increasing knowledge about HBV infection and HBV screening as a first step to reducing liver cancer risk.
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Affiliation(s)
- Kemi Bolutayo
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA.
| | - Alexandre Ly van Manh
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
| | - Noah Cohen
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
| | - Daouda Ndiaye
- African Services Committee, Inc., 429 W 127th St, New York, NY, 10027, USA
| | - Lina Jandorf
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
| | - Ponni V Perumalswami
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1130, New York, NY, 10029, USA
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Winters AC, Sung JC, Wyatt B, Berera D, Schiano TD, Schwartz ME, Perumalswami PV, Branch AD. At diagnosis of hepatocellular carcinoma, African Americans with hepatitis C have better liver function than other patients. Clin Liver Dis (Hoboken) 2018; 12:109-112. [PMID: 30416720 PMCID: PMC6220896 DOI: 10.1002/cld.745] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Adam C. Winters
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Julie C. Sung
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Brooke Wyatt
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Deeva Berera
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Thomas D. Schiano
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Myron E. Schwartz
- Department of Surgery, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Ponni V. Perumalswami
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
| | - Andrea D. Branch
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai Medical CenterNew YorkNY
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Teixeira PA, Bresnahan MP, Laraque F, Litwin AH, Shukla SJ, Schwartz JM, Reynoso S, Perumalswami PV, Weiss JM, Wyatt B, Schackman BR. Telementoring of primary care providers delivering hepatitis C treatment in New York City: Results from Project INSPIRE. Learn Health Syst 2018; 2:e10056. [PMID: 31106275 PMCID: PMC6508766 DOI: 10.1002/lrh2.10056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/30/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The recent availability of highly effective, easily administered, and relatively nontoxic treatments for hepatitis C virus (HCV) infection provides an opportunity for clinicians to treat HCV in nonspecialist settings with appropriate support. Project INSPIRE provides care coordination to HCV patients and a web-based training program (telementoring) on disease management and treatment by HCV specialists to primary care providers inexperienced in HCV treatment. Weekly telementoring sessions use a didactic and case-based approach to instruct non-HCV providers on how to identify and assess HCV treatment candidates and prescribe appropriate treatment. METHODS We used mixed methods to assess the telementoring service, including provider surveys and semistructured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed to identify dominant themes. RESULTS Provider survey responses indicated an increased ability to identify and evaluate HCV treatment candidates and increased confidence in sharing knowledge with peers and patients. Interviews revealed a high degree of satisfaction with the telementoring service and Project INSPIRE overall. The telementoring service was viewed as having enhanced providers' knowledge, confidence, and ability to treat their own HCV-infected patients rather than having to refer them to an HCV specialist with resulting benefits for continuity of care. Providers reported comradery and collegiality with other INSPIRE providers and satisfaction with professional growth from attaining new knowledge and skills via the telementoring service. CONCLUSIONS Using readily available web conferencing technology, telementoring can facilitate knowledge transfer between specialists and primary care providers, facilitating continuity of care for patients and increased provider satisfaction.
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Affiliation(s)
- Paul A. Teixeira
- Heathcare Policy & ResearchWeill Cornell Medical CollegeNew York CityNew York
| | - Marie P. Bresnahan
- Bureau of Communicable DiseasesNew York City Department of Health and Mental HygieneNew York CityNew York
| | - Fabienne Laraque
- Bureau of Communicable DiseasesNew York City Department of Health and Mental HygieneNew York CityNew York
| | - Alain H. Litwin
- Department of MedicineMontefiore Medical CenterNew York CityNew York
| | - Shuchin J. Shukla
- Department of MedicineMontefiore Medical CenterNew York CityNew York
| | | | - Sheila Reynoso
- Department of MedicineMontefiore Medical CenterNew York CityNew York
| | | | - Jeffrey M. Weiss
- Department of MedicineMount Sinai Medical CenterNew York CityNew York
| | - Brooke Wyatt
- Department of MedicineMount Sinai Medical CenterNew York CityNew York
| | - Bruce R. Schackman
- Heathcare Policy & ResearchWeill Cornell Medical CollegeNew York CityNew York
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Kamath GR, Taioli E, N Egorova N, Llovet JM, Perumalswami PV, Weiss JJ, Schwartz M, Ewala S, Bickell NA. Liver Cancer Disparities in New York City: A Neighborhood View of Risk and Harm Reduction Factors. Front Oncol 2018; 8:220. [PMID: 29963497 PMCID: PMC6011126 DOI: 10.3389/fonc.2018.00220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/29/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Liver cancer is the fastest increasing cancer in the United States and is one of the leading causes of cancer-related death in New York City (NYC), with wide disparities among neighborhoods. The purpose of this cross-sectional study was to describe liver cancer incidence by neighborhood and examine its association with risk factors. This information can inform preventive and treatment interventions. Materials and methods Publicly available data were collected on adult NYC residents (n = 6,407,022). Age-adjusted data on liver and intrahepatic bile duct cancer came from the New York State Cancer Registry (1) (2007–2011 average annual incidence); and the NYC Vital Statistics Bureau (2015, mortality). Data on liver cancer risk factors (2012–2015) were sourced from the New York City Department of Health and Mental Hygiene: (1) Community Health Survey, (2) A1C registry, and (3) NYC Health Department Hepatitis surveillance data. They included prevalence of obesity, diabetes, diabetic control, alcohol-related hospitalizations or emergency department visits, hepatitis B and C rates, hepatitis B vaccine coverage, and injecting drug use. Results Liver cancer incidence in NYC was strongly associated with neighborhood poverty after adjusting for race/ethnicity (β = 0.0217, p = 0.013); and with infection risk scores (β = 0.0389, 95% CI = 0.0088–0.069, p = 0.011), particularly in the poorest neighborhoods (β = 0.1207, 95% CI = 0.0147–0.2267, p = 0.026). Some neighborhoods with high hepatitis rates do not have a proportionate number of hepatitis prevention services. Conclusion High liver cancer incidence is strongly associated with infection risk factors in NYC. There are gaps in hepatitis prevention services like syringe exchange and vaccination that should be addressed. The role of alcohol and metabolic risk factors on liver cancer in NYC warrants further study.
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Affiliation(s)
- Geetanjali R Kamath
- Institute for Translational Epidemiology, New York, NY, United States.,Tisch Cancer Institute, New York, NY, United States.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Emanuela Taioli
- Institute for Translational Epidemiology, New York, NY, United States.,Tisch Cancer Institute, New York, NY, United States.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Natalia N Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Josep M Llovet
- Mount Sinai Liver Cancer Program, Divisions of Liver Diseases, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, United States.,Liver Cancer Translational Research Laboratory, BCLC, Liver Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Institut d'Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain.,Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jeffrey J Weiss
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Myron Schwartz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stanley Ewala
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nina A Bickell
- Tisch Cancer Institute, New York, NY, United States.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Perumalswami PV, Talal AH. Improvements in Quality of Life: A New Indication for Treating Hepatitis C Virus Infection in Persons With Substance Use Disorders. J Infect Dis 2017; 217:1020-1023. [DOI: 10.1093/infdis/jix682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ponni V Perumalswami
- Division of Hepatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, University at Buffalo, State University of New York, Buffalo, New York
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Bichoupan K, Tandon N, Crismale JF, Hartman J, Del Bello D, Patel N, Chekuri S, Harty A, Ng M, Sigel KM, Bansal MB, Grewal P, Chang CY, Leong J, Im GY, Liu LU, Odin JA, Bach N, Friedman SL, Schiano TD, Perumalswami PV, Dieterich DT, Branch AD. Real-world cure rates for hepatitis C virus treatments that include simeprevir and/or sofosbuvir are comparable to clinical trial results. World J Virol 2017; 6:59-72. [PMID: 29147645 PMCID: PMC5680347 DOI: 10.5501/wjv.v6.i4.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/03/2017] [Accepted: 09/17/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To assess the real-world effectiveness and cost of simeprevir (SMV), and/or sofosbuvir (SOF)-based therapy for chronic hepatitis C virus (HCV) infection.
METHODS The real-world performance of patients treated with SMV/SOF ± ribavirin (RBV), SOF/RBV, and SOF/RBV with pegylated-interferon (PEG) were analyzed in a consecutive series of 508 patients with chronic HCV infection treated at a single academic medical center. Patients with genotypes 1 through 4 were included. Rates of sustained virological response - the absence of a detectable serum HCV RNA 12 wk after the end of treatment [sustained virological response (SVR) 12] - were calculated on an intention-to-treat basis. Costs were calculated from the payer’s perspective using Medicare/Medicaid fees and Redbook Wholesale Acquisition Costs. Patient-related factors associated with SVR12 were identified using multivariable logistic regression.
RESULTS SVR12 rates were as follows: 86% (95%CI: 80%-91%) among 178 patients on SMV/SOF ± RBV; 62% (95%CI: 55%-68%) among 234 patients on SOF/RBV; and 78% (95%CI: 68%-86%) among 96 patients on SOF/PEG/RBV. Mean costs-per-SVR12 were $174442 (standard deviation: ± $18588) for SMV/SOF ± RBV; $223003 (± $77946) for SOF/RBV; and $126496 (± $31052) for SOF/PEG/RBV. Among patients on SMV/SOF ± RBV, SVR12 was less likely in patients previously treated with a protease inhibitor [odds ratio (OR): 0.20, 95%CI: 0.06-0.56]. Higher bilirubin (OR: 0.47, 95%CI: 0.30-0.69) reduced the likelihood of SVR12 among patients on SOF/RBV, while FIB-4 score ≥ 3.25 reduced the likelihood of SVR12 (OR: 0.18, 95%CI: 0.05-0.59) among those on SOF/PEG/RBV.
CONCLUSION SVR12 rates for SMV and/or SOF-based regimens in a diverse real-world population are comparable to those in clinical trials. Treatment failure accounts for 27% of costs.
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Affiliation(s)
- Kian Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Neeta Tandon
- Janssen Scientific Affairs, LLC, Titusville, NJ 08560, United States
| | - James F Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Joshua Hartman
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - David Del Bello
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Neal Patel
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Sweta Chekuri
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Alyson Harty
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Michel Ng
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Keith M Sigel
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Meena B Bansal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Priya Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Charissa Y Chang
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jennifer Leong
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Gene Y Im
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Lawrence U Liu
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Joseph A Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Nancy Bach
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Scott L Friedman
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Thomas D Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Ponni V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Douglas T Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Andrea D Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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Shankar H, Blanas D, Bichoupan K, Ndiaye D, Carmody E, Martel-Laferriere V, Culpepper-Morgan J, Dieterich DT, Branch AD, Bekele M, Nichols K, Perumalswami PV. A Novel Collaborative Community-Based Hepatitis B Screening and Linkage to Care Program for African Immigrants. Clin Infect Dis 2017; 62 Suppl 4:S289-97. [PMID: 27190318 DOI: 10.1093/cid/ciw090] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sub-Saharan African nations have among the highest rates of chronic hepatitis B virus (HBV) infection worldwide, but little is known about HBV infection in African-born persons in the United States. METHODS From October 2011 to July 2013, community-based HBV screenings were conducted targeting persons originating from Africa in New York City. Persons were identified as currently HBV infected (HBsAg positive) or exposed (HBcAb positive). RESULTS Overall, 955 persons were screened for HBV; the median age was 45 years (interquartile range, 35-54 years) and 75.5% were men. Of these, 919 persons had no history of liver disease, of whom 9.6% (n = 88) had current HBV infection and 73.9% (n = 679) had exposure. In logistic regression, older age (odds ratio [OR], 0.97; 95% confidence interval [CI], .94-.99; P < .01) and female sex (OR, 0.35; 95% CI, .14-.75; P < .01) were less likely to be associated with HBV infection, whereas having a mother with hepatitis was associated with infection (OR, 18.8; 95% CI, 2.72-164.65; P < .01). HBV exposure was associated with older age (OR, 1.03; 95% CI, 1.01-1.04; P < .01), whereas female sex (OR, 0.46; 95% CI, .33-.66; P < .01) and history of blood transfusion (OR, 0.43; 95% CI, .22-.83; P = .01) were negatively associated. A patient navigator linked 97% of infected persons to care. Eleven persons were recommended for treatment, of whom 9 (82%) started therapy. Three persons were diagnosed with hepatocellular carcinoma on the first screening ultrasound. CONCLUSIONS The high burden of HBV infection among African immigrants in the United States underscores a need for continued screening and linkage to care in this at-risk population.
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Affiliation(s)
- Hari Shankar
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
| | - Demetri Blanas
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
| | - Kian Bichoupan
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
| | | | - Ellie Carmody
- Division of Infectious Diseases and Immunology, Department of Medicine, New York University School of Medicine
| | | | - Joan Culpepper-Morgan
- Division of Gastroenterology, Department of Medicine, Harlem Hospital Center, New York, New York
| | - Dougles T Dieterich
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
| | - Andrea D Branch
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
| | | | | | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine
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36
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Goel A, Sanchez J, Paulino L, Feuille C, Arend J, Shah B, Dieterich D, Perumalswami PV. A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care. J Viral Hepat 2017; 24:477-485. [PMID: 28039935 DOI: 10.1111/jvh.12669] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/20/2016] [Indexed: 12/12/2022]
Abstract
Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link-to-care programme with patient navigation in two New York City primary care practices. This was a 2-year prospective study of patients born between 1945-1965 ("baby boomers") with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV-infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well-studied principles identifies a large number of undiagnosed baby boomers within hospital-based primary care and improves access to specialty providers in a timely manner.
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Affiliation(s)
- A Goel
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - J Sanchez
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - L Paulino
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - C Feuille
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - J Arend
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - B Shah
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - D Dieterich
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - P V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
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Bichoupan K, Tandon N, Martel-Laferriere V, Patel NM, Sachs D, Ng M, Schonfeld EA, Pappas A, Crismale J, Stivala A, Khaitova V, Gardenier D, Linderman M, Olson W, Perumalswami PV, Schiano TD, Odin JA, Liu LU, Dieterich DT, Branch AD. Factors associated with success of telaprevir- and boceprevir-based triple therapy for hepatitis C virus infection. World J Hepatol 2017; 9:551-561. [PMID: 28469811 PMCID: PMC5395804 DOI: 10.4254/wjh.v9.i11.551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate new therapies for hepatitis C virus (HCV), data about real-world outcomes are needed.
METHODS Outcomes of 223 patients with genotype 1 HCV who started telaprevir- or boceprevir-based triple therapy (May 2011-March 2012) at the Mount Sinai Medical Center were analyzed. Human immunodeficiency virus-positive patients and patients who received a liver transplant were excluded. Factors associated with sustained virological response (SVR24) and relapse were analyzed by univariable and multivariable logistic regression as well as classification and regression trees. Fast virological response (FVR) was defined as undetectable HCV RNA at week-4 (telaprevir) or week-8 (boceprevir).
RESULTS The median age was 57 years, 18% were black, 44% had advanced fibrosis/cirrhosis (FIB-4 ≥ 3.25). Only 42% (94/223) of patients achieved SVR24 on an intention-to-treat basis. In a model that included platelets, SVR24 was associated with white race [odds ratio (OR) = 5.92, 95% confidence interval (CI): 2.34-14.96], HCV sub-genotype 1b (OR = 2.81, 95%CI: 1.45-5.44), platelet count (OR = 1.10, per x 104 cells/μL, 95%CI: 1.05-1.16), and IL28B CC genotype (OR = 3.54, 95%CI: 1.19-10.53). Platelet counts > 135 x 103/μL were the strongest predictor of SVR by classification and regression tree. Relapse occurred in 25% (27/104) of patients with an end-of-treatment response and was associated with non-FVR (OR = 4.77, 95%CI: 1.68-13.56), HCV sub-genotype 1a (OR = 5.20; 95%CI: 1.40-18.97), and FIB-4 ≥ 3.25 (OR = 2.77; 95%CI: 1.07-7.22).
CONCLUSION The SVR rate was 42% with telaprevir- or boceprevir-based triple therapy in real-world practice. Low platelets and advanced fibrosis were associated with treatment failure and relapse.
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Perumalswami PV, Patel N, Bichoupan K, Ku L, Yalamanchili R, Harty A, Motamed D, Khaitova V, Chang C, Grewal P, Liu L, Schiano TD, Woodward M, Dieterich DT, Branch AD. High baseline bilirubin and low albumin predict liver decompensation and serious adverse events in HCV-infected patients treated with sofosbuvir-containing regimens. J Viral Hepat 2016; 23:667-76. [PMID: 26989855 DOI: 10.1111/jvh.12530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/11/2016] [Indexed: 01/05/2023]
Abstract
To conduct surveillance and determine the safety profile of new hepatitis C virus treatments in real-world clinical practice. Hepatic decompensation and other serious adverse events were investigated in an observational cohort study of 511 patients treated with regimens containing sofosbuvir, December 2013-June 2014. Among 499 previously stable patients (no history of hepatic decompensation during the previous 12 months), a nested case-control study was performed to identify predictors of decompensation/serious adverse event. Cases and controls were matched 1:5 based on treatment regimen and duration. Matched conditional logistic regression was used for analysis. Providers scored the likelihood that events were treatment-related (scale = 0-4). The cumulative incidence of decompensation/events was 6.4% for the total cohort. Among 499 previously stable patients, the incidence of decompensation/events was 4.5%; the mortality rate was 0.6%. Sixteen of the 499 experienced one or more serious complications considered to be at least potentially treatment-related, and the sustained virological response rate was 7/16 (44%). Two cases, both on sofosbuvir/simeprevir (without interferon or ribavirin), had complications consistent with autoimmune events (score 3, 'likely treatment-related'), and one experienced a flare of autoimmune hepatitis. Compared to controls, cases had higher baseline median model for end-stage liver disease scores (14 vs 8, P < 0.01). Decompensation/events was independently associated with lower baseline albumin (OR = 0.12/g/dL, P = 0.01) and higher total bilirubin (OR = 4.31/mg/dL, P = 0.01). Reduced hepatic function at baseline increased the risk of liver decompensation/events.
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Affiliation(s)
- P V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - N Patel
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L Ku
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - R Yalamanchili
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Harty
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - D Motamed
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - V Khaitova
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Chang
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - P Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L Liu
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - T D Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Woodward
- Nuffield Department of Population Health, The George Institute for Global Health, University of Oxford, Oxford, UK.,The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - D T Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A D Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Chekuri S, Nickerson J, Bichoupan K, Sefcik R, Doobay K, Chang S, DelBello D, Harty A, Dieterich DT, Perumalswami PV, Branch AD. Liver Stiffness Decreases Rapidly in Response to Successful Hepatitis C Treatment and Then Plateaus. PLoS One 2016; 11:e0159413. [PMID: 27442255 PMCID: PMC4956253 DOI: 10.1371/journal.pone.0159413] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/02/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIM To investigate the impact of a sustained virological response (SVR) to hepatitis C virus (HCV) treatment on liver stiffness (LS). METHODS LS, measured by transient elastography (FibroScan), demographic and laboratory data of patients treated with interferon (IFN)-containing or IFN-free regimens who had an SVR24 (undetectable HCV viral load 24 weeks after the end of treatment) were analyzed using two-tailed paired t-tests, Mann-Whitney Wilcoxon Signed-rank tests and linear regression. Two time intervals were investigated: pre-treatment to SVR24 and SVR24 to the end of follow-up. LS scores ≥ 12.5 kPa indicated LS-defined cirrhosis. A p-value below 0.05 was considered statistically significant. RESULTS The median age of the patients (n = 100) was 60 years [IQR (interquartile range) 54-64); 72% were male; 60% were Caucasian; and 42% had cirrhosis pre-treatment according to the FibroScan measurement. The median LS score dropped from 10.40 kPa (IQR: 7.25-18.60) pre-treatment to 7.60 kPa (IQR: 5.60-12.38) at SVR24, p <0.01. Among the 42 patients with LS-defined cirrhosis pre-treatment, 25 (60%) of patients still had LS scores ≥ 12.5 kPa at SVR24, indicating the persistence of cirrhosis. The median change in LS was similar in patients receiving IFN-containing and IFN-free regimens: -1.95 kPa (IQR: -5.75 --0.38) versus -2.40 kPa (IQR: -7.70 --0.23), p = 0.74. Among 56 patients with a post-SVR24 LS measurement, the LS score changed by an additional -0.90 kPa (IQR: -2.98-0.5) during a median follow-up time of 1.17 (IQR: 0.88-1.63) years, which was not a statistically significant decrease (p = 0.99). CONCLUSIONS LS decreased from pre-treatment to SVR24, but did not decrease significantly during additional follow-up. Earlier treatment may be needed to reduce the burden of liver disease.
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Affiliation(s)
- Sweta Chekuri
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jillian Nickerson
- Department of Medical Education, Icahn School of Medicine at the Mount Sinai Medical Center, New York, NY, United States of America
| | - Kian Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Roberta Sefcik
- Department of Medical Education, Icahn School of Medicine at the Mount Sinai Medical Center, New York, NY, United States of America
| | - Kamini Doobay
- Department of Medical Education, Icahn School of Medicine at the Mount Sinai Medical Center, New York, NY, United States of America
| | - Sanders Chang
- Department of Medical Education, Icahn School of Medicine at the Mount Sinai Medical Center, New York, NY, United States of America
| | - David DelBello
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Alyson Harty
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Douglas T. Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Ponni V. Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Andrea D. Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Del Bello D, Cha A, Sorbera M, Bichoupan K, Levine C, Doyle E, Harty A, Patel N, Ng M, Gardenier D, Odin J, Schiano TD, Fierer DS, Berkowitz L, Perumalswami PV, Dieterich DT, Branch AD. Real-World Sustained Virologic Response Rates of Sofosbuvir-Containing Regimens in Patients Coinfected With Hepatitis C and HIV. Clin Infect Dis 2016; 62:1497-1504. [PMID: 26936665 DOI: 10.1093/cid/ciw119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients with hepatitis C virus (HCV) with or without human immunodeficiency virus (HIV) achieve high sustained virological response (SVR) rates on sofosbuvir (SOF)-containing regimens in clinical trials. Real world data on patients coinfected with HCV and HIV treated with SOF-based regimens are lacking. METHODS This observational cohort study included HIV/HCV-coinfected adults with genotype 1 HCV who initiated treatment with a SOF-containing regimen between December 2013 and December 2014 (n = 89) at the Mount Sinai Hospital or the Brooklyn Hospital Center. The primary outcome was SVR at 12 weeks after the end of treatment. The secondary outcomes were risk factors for treatment failure, serious adverse events, and side effects. A post hoc per protocol analysis of SVR was performed on patients who completed treatment and follow-up. RESULTS In an intention-to-treat analysis, SVR rates were 76% (31/41) for simeprevir (SMV)/SOF, 94% (16/17) for SMV/SOF/ribavirin (RBV), and 52% (16/31) for SOF/RBV. The SVR rates of SMV/SOF/RBV and SMV/SOF did not differ significantly in this small study (P = .15). However the SVR rate of SMV/SOF/RBV was higher than that of SOF/RBV (P < .01). In a per protocol analysis, SMV/SOF/RBV had a higher SVR rate than SOF/RBV: 100% (16/16) vs 57% (16/28) (P < .01). The most commonly reported adverse effects were rash, pruritus, fatigue, and insomnia. One patient who had decompensated cirrhosis prior to treatment initiation died after receiving SMV/SOF. CONCLUSIONS SMV/SOF ± RBV is an effective option with minimal adverse effects for most HIV-positive patients with genotype 1 HCV. SMV should be used with caution in patients with decompensated cirrhosis.
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Affiliation(s)
- David Del Bello
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai
| | - Agnes Cha
- Department of Pharmacotherapy, Brooklyn Hospital Center
| | - Maria Sorbera
- Department of Pharmacotherapy, Brooklyn Hospital Center
| | | | - Calley Levine
- Department of Medicine, Icahn School of Medicine at Mount Sinai
| | | | - Alyson Harty
- Faculty Practice Associates, Mount Sinai Hospital
| | | | - Michel Ng
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai
| | | | | | | | - Daniel S Fierer
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai
| | | | | | - Douglas T Dieterich
- Division of Liver Diseases, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York City, New York
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Blanas DA, Nichols K, Bekele M, Shankar H, Bekele S, Jandorf L, Izzeldin S, Ndiaye D, Traore A, Bassam M, Perumalswami PV. Adapting the Andersen model to a francophone West African immigrant population: hepatitis B screening and linkage to care in New York City. J Community Health 2015; 40:175-84. [PMID: 25000917 DOI: 10.1007/s10900-014-9916-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis B virus (HBV) is highly endemic in West Africa and immigration from this region to the United States has greatly increased over the past quarter century. Using the Andersen Model as a conceptual framework, this study qualitatively examines francophone West African immigrants' perceptions of factors affecting access to HBV screening and linkage-to-care in New York City. Four focus groups were conducted with 39 purposefully selected participants. The focus groups were conducted in French, audio-recorded, translated into English, transcribed, analyzed, and coded for major themes. Participants identified increasing knowledge of HBV and opportunities to access care in a culturally-sensitive manner that decreases fatalism and avoids generating stigma as priorities. They also emphasized the importance of engaging religious establishments and social networks and employing the Internet to disseminate HBV-relevant information. Cost and health insurance are identified as future challenges that will need to be addressed in a health care environment in which undocumented immigrants are ineligible for health insurance. The qualitative analysis in this study highlights the recursive and interdependent nature of the Andersen Model, and a modification of the model is proposed that is intended to inform examinations of other minority communities' access to health care.
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Affiliation(s)
- Demetri A Blanas
- Institute for Family Health, Harlem Residency in Family Medicine, 1824 Madison Ave, New York, NY, 10035, USA,
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Martel-Laferrière V, Michel A, Schaefer S, Bindal S, Bichoupan K, Branch AD, Huprikar S, Schiano TD, Perumalswami PV. Clinical characteristics of human immunodeficiency virus patients being referred for liver transplant evaluation: a descriptive cohort study. Transpl Infect Dis 2015; 17:527-35. [PMID: 25929731 DOI: 10.1111/tid.12395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/05/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Liver transplantation (LT) is a treatment option for select human immunodeficiency virus (HIV)-infected patients with advanced liver disease. The aim of this study was to describe LT evaluation outcomes in HIV-infected patients. METHODS All HIV-infected patients referred for their first LT evaluation at the Mount Sinai Medical Center were included in this retrospective, descriptive cohort study. Multivariable logistic regression was used to identify factors independently associated with listing. RESULTS Between February 2000 and April 2012, 366 patients were evaluated for LT, with 66 (18.0%) listed for LT and 300 (82.0%) not listed. Fifty-one patients (13.9%) died before completing evaluation and 85 (23.2%) were too early for listing. Reasons patients were declined for listing were psychosocial (15.8%), HIV-related (10.4%), loss to follow-up (9.6%), surgical/medical (6.0%), liver-related (4.4%), patient choice (3.4%), and financial (1.6%). Listed patients were more likely to have hepatocellular carcinoma (HCC) (43.1% vs. 17.1%; P < 0.0001) and less likely to have hepatitis B (6.2% vs. 15.7%; P = 0.04) or a psychiatric history (19.7% vs. 35.2%; P = 0.02) than those not listed. In multivariable analysis, HCC (odds ratio [OR] 5.79; 95% confidence interval [95% CI]: 2.97-11.28), model for end-stage liver disease (MELD) score at referral (OR 1.06; 95% CI 1.01-1.11), and hepatitis B (OR 0.26; 95% CI 0.08-0.79) were associated with listing. CONCLUSION MELD score and HCC were positive predictors of listing in HIV-infected patients referred for LT evaluation and, therefore, timely referrals are vital in these patients. As MELD is a predictor for death while undergoing evaluation, rapid evaluation should be performed in HIV-infected patients with a higher MELD score.
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Affiliation(s)
- V Martel-Laferrière
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - A Michel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - S Schaefer
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - S Bindal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - K Bichoupan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - A D Branch
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - S Huprikar
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - T D Schiano
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - P V Perumalswami
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Asselah T, Perumalswami PV, Dieterich D. Is screening baby boomers for HCV enough? A call to screen for hepatitis C virus in persons from countries of high endemicity. Liver Int 2014; 34:1447-51. [PMID: 24840955 DOI: 10.1111/liv.12599] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tarik Asselah
- Centre de Recherche sur l'Inflammation (CRI), INSERM UMR 1149, Université Paris Diderot and Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, Paris, France
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Bichoupan K, Martel-Laferriere V, Sachs D, Ng M, Schonfeld EA, Pappas A, Crismale J, Stivala A, Khaitova V, Gardenier D, Linderman M, Perumalswami PV, Schiano TD, Odin JA, Liu L, Moskowitz AJ, Dieterich DT, Branch AD. Costs of telaprevir-based triple therapy for hepatitis C: $189,000 per sustained virological response. Hepatology 2014; 60:1187-95. [PMID: 25065814 PMCID: PMC4190678 DOI: 10.1002/hep.27340] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/11/2014] [Accepted: 07/24/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED In registration trials, triple therapy with telaprevir (TVR), pegylated interferon (Peg-IFN), and ribavirin (RBV) achieved sustained virological response (SVR) rates between 64% and 75%, but the clinical effectiveness and economic burdens of this treatment in real-world practice remain to be determined. Records of 147 patients who initiated TVR-based triple therapy at the Mount Sinai Medical Center (May-December 2011) were reviewed. Direct medical costs for pretreatment, on-treatment, and posttreatment care were calculated using data from Medicare reimbursement databases, RED Book, and the Healthcare Cost and Utilization Project database. Costs are presented in 2012 U.S. dollars. SVR (undetectable hepatitis C virus [HCV] RNA 24 weeks after the end of treatment) was determined on an intention-to-treat basis. Cost per SVR was calculated by dividing the median cost by the SVR rate. Median age of the 147 patients was 56 years (interquartile range [IQR] = 51-61), 68% were male, 19% were black, 11% had human immunodeficiency virus/HCV coinfection, 36% had advanced fibrosis/cirrhosis (FIB-4 scores ≥3.25), and 44% achieved an SVR. The total cost of care was $11.56 million. Median cost of care was $83,721 per patient (IQR = $66,652-$98,102). The median cost per SVR was $189,338 (IQR = $150,735-$221,860). Total costs were TVR (61%), IFN (24%), RBV (4%), adverse event management (8%), professional fees (2%), and laboratory tests (1%). CONCLUSIONS TVR and Peg-IFN accounted for 85% of costs. Pharmaceutical prices and the low (44%) SVR rate, in this real-world study, were major contributors to the high cost per SVR.
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Affiliation(s)
- Kian Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - David Sachs
- Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michel Ng
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Alexis Pappas
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alicia Stivala
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viktoriya Khaitova
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Donald Gardenier
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Linderman
- Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Thomas D. Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph A. Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence Liu
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan J. Moskowitz
- Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas T. Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrea D. Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
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Crismale JF, Martel-Laferrière V, Bichoupan K, Schonfeld E, Pappas A, Wyatt C, Odin JA, Liu LU, Schiano TD, Perumalswami PV, Bansal M, Dieterich DT, Branch AD. Diabetes mellitus and advanced liver fibrosis are risk factors for severe anaemia during telaprevir-based triple therapy. Liver Int 2014; 34:1018-24. [PMID: 24118693 PMCID: PMC3972374 DOI: 10.1111/liv.12342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 09/22/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Adding telaprevir to pegylated-interferon and ribavirin increased both response rates and side effects of hepatitis C virus (HCV) treatment. We identified variables associated with severe anaemia during telaprevir-based triple therapy. METHODS An observational study was performed on 142 HCV-infected patients between June 2011 and March 2012. All subjects completed 12 weeks of telaprevir-based triple therapy or discontinued early because of anaemia. Severe anaemia was defined by a haemoglobin≤8.9 g/dl; advanced fibrosis was determined by Fib-4≥3.25. RESULTS The 47 (33%) patients who developed severe anaemia were similar to those who did not in sex, race, and prior response to dual therapy, but they were more likely to have diabetes (23.4% vs. 6.3%, P<0.01), advanced fibrosis (46.8% vs. 29.5%, P=0.04) and a history of anaemia during previous dual therapy (29.7% vs. 11.4%, P=0.02). Patients developing severe anaemia were older (59 vs. 56 years, P=0.02), had lower baseline platelet counts (134 vs. 163×10(9) /L, P=0.04), haemoglobin (14.0 vs. 15.0 g/dl, P<0.01), estimated glomerular filtration rate (79 vs. 90 ml/min/1.73 m2, P=0.03) and a higher median ribavirin/weight ratio (14.9 vs. 13.2 mg/kg, P<0.01). In multivariable logistic regression, presence of diabetes (OR=5.61, 95% CI: 1.59-19.72), Fib-4≥3.25 (OR=3.09, 95% CI: 1.28-7.46), higher ribavirin/weight ratio (OR=1.31 per mg/kg, 95% CI: 1.13-1.52) and lower baseline haemoglobin (OR=0.57 per g/dl, 95% CI, 0.41-0.80) were independently associated with developing severe anaemia. CONCLUSIONS Severe anaemia occurred in one-third of patients receiving telaprevir-based triple therapy. Risk was greater in patients with diabetes, advanced liver fibrosis, higher ribavirin/weight ratio and lower baseline haemoglobin.
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Affiliation(s)
- James F. Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Kian Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emily Schonfeld
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexis Pappas
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Christina Wyatt
- Division of Renal Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph A. Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence U. Liu
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas D. Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Meena Bansal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas T. Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrea D. Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
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Han H, Perumalswami PV, Kleinman LC, Jandorf LH. Voices of multi-ethnic providers in NYC: health care for viral hepatitis to prevent hepatocellular carcinoma. J Cancer Educ 2014; 29:214-223. [PMID: 24189830 DOI: 10.1007/s13187-013-0569-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Worldwide, hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths and the ninth in the US. Hepatitis B and C make up almost 80% of HCC cases. Based on our Hepatitis Outreach Network screening program data, approximately 40% of at-risk foreign-born community members who tested positive for viral hepatitis B and/or C did not follow up for additional care. Our aim was to use theory-driven qualitative research to identify barriers and facilitators to follow-up after viral hepatitis diagnosis among these community members from the viewpoint of primary care providers (PCPs). As viral hepatitis is a precursor of liver cancer, timely treatment of the virus has the potential to reduce the incidence and burden of liver cancer. We performed semi-structured key informant interviews with 20 primary care physicians who predominantly serve Korean, Chinese, Egyptian, and Russian communities. Barriers detected included cultural factors commonly seen amongst immigrant populations such as busy work schedules and non-English language. Common facilitators include increased primary care physician involvement and linkages to care within communities in which patients reside. Providers perceived that they are gatekeepers to specialty care for their patients and therefore key persons to engage in viral hepatitis evaluation and management by specialists. This initial study suggests that re-focusing energy into primary care physicians might offer promise for improved care for individuals from immigrant communities who have viral hepatitis to help them engage in care and thereby reduce the burden of liver cancer.
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Affiliation(s)
- Hyosun Han
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Room 11-70, Box 1123, New York, NY, 10029, USA
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Levine C, Trivedi A, Thung SN, Perumalswami PV. Severe ductopenia and cholestasis from levofloxacin drug-induced liver injury: a case report and review. Semin Liver Dis 2014; 34:246-51. [PMID: 24879988 DOI: 10.1055/s-0034-1375964] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A 67-year-old woman with hypertension, hypothyroidism, and glaucoma was referred for jaundice and elevated liver function tests. She was treated for streptococcal endophthalmitis with 2 weeks of intravenous (IV) levofloxacin followed by 2 months of oral levofloxacin. The patient had no prior history of liver disease and denied alcohol intake. Her physical exam was remarkable for jaundice and scleral icterus without any stigmata of liver disease. Viral hepatitis serologies and antibodies, including myeloperoxidase, proteinase 3, and antinuclear, antimitochondrial, antiliver kidney microsome, antismooth muscle antibodies, were all within normal limits. The liver biopsy revealed severe cholestasis, extensive bile duct loss, and fibrosis. The patient had no known exposure to any other systemic medications or inciting factors other than levofloxacin. Although there are a few reported cases of drug-induced liver disease (DILI) related to levofloxacin, this case is believed to be the first reported case of ductopenia or vanishing bile duct syndrome (VBDS) associated with levofloxacin. Although fluoroquinolones, such as levofloxacin, are generally considered safe antibiotics, health practitioners must be aware of their association with DILI, as the diagnosis of DILI is one of exclusion and requires a high index of suspicion.
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Affiliation(s)
- Calley Levine
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anshu Trivedi
- The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Swan N Thung
- The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ponni V Perumalswami
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Perumalswami PV, DeWolfe Miller F, Orabee H, Regab A, Adams M, Kapelusznik L, Aljibawi F, Pagano W, Tong V, Dieterich DT. Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community. Liver Int 2014; 34:253-8. [PMID: 23890188 DOI: 10.1111/liv.12259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 06/17/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Many Egyptian-born persons in the U.S. are at high risk of chronic hepatitis C virus (HCV) infection, yet are not aware of their infection and lack healthcare coverage or linkage to care. In this study, we target Egyptian-born persons living in the New York City area for screening and link to care. METHODS A unique partnership, the Hepatitis Outreach Network (HONE), combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis. RESULTS Through four community-based screening events, 192 Egyptian-born persons were screened for HCV. Thirty (15.6%) persons were HCV positive. HCV antibody prevalence in those, whose national origin was Egypt, increased strongly with age and was associated with increasing number of years resident in Egypt and rural residents. Of the 30 Egyptian persons with HCV infection, 18 (60%) received a medical evaluation (2 with local providers and 16 at Mount Sinai). Of the HCV-infected persons evaluated, treatment was recommended in four and begun in three (75%). CONCLUSION Egyptian-born persons living in the New York City area have a high burden of HCV disease. HONE has successfully established targeted HCV screening in Egyptian-born persons through use of several unique elements that effectively link them to care.
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Affiliation(s)
- Ponni V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Perumalswami PV, Factor SH, Kapelusznik L, Friedman SL, Pan CQ, Chang C, Di Clemente F, Dieterich DT. Hepatitis Outreach Network: a practical strategy for hepatitis screening with linkage to care in foreign-born communities. J Hepatol 2013; 58:890-7. [PMID: 23333446 DOI: 10.1016/j.jhep.2013.01.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/26/2012] [Accepted: 01/07/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Many foreign-born persons in the US are at high risk of chronic hepatitis B (HBV) and C (HCV) infections, yet are not aware of their infection, and lack healthcare coverage or linkage to care. METHODS A unique partnership, the Hepatitis Outreach Network, combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene, and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis. Comprehensive HBV and HCV screening identifies infected patients, who then receive further evaluation from either local or Mount Sinai physicians, combined with patient-navigators who organize follow-up visits. RESULTS Of 1603 persons screened, 76 had HBV and 75 had HCV. Importantly, screening for HCV based on traditional risk factors would have missed 67% of those who tested positive. Of the 76 persons with HCV infection, 49 (64%) received a medical evaluation (26 with local providers and 23 at Mount Sinai). Of the 49 HCV-infected persons evaluated, treatment was recommended in 11 and begun in 8 (73%). Of the 76 persons with HBV infection, 43 (57%) received a medical evaluation (31 with local providers and 12 at Mount Sinai). Of the 43 HBV-infected persons evaluated, treatment was recommended and begun in 5 (100%). CONCLUSIONS Hepatitis Outreach Network has successfully established novel proof of concept for identifying HBV and HCV infections in foreign-born persons through use of several unique elements that effectively link them to care.
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Affiliation(s)
- Ponni V Perumalswami
- Division of Liver Diseases, The Mount Sinai Medical Center, Mount Sinai School of Medicine, NY 10029, United States.
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Abstract
A 51-year-old man from Puerto Rico with Child-Turcotte-Pugh Class C decompensated cirrhosis due to genotype 1a chronic hepatitis C was referred for worsening jaundice and diuretic-resistant ascites. He began experiencing symptoms of hepatic decompensation 5 months prior to referral with new-onset ascites and spontaneous bacterial peritonitis, evolving into diuretic-resistant ascites, increasing jaundice, and a MELD increase from 12 to 29. During his hospitalization, his MELD score increased to >40 from a rapidly increasing international normalized ratio (INR) and evolving type 1 hepatorenal syndrome. Clinically, the patient appeared quite well despite such a high MELD score. After an extensive pretransplant evaluation and exclusion of infection, he underwent successful orthotopic liver transplantation. After histologic examination of the explanted liver, he subsequently admitted to 5 months of daily use of a detoxifying supplement known as MaxOne (®), containing D-ribose- L-cysteine, consistent with a drug-induced acute-on-chronic liver failure. The use of complementary and alternative medicines and its potential for causing drug-induced liver injury and acute-on chronic liver failure requires a high index of suspicion and increased awareness among health care providers.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA
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