An Experimental Approach to Assess Fluorine Incorporation into Disordered Rock Salt Oxide Cathodes

Disordered rock salt oxides (DRX) have shown great promise as high-energy-density and sustainable Li-ion cathodes. While partial substitution of oxygen for fluorine in the rock salt framework has been related to increased capacity, lower charge-discharge hysteresis, and longer cycle life, fluorination is poorly characterized and controlled. This work presents a multistep method aimed at assessing fluorine incorporation into DRX cathodes, a challenging task due to the difficulty in distinguishing oxygen from fluorine using X-ray and neutron-based techniques and the presence of partially amorphous impurities in all DRX samples. This method is applied to "Li1.25Mn0.25Ti0.5O1.75F0.25" prepared by solid-state synthesis and reveals that the presence of LiF impurities in the sample and F content in the DRX phase is well below the target. Those results are used for compositional optimization, and a synthesis product with drastically reduced LiF content and a DRX stoichiometry close to the new target composition (Li1.25Mn0.225Ti0.525O1.85F0.15) is obtained, demonstrating the effectiveness of the strategy. The analytical method is also applied to "Li1.33Mn0.33Ti0.33O1.33F0.66" obtained via mechanochemical synthesis, and the results confirm that much higher fluorination levels can be achieved via ball-milling. Finally, a simple and rapid water washing procedure is developed to reduce the impurity content in as-prepared DRX samples: this procedure results in a ca. 10% increase in initial discharge capacity and a ca. 11% increase in capacity retention after 25 cycles for Li1.25Mn0.25Ti0.50O1.75F0.25. Overall, this work establishes new analytical and material processing methods that enable the development of more robust design rules for high-energy-density DRX cathodes.

Molecular confirmation of alpha 1-antitrypsin deficiency in liver transplant setting: A province-wide experience

Background and Aim

Patients suspected of Alpha 1-Antitrypsin (A1AT) abnormality based on low serum concentration are routinely confirmed through polymerase chain reaction (PCR) testing of peripheral blood. Genotyping formalin-fixed paraffin-embedded (FFPE) tissue is a novel approach that could aid in detecting variant A1AT. We performed qPCR on FFPE liver explants with Periodic Acid Schiff after Diastase (PASD)- and A1AT-positive globules to confirm and estimate the frequency of A1AT deficiency in transplant cases.

Materials and Methods

Eighteen (12.68%) of 142 patients with end-stage liver disease showed PASD/A1AT positive globules. FFPE of the explants was tested through qPCR to detect S and Z alleles. A second age- and sex-matched control group consisting of five liver transplant patients with negative globules was included in the study.

Results

qPCR assay was successful with all the samples meeting QC parameters. All patients included in the study elucidated Z allele variants; 2 homozygous (11.1%) and 16 heterozygous (88.9%). The control group demonstrated normal wild-type MM allele.

Conclusion

Screening for A1AT deficiency using serum levels is not sufficiently sensitive to detect deficiency, especially in carriers. If A1AT testing was not performed preoperatively and the risk is high based on the PASD/A1AT-positive globules in the explants, then molecular testing of FFPE tissue can be a viable method for confirming the diagnosis.

Polymorphism in Weberite Na2Fe2F7 and its Effects on Electrochemical Properties as a Na-Ion Cathode

Weberite-type sodium transition metal fluorides (Na₂M²⁺M'³⁺F₇) have emerged as potential high-performance sodium intercalation cathodes, with predicted energy densities in the 600-800 W h/kg range and fast Na-ion transport. One of the few weberites that have been electrochemically tested is Na₂Fe₂F₇, yet inconsistencies in its reported structure and electrochemical properties have hampered the establishment of clear structure-property relationships. In this study, we reconcile structural characteristics and electrochemical behavior using a combined experimental-computational approach. First-principles calculations reveal the inherent metastability of weberite-type phases, the close energetics of several Na₂Fe₂F₇ weberite polymorphs, and their predicted (de)intercalation behavior. We find that the as-prepared Na₂Fe₂F₇ samples inevitably contain a mixture of polymorphs, with local probes such as solid-state nuclear magnetic resonance (NMR) and Mössbauer spectroscopy providing unique insights into the distribution of Na and Fe local environments. Polymorphic Na₂Fe₂F₇ exhibits a respectable initial capacity yet steady capacity fade, a consequence of the transformation of the Na₂Fe₂F₇ weberite phases to the more stable perovskite-type NaFeF₃ phase upon cycling, as revealed by ex situ synchrotron X-ray diffraction and solid-state NMR. Overall, these findings highlight the need for greater control over weberite polymorphism and phase stability through compositional tuning and synthesis optimization.

A248 OUTCOMES OF COVID-19 ILLNESS AND ACCESS TO APPROPRIATE TREATMENT IN LIVER TRANSPLANT RECIPIENTS IN BRITISH COLUMBIA THROUGHOUT THE PANDEMIC

Background

COVID-19 continues to cause significant illness and mortality worldwide. Solid Organ Transplant Recipients (SOTR) have a higher rate of COVID-19 infection and worse outcomes than those who are immunocompetent. Dexamethasone, tocilizumab, and baricitinib have improved inpatient outcomes. Sotrovimab, remdesivir, and nirmatrelvir/ritonavir have recently been approved for used in high risk, minimally symptomatic outpatients. Previous experience has shown that use of monoclonal antibodies and oral antiviral agents have reduced morbidity and mortality of COVID-19 in SOTR.

Purpose

To assess the experiences and outcomes of COVID-19 and access to directed therapy in SOTR in British Columbia (BC).

Method

Data was compiled from patient disclosure to liver transplant clinicians on COVID-19 infection and gathered from patient charts in the SOTR Clinic at Vancouver General Hospital. Inclusion criteria were patients followed at the clinic with a positive COVID-19 test or clinical confirmation of COVID-19 syndrome. This is a retrospective, quality assurance study and did not require ethics review.

Result(s)

158 SOTR reported COVID-19 infections between March 2020 and September 2022. 3 patients died within 30 days of COVID-19 infection, 2 (1.26%) of which the cause of death was directly due to COVID-19, and the other who had cholangitis with severe sepsis and multi-organ system failure. 24 patients required admission to hospital, 7 requiring critical care support.

41 patients did not receive any therapy for COVID-19: there was none available at that time (n=26), it was contraindicated due to a drug interaction (n=2) or medical condition (n=1), was refused (n=1), or the infection was reported too late to qualify (n=10). 83% (92/112) of outpatients received available anti-viral treatment: sotrovimab (n=27), remdesivir (n=63), or nirmatrelvir/ritonavir (n=2). In inpatients (n=24), 13 received corticosteroids, 6 dual treated with tocilizumab (n=4) or baracitinib (n=2). 4 inpatients received remdesivir.

Three patients were treated in hospital after initiating outpatient therapy, one with progression of COVID-19 illness despite starting remdesivir. Two patients had adverse effects of medications provided: one was prescribed nirmatrelvir/ritonavir by a physician outside of the transplant program, which caused tacrolimus toxicity (serum concentration of 69.4 ng/mL) with nausea, vomiting, and diarrhea. Another patient had an episode of hypotension after receiving sotrovimab and sustained an acute kidney injury (AKI). Both patients fully recovered. There were no deaths on antiviral therapy.

Of 145 patients who had laboratory investigations done within 30 days of COVID-19 infection, 16 had a transient rise in liver enzymes, 14 had an AKI and 11required an adjustment in their tacrolimus dose.

Conclusion(s)

Involving the liver transplant team early in the course of COVID-19 illness allows patients to safely access COVID-19 directed therapy to avoid progression of illness, and medication interactions or toxicity.

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A240 "MY FEELINGS AND MY THOUGHTS ARE MY LIVED EXPERIENCE, NOT THE NUMBERS THEY SHOW ME ON A PIECE OF PAPER”: INDIGENOUS EXPERIENCES OF LIVER TRANSPLANTATION IN BRITISH COLUMBIA, CANADA

Background

Indigenous peoples in Canada face inequities in healthcare access due to historic and ongoing colonial systems and structures of oppression. Indigenous peoples face greater health challenges including acute/chronic disease and may require consideration for transplantation including liver, kidney, heart, and lung. In a renal transplant study, Indigenous patients were less likely to undergo transplantation compared to non-Indigenous patients on dialysis; the reasons for this disparity are not known. The experiences of Indigenous patients during the liver transplant process in British Columbia, and how transplant professionals perceive challenges faced by Indigenous people, has not been studied.

Purpose

The purpose of this study is to explore experiences of Indigenous patients during the liver transplant process in British Columbia, and how transplant professionals perceive challenges faced by Indigenous people. This work will provide foundational evidence for improving Indigenous patient care in the transplant process in British Columbia, in response to recommendations made to address systemic and interpersonal racism documented in the In Plain Sight report in 2020.

Method

Thirteen semi-structured qualitative interviews were conducted with Indigenous patients (n=7) and transplant care providers (n=6) across British Columbia, Canada. Interpretive description identified themes to inform clinical approaches and transplant care planning. Themes and related recommendations were validated by Indigenous health experts prior to contextualization.

Result(s)

Interviews were conducted via Zoom from April 2021-May 2022. Among liver transplant patient participants: transplants had occurred between 1992-2020; all were women; and the median age at the time of their interview was 58 years. Among transplant care provider participants, roles included nursing, social work, and surgery; 83% were women; and the median number of years in transplant care was ten. Three broad themes were identified: 1) Indigenous transplant patient participants had strong familial, cultural, and financial supports that were essential to accessing liver transplantation; 2) colonialism has created and perpetuated structural barriers preventing many more Indigenous peoples from being considered eligible for liver transplant; 3) anti-Indigenous racism and a lack of cultural safety and humility are barriers for Indigenous peoples who require timely care for liver disease and for establishing trusting relationships with care providers.

Conclusion(s)

To our knowledge, this study is the first to explore experiences of Indigenous liver transplant recipients and transplant care providers’ understanding of inequities uniquely experienced by Indigenous peoples. Addressing structural barriers to early linkage to care is needed and training for transplant clinicians on Indigenous histories, complex and intergenerational trauma, and cultural safety is strongly recommended.

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Nanolattice-Forming Hybrid Collagens in Protective Shark Egg Cases

Nanoscopic structural control with long-range ordering remains a profound challenge in nanomaterial fabrication. The nanoarchitectured egg cases of elasmobranchs rely on a hierarchically ordered latticework for their protective function─serving as an exemplary system for nanoscale self-assembly. Although the proteinaceous precursors are known to undergo intermediate liquid crystalline phase transitions before being structurally arrested in the final nanolattice architecture, their sequences have so far remained unknown. By leveraging RNA-seq and proteomic techniques, we identified a cohort of nanolattice-forming proteins comprising a collagenous midblock flanked by domains typically associated with innate immunity and network-forming collagens. Structurally homologous proteins were found in the genomes of other egg-case-producing cartilaginous fishes, suggesting a conserved molecular self-assembly strategy. The identity and stabilizing role of cross-links were subsequently elucidated using mass spectrometry and in situ small-angle X-ray scattering. Our findings provide a new design approach for protein-based liquid crystalline elastomers and the self-assembly of nanolattices.

Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis

BACKGROUND

Cervical inlet patch (CIP), also called gastric inlet patch, is a heterotopic columnar mucosal island located in the cervical esophagus, which has been under-recognized by clinicians.

AIM

We conducted a systemic review and meta-analysis to explore the prevalence and clinical and endoscopic characteristics of CIP.

MATERIALS AND METHODS

Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The prevalence of CIP with 95% confidence interval (CI) was pooled by using a random-effect model. The association of CIP with demographics, clinical presentations, and endoscopic features was evaluated by odds ratios (ORs).

RESULTS

Fifty-three studies including 932,777 patients were eligible. The pooled prevalence of CIP was 3.32% (95% CI=2.86%-3.82%). According to the endoscopic mode, the pooled prevalence of CIP was higher in studies using narrow-band imaging than in those using white light and esophageal capsule endoscopy (9.34% vs. 2.88% and 0.65%). The pooled prevalence of CIP was higher in studies where the endoscopists paid specific attention to the detection of this lesion (5.30% vs. 0.75%). CIP was significantly associated with male (OR=1.24, 95% CI=1.09-1.42, P=0.001), gastroesophageal reflux disease (OR=1.32, 95% CI=1.04-1.68, P=0.03), reflux symptoms (OR=1.44, 95% CI=1.14-1.83, P=0.002), dysphagia (OR=1.88, 95% CI=1.28-2.77, P=0.001), throat discomfort (OR=4.58, 95% CI=1.00-21.02, P=0.05), globus (OR=2.95, 95% CI=1.52-5.73, P=0.001), hoarseness (OR=4.32, 95% CI=1.91-9.78, P=0.0004), cough (OR=3.48, 95% CI=1.13-10.72, P=0.03), Barrett's esophagus (OR=2.01, 95% CI=1.37-2.94, P=0.0003), and esophagitis (OR=1.62, 95% CI=1.27-2.07, P=0.0001).

CONCLUSION

CIP appears to be common by using narrow-band imaging, especially if the endoscopists would like to pay attention to the detection of this lesion. CIP is clearly associated with acid-related symptoms and Barrett's esophagus.

Women in the 2019 hepatitis C cascade of care: findings from the British Columbia Hepatitis Testers cohort study

BACKGROUND

Women living with hepatitis C virus (HCV) are rarely addressed in research and may be overrepresented within key populations requiring additional support to access HCV care and treatment. We constructed the HCV care cascade among people diagnosed with HCV in British Columbia, Canada, as of 2019 to compare progress in care and treatment and to assess sex/gender gaps in HCV treatment access.

METHODS

The BC Hepatitis Testers Cohort includes 1.7 million people who tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 2000 to 2019. Test results were linked to medical visits, hospitalizations, cancers, prescription drugs, and mortality data. Six HCV care cascade stages were identified: (1) antibody diagnosed; (2) RNA tested; (3) RNA positive; (4) genotyped; (5) initiated treatment; and (6) achieved sustained virologic response (SVR). HCV care cascade results were assessed for women, and an 'inverse' cascade was created to assess gaps, including not being RNA tested, genotyped, or treatment initiated, stratified by sex.

RESULTS

In 2019, 52,638 people with known sex were anti-HCV positive in BC; 37% (19,522) were women. Confirmatory RNA tests were received by 86% (16,797/19,522) of anti-HCV positive women and 83% (27,353/33,116) of men. Among people who had been genotyped, 68% (6756/10,008) of women and 67% (12,640/18,828) of men initiated treatment, with 94% (5023/5364) of women and 92% (9147/9897) of men achieving SVR. Among the 3252 women and 6188 men not yet treated, higher proportions of women compared to men were born after 1975 (30% vs. 21%), had a mental health diagnosis (42% vs. 34%) and had used injection drugs (50% vs. 45%). Among 1619 women and 2780 men who had used injection drugs and were not yet treated, higher proportions of women than men used stimulants (64% vs. 57%), and opiates (67% vs. 60%).

CONCLUSIONS

Women and men appear to be equally engaged into the HCV care cascade; however, women with concurrent social and health conditions are being left behind. Treatment access may be improved with approaches that meet the needs of younger women, those with mental health diagnoses, and women who use drugs.

Post-traumatic Stress Disorder in Resident Physicians

Background

Research suggests that symptoms of post-traumatic stress disorder (PTSD) may be common in physicians who have experienced a traumatic event, but it is unclear if medical residents suffer from similar symptoms.

Objective

To determine the prevalence of PTSD symptoms in the resident physician population of the University of British Columbia based on the new Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) criteria.

Method

A link to an online questionnaire containing 27 questions, including residency training and year, as well as the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (PCL-5) was e-mailed and completed by the resident physicians of the University of British Columbia.

Results

Forty-three residents completed the survey and 38 had complete data. Mean PCL-5 score was 10.3 for the 38 subjects. Differences between PCL-5 score and resident year yielded the following: postgraduate year (PGY)-1=8.6; PGY-2=16.5; PGY-3=3.6; PGY-4=4.0; PGY-5=7.7. With respect to the type of traumatic event and PCL-5 score, the following was observed: Death=5.3, Violence=13.8, Medical Error=8.0, Bullying=38.0, None=45.0. The Kruskal-Wallis test showed no statistically significant differences in total PCL-5 score for PGY or type of traumatic event. Regardless of post-graduate year or trauma experience, four subjects out of 38 (10.5%) had a total PCL-5 score of 33 or greater, while one subject (2.5%) had a score greater than 50.

Conclusion

The results from this study conclude that resident physicians do suffer from PTSD symptoms at a rate higher than the average American population. As PTSD symptoms can often be very distressing and potentially affect work ethic negatively, further studies are indicated to better understand these symptoms and hopefully lead to better care in treating PTSD symptoms in resident physicians.

Estimating the impact of early hepatitis C virus clearance on hepatocellular carcinoma risk

Although achieving sustained virological response (SVR) through antiviral therapy could reduce the risk of hepatocellular carcinoma (HCC) attributable to hepatitis C virus (HCV) infection, the impact of early viral clearance on HCC is not well defined. In this study, we compared the risk of HCC among individuals who spontaneously cleared HCV (SC), the referent population, with the risk in untreated chronic HCV (UCHC), those achieved SVR, and those who failed interferon-based treatment (TF). The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV between 1990-2013, integrated with medical visits, hospitalizations, cancers, prescription drugs and mortality data. This analysis included all HCV-positive patients with at least one valid HCV RNA by PCR on or after HCV diagnosis. Of 46 666 HCV-infected individuals, there were 12 527 (26.8%) SC; 24 794 (53.1%) UCHC; 5355 (11.5%) SVR and 3990 (8.5%) TF. HCC incidence was lowest (0.3/1000 person-years (PY)) in the SC group and highest in the TF group (7.7/1000 PY). In a multivariable model, compared to SC, TF had the highest HCC risk (hazard ratio (HR):14.52, 95% confidence interval (CI): 9.83-21.47), followed by UCHC (HR: 5.85; 95% CI: 4.07-8.41). Earlier treatment-based viral clearance similar to SC could decrease HCC incidence by 69.4% (95% CI: 57.5-78.0), 30% (95% CI: 10.8-45.1) and 77.5% (95% CI: 69.4-83.5) among UCHC, SVR and TF patients, respectively. In conclusion, using SC as a real-world comparator group, it showed that substantial reduction in HCC risk could be achieved with earlier treatment initiation. These analyses should be replicated in patients who have been treated with direct acting antiviral therapies.

Experimental validation of the FLUKA Monte Carlo code for dose and [Formula: see text]-emitter predictions of radioactive ion beams

In the context of hadrontherapy, whilst ions are capable of effectively destroying radio resistant, deep seated tumors, their treatment localization must be well assessed to ensure the sparing of surrounding healthy tissue and treatment effectiveness. Thus, range verification techniques, such as online positron-emission-tomography (PET) imaging, hold great potential in clinical practice, providing information on the in vivo beam range and consequent tumor targeting. Furthermore, [Formula: see text] emitting radioactive ions can be an asset in online PET imaging, depending on their half-life, compared to their stable counterparts. It is expected that using these radioactive ions the signal obtained by a PET apparatus during beam delivery will be greatly increased, and exhibit a better correlation to the Bragg Peak. To this end, FLUKA Monte Carlo particle transport and interaction code was used to evaluate, in terms of annihilation events at rest and dose, the figure of merit in using [Formula: see text] emitter, radioactive ion beams (RI [Formula: see text]). For this purpose, the simulation results were compared with experimental data obtained with an openPET prototype in various online PET acquisitions at the Heavy Ion Medical Accelerator in Chiba (HIMAC), in collaboration with colleagues from the National Institute of Radiological Sciences' (NIRS) Imaging Physics Team. The dosimetry performance evaluation with FLUKA benefits from its recent developments in fragmentation production models. The present work estimated that irradiations with RI [Formula: see text], produced via projectile fragmentation and their signal acquisition with state-of-the-art PET scanner, lead to nearly a factor of two more accurate definition of the signals' peak position. In addition to its more advantageous distribution shape, it was observed at least an order magnitude higher signal acquired from ¹¹C and ¹⁵O irradiations, with respect to their stable counterparts.

Isolation and Characterization of jararaca GPIb-BP, a Snake Venom Antagonist Specific to Platelet Glycoprotein lb

A platelet glycoprotein lb-binding protein (GPIb-BP) was isolated from the snake venom of Bothrops jararaca. Jararaca GPIb-BP showed a single band with Mr of 30,000, and two distinct bands with Mr. of 17,000/13,000 under non-reducing and reducing conditions, respectively, on SDS-polyacrylamide gel electrophoresis. Jararaca GPIb-BP itself induced neither platelet aggregation nor serotonin release from platelets, but specifically bound to GPIb (40,629 ± 2,521 molecules per normal platelet, with Kd 39.1 ± 2.4 nM at saturation). The purified venom protein completely inhibited ristocetin- or botrocetin-induccd von Willebrand factor (vWF) binding, and blocked the bovine vWF binding to GPIb, with IC50 values ranging from 28 to 42 nM, without affecting the platelet aggregation induced by ADP or α-thrombin. 1251-jararaca GPIb-BP binding to GPIb was not altered by the presence of human α-thrombin. Jararaca GPIb-BP at a final concentration of 104 nM totally abolished vWF-dependent shear- induced platelet aggregation (SIPA) at a high shear stress, but had no effect on SIPA at a low shear stress. Reduced and S-carboxyamidomethylated jararaca GPIb-BP lost its inhibitory activity on SIPA. The NH2-terminal amino acid sequences of the subunits revealed a high degree of homology with those of several Ca2+-dependent lectins, especially to those of two functionally opposite venom proteins, botrocetin (a vWF-modulator) and alboaggregin-B (a GPIb- modulator).

Cutaneous Toxoplasmosis in a Female Japanese Cat

A 16-year-old female Japanese cat was presented with a single mammary-gland nodule approximately 3 cm in diameter. Histologically, the nodule consisted of necrotizing granulomatous panniculitis, vasculitis, and mastitis, and contained free and clustered protozoal organisms. The organism was present in the cytoplasm of macrophages, fibroblasts, endothelial cells, and mammary-gland epithelia. The organism was positive for anti- Toxoplasma gondii and anti- Neospora caninum antibodies. Electron microscopy showed single and grouped tachyzoites, with morphologic features similar to those of T. gondii. Polymerase chain reaction and deoxyribonucleic acid sequence analysis was consistent with T. gondii infection. This is the first report of cutaneous toxoplasmosis in a Japanese cat.

Use of Monitoring Gamma-Glutamyl Transpeptidase Levels After Liver Transplant: A Longitudinal Retrospective Analysis of a Single-Center's Experience

OBJECTIVES

Recently, gamma-glutamyl transpeptidase has garnered increased attention as a diagnostic tool in the early identification of liver disease. However, its value in liver transplant is largely unknown, as the disease processes leading to abnormal gamma-glutamyl transpeptidase levels and the expected temporal trends in gamma-glutamyl transpeptidase levels during the period after liver transplant remain unclear.

MATERIALS AND METHODS

Between January 2010 and August 2013, consecutive patients who underwent liver transplant at Vancouver General Hospital (Vancouver, Canada) were assessed longitudinally up to 1 year after liver transplant. A "gamma-glutamyl transpeptidase event" was defined as 2 abnormal gamma-glutamyl transpeptidase values (exceeding sex-specific limits of normal, at 55 U/L for female and 80 U/L for male patients) ≥ 1 week apart.

RESULTS

Our study included 147 liver transplant recipients. The median gamma-glutamyl transpeptidase level on day 1 after liver transplant was 73 U/L, which peaked to 435 U/L during the first month after liver transplant and returned to within normal parameters by 1 year. In total, there were 282 gamma-glutamyl transpeptidase events, with biliary complications (22%), acute rejection (16%), and hepatitis C virus recurrence (10%) being the most common causes. In 39% of events, no cause was identified. When attempting to identify a disease-associated event, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to double in value, it had 42% sensitivity and 40% specificity. Comparatively, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to become abnormal, it had 3% sensitivity and 93% specificity.

CONCLUSIONS

Although gamma-glutamyl transpeptidase almost universally becomes abnormal after liver transplant, a specific pathologic cause was not commonly identified. Interpreting the characteristics of gamma-glutamyl transpeptidase elevation has limited use for identifying the underlying reason for its elevation.

Response to Sildenafil in a Patient With Coexisting Post-Liver Transplant Portopulmonary Hypertension and Hepatopulmonary Syndrome

Hepatopulmonary syndrome and portopulmonary hypertension are complications of portal hypertension with opposing mechanisms that can coexist. Moderate portopulmonary hypertension, which is a contraindication to a liver transplant, must be managed with pulmonary vasodilators to normalize pulmonary arterial pressures before a transplant listing. Concomitant hepatopulmonary syndrome complicates the management of portopulmonary hypertension, as pulmonary vasodilators can theoretically exacerbate the intrapulmonary dilatation believed to cause hepatopulmonary syndrome. We describe a case of a post-liver transplant patient with concomitant hepatopulmonary syndrome and portopulmonary hypertension safely treated with sildenafil.

Sofosbuvir and Velpatasvir for HCV Genotype 1, 2, 4, 5, and 6 Infection

BACKGROUND

A simple treatment regimen that is effective in a broad range of patients who are chronically infected with the hepatitis C virus (HCV) remains an unmet medical need.

METHODS

We conducted a phase 3, double-blind, placebo-controlled study involving untreated and previously treated patients with chronic HCV genotype 1, 2, 4, 5, or 6 infection, including those with compensated cirrhosis. Patients with HCV genotype 1, 2, 4, or 6 were randomly assigned in a 5:1 ratio to receive the nucleotide polymerase inhibitor sofosbuvir and the NS5A inhibitor velpatasvir in a once-daily, fixed-dose combination tablet or matching placebo for 12 weeks. Because of the low prevalence of genotype 5 in the study regions, patients with genotype 5 did not undergo randomization but were assigned to the sofosbuvir-velpatasvir group. The primary end point was a sustained virologic response at 12 weeks after the end of therapy.

RESULTS

Of the 624 patients who received treatment with sofosbuvir-velpatasvir, 34% had HCV genotype 1a, 19% genotype 1b, 17% genotype 2, 19% genotype 4, 6% genotype 5, and 7% genotype 6. A total of 8% of patients were black, 19% had cirrhosis, and 32% had been previously treated for HCV. The rate of sustained virologic response among patients receiving sofosbuvir-velpatasvir was 99% (95% confidence interval, 98 to >99). Two patients receiving sofosbuvir-velpatasvir, both with HCV genotype 1, had a virologic relapse. None of the 116 patients receiving placebo had a sustained virologic response. Serious adverse events were reported in 15 patients (2%) in the sofosbuvir-velpatasvir group and none in the placebo group.

CONCLUSIONS

Once-daily sofosbuvir-velpatasvir for 12 weeks provided high rates of sustained virologic response among both previously treated and untreated patients infected with HCV genotype 1, 2, 4, 5, or 6, including those with compensated cirrhosis. (Funded by Gilead Sciences; ClinicalTrials.gov number, NCT02201940.).

Are Interferon-Free Direct-Acting Antivirals for the Treatment of HCV Enough to Control the Epidemic among People Who Inject Drugs?

BACKGROUND

Widely access to interferon-free direct-acting antiviral regimens (IFN-free DAA) is poised to dramatically change the impact of the HCV epidemic among people who inject drugs (PWID). We evaluated the long-term effect of increasing HCV testing, treatment and engagement into harm-reduction activities, focused on active PWID, on the HCV epidemic in British Columbia (BC), Canada.

METHODS

We built a compartmental model of HCV disease transmission stratified by disease progression, transmission risk, and fibrosis level. We explored the effect of: (1) Increasing treatment rates from 8 to 20, 40 and 80 per 1000 infected PWID/year; (2) Increasing treatment eligibility based on fibrosis level; (3) Maximizing the effect of testing by performing it immediately upon ending the acute phase; (4) Increasing access to harm-reduction activities to reduce the risk of re-infection; (5) Different HCV antiviral regimens on the Control Reproduction Number Rc. We assessed the impact of these interventions on incidence, prevalence and mortality from 2016 to 2030.

RESULTS

Of all HCV antiviral regimens, only IFN-free DAAs offered a high chance of disease elimination (i.e. Rc < 1), but it would be necessary to substantially increase the current low testing and treatment rates. Assuming a treatment rate of 80 per 1000 infected PWID per year, coupled with a high testing rate, the incidence rate, at the end of 2030, could decrease from 92.9 per 1000 susceptible PWID per year (Status Quo) to 82.8 (by treating only PWID with fibrosis level F2 and higher) or to 65.5 (by treating PWID regardless of fibrosis level). If PWID also had access to increased harm-reduction activities, the incidence rate further decreased to 53.1 per 1000 susceptible PWID per year. We also obtained significant decreases in prevalence and mortality at the end of 2030.

CONCLUSIONS

The combination of increased access to HCV testing, highly efficacious antiviral treatment and harm-reduction programs can substantially decrease the burden of the HCV epidemic among PWID. However, unless we increase the current levels of treatment and testing, the HCV epidemic among PWID in BC, and in other parts of the world with similar epidemiological background, will remain a substantial public health concern for many years.

DAUPHINE: a randomized phase II study of danoprevir/ritonavir plus peginterferon alpha-2a/ribavirin in HCV genotypes 1 or 4

BACKGROUND & AIMS

Danoprevir is a hepatitis C virus (HCV) protease inhibitor with activity against genotypes (G)1/G4, which is maintained at lower doses by ritonavir-boosting. We report results of a large, randomized, active-controlled phase IIb study of ritonavir-boosted danoprevir (danoprevir/r) plus peginterferon alpha-2a/ribavirin (P/R) in treatment-naive patients with HCV G1/4 infection.

METHODS

Treatment-naive patients with HCV G1/4 infection were randomized to twice-daily danoprevir/r 200/100 mg (A, n = 92); 100/100 mg (B, n = 93); or 50/100 mg (C, n = 94) plus P/R for 24 weeks; twice-daily danoprevir/r 100/100 mg (D, n = 94) plus P/R for 12 or 24 weeks; or P/R alone (E, n = 44) for 48 weeks. Patients in the response-guided therapy arm (D) with an extended rapid virological response (eRVR2: HCV RNA <15 IU/ml during Weeks 2-10) stopped all therapy at Week 12; non-eRVR2 patients continued all treatment to Week 24. The primary efficacy endpoint was sustained the virological response (SVR24: HCV RNA <15 IU/ml after 24 weeks of untreated follow-up).

RESULTS

SVR24 rates in Arms A, B, C, D and E were 89.1%, 78.5%, 66.0%, 69.1% and 36.4%, respectively, in the overall population; 83.6%, 69.6%, 60.3%, 59.2% and 38.5% in G1a-infected patients, 96.6%, 93.1%, 73.1%, 78.4% and 28.6% in G1b-infected patients and 100%, 87.5%, 100%, 100% and 66.7% in G4-infected patients. Danoprevir/r plus P/R was generally well tolerated compared with P/R alone. There was a higher incidence of serious adverse events in danoprevir-treatment arms, but most were associated with P/R.

CONCLUSIONS

The combination of danoprevir/r plus P/R is efficacious in treatment-naïve patients with HCV genotype 1 or 4 infection.

Compact 100Gb/s DP-QPSK integrated receiver module employing three-dimensional assembly technology

We demonstrate a compact 100 Gbit/s DP-QPSK receiver module that is only 18 mm (W) x 16 mm (D) x 2.8 mm (H). The module size is reduced by using a ball grid array (BGA) package with three-dimensional assembly technology and by applying a heterogeneous integrated PLC. Error-free DP-QPSK signal demodulation is successfully demonstrated.

Randomized controlled trial of danoprevir plus peginterferon alfa-2a and ribavirin in treatment-naïve patients with hepatitis C virus genotype 1 infection

BACKGROUND & AIMS

The combination of a hepatitis C virus (HCV) protease inhibitor, peginterferon, and ribavirin is the standard of care for patients with HCV genotype 1 infection. We report the efficacy and safety of response-guided therapy with danoprevir (a potent second-generation protease inhibitor), peginterferon alfa-2a (40 KD), and ribavirin in these patients.

METHODS

Treatment-naïve patients (N = 237) were randomly assigned to groups given 12 weeks of danoprevir (300 mg every 8 hours; 600 mg every 12 hours, and 900 mg every 12 hours) or placebo plus peginterferon alfa-2a and ribavirin, followed by peginterferon alfa-2a and ribavirin. Patients given danoprevir who had an extended rapid virologic response (eRVR4-20: HCV RNA <15 IU/mL during weeks 4-20) stopped therapy at week 24; those without an eRVR4-20 continued therapy to 48 weeks. Patients who were given placebo received 48 weeks of peginterferon alfa-2a and ribavirin. The primary efficacy end point was sustained virologic response (SVR: HCV RNA <15 IU/mL after 24 weeks without treatment).

RESULTS

Rates of SVR were higher among patients given danoprevir 300 mg (68%), 600 mg (85%), and 900 mg (76%) than placebo (42%) (95% confidence interval: 26%-59%). Seventy-nine percent of patients given danoprevir 600 mg had an eRVR4-20; among these, 96% had an SVR. Serious adverse events were reported in 7% to 8% of patients given danoprevir and 19% given placebo. Four patients given danoprevir (1 patient in the 600-mg group and 3 in the 900-mg group) had reversible, grade 4 increases in alanine aminotransferase, which led to early discontinuation of the 900-mg arm of the study.

CONCLUSIONS

The combination of danoprevir, peginterferon alfa-2a, and ribavirin leads to high rates of SVR in patients with HCV genotype 1 infection, but high doses of danoprevir can lead to grade 4 increases in alanine aminotransferase. Studies of lower doses of danoprevir with ritonavir, to reduce overall danoprevir exposure while maintaining potent antiviral activity, are underway; Clinicaltrials.gov number, NCT00963885.

Health care costs associated with hepatocellular carcinoma: a population-based study

Although the burden of hepatocellular carcinoma (HCC) is an escalating public health problem, it has not been rigorously estimated within a Canadian context. We conducted a population-based study using Ontario Cancer Registry linked administrative data. The mean net costs of care due to HCC were estimated using a phase of care approach and generalized estimating equations. Using an incidence approach, the mean net costs of care were applied to survival probabilities of HCC patients to estimate 5-year net costs of care and extrapolated to the Canadian population of newly diagnosed HCC patients in 2009. During 2002-2008, 2,341 HCC cases were identified in Ontario. The mean (95% confidence interval [CI]) net costs of HCC care per 30 patient-days (2010 US dollars) were $3,204 ($2,863-$3,545) in the initial phase, $2,055 ($1,734-$2,375) in the continuing care phase, and $7,776 ($5,889-$9,663) in the terminal phase. The mean (95% CI) 5-year net cost of care was $77,509 ($60,410-$94,607) and the 5-year aggregate net cost of care was $106 million ($83-$130 million) (undiscounted). The net costs of patients receiving liver transplantation only and those undergoing surgical resection only were highest in the terminal phase. The net cost of patients receiving radiofrequency ablation as the only treatment was relatively low in the initial phase, and there were no significant differences in the continuing and terminal phases.

CONCLUSION

Our findings suggest that costs attributable to HCC are significant in Canada and expected to increase. Our findings of phase-specific cost estimates by resource categories and type of treatment provide information for future cost-effectiveness analysis of potential innovative interventions, resource allocation, and health care budgeting, and public health policy to improve the health of the population.

Magnetic resonance venography and liver transplant complications

Hepatic vein stenosis is a rare but serious complication following liver transplantation. Multiple modalities can be utilized to image the hepatic vasculature. Magnetic resonance venography (MRV) provides certain advantages over ultrasound, computed tomography angiography and digital subtraction venography. MRV utilizes the same imaging principles of magnetic resonance angiography in order to image the venous system. Blood pool contrast agents, specifically gadofosveset trisodium, allow for steady state imaging up to 1 h following injection, with improved visualisation of vital venous structures by utilising delayed steady state imaging. Additionally, the inherent physics properties of magnetic resonance imaging also provide excellent soft tissue detail and thus help define the extent of complications that often plague the post-liver transplant patient. This case report describes the use of gadofosveset trisodium in a patient with hepatic venous stenosis following liver transplantation. Initial venography failed to outline the stenoses and thus MRV using a blood pool contrast agent was utilised in order to delineate the anatomy and plan a therapeutic endovascular procedure.

Hepatic embolotherapy in interventional oncology: technology, techniques, and applications

Embolotherapy continues to play a growing role in the management of primary and secondary hepatic malignancies. In this review article, we examine the basis of therapy with a focus on neovascularization, which makes treatments via the hepatic artery possible. An overview of the three generations of embolic and therapeutic agents follows. The techniques, technologies, and complications of bland embolization, transarterial chemoembolization, drug-eluting beads, and selective internal radiotherapy are covered to give the reader an overview of this exciting field in interventional radiology.

Influence of socioeconomic status on survival of hepatocellular carcinoma in the Ontario population; a population-based study, 1990-2009

Background

Research has shown that people from higher socioeconomic status (SES) have better hepatocellular carcinoma (HCC) survival outcomes, although no such research has been carried out in Canada. We aimed to assess if an association between SES and HCC survival existed in the Canadian context.

Methodology/Prinicpal Findings

We conducted a population-based cohort study linking HCC cases identified in the Ontario Cancer Registry between 1990 and 2009 to administrative and hospital data. Logistic regression and chi-squared tests were used to evaluate associations between SES (income quintile) and covariates. The Kaplan-Meier method was used to estimate survival. Sequential analysis of the proportional-hazards models were used to determine the association between SES and HCC survival controlling for potential prognostic covariates. During the period 1990–2009, 5,481 cases of HCC were identified. A significant association was found between SES and curative treatment (p = 0.0003), but no association was found between SES and non-curative treatment (p = 0.064), palliative treatment (p = 0.680), or ultrasound screening (p = 0.615). The median survival for the lowest SES was 8.5 months, compared to 8.8 months for the highest SES group. The age- and sex-adjusted proportional-hazards model showed statistically significant difference in HCC survival among the SES groups, with hazard ratio 0.905 (95% confidence intervals 0.821, 0.998) when comparing highest to lowest SES group. Further adjustments indicated that potentially curative treatment was the likely explanation for the association between SES and HCC survival.

Conclusions/Significance

Our findings suggest that a 10% HCC survival advantage exists for the higher SES groups. This association between SES and HCC survival is most likely a reflection of lack of access to care for low SES groups, revealing inequities in the Canadian healthcare system.

Cholestatic jaundice, acute kidney injury and acute pancreatitis secondary to the recreational use of methandrostenolone: a case report

Introduction

Over the last few years the use of anabolic steroids has become increasingly common amongst amateur athletes and for aesthetic purposes. As a result, the adverse events related to their use are being seen more frequently. Methandrostenolone is an anabolic steroid which is widely available and has been used for both performance enhancement and aesthetic purposes. This drug has also been reported to cause cholestasis of the intra-hepatic bile ducts resulting in elevated aminotransferases, hyperbilirubinemia and clinical jaundice. However, to the best of our knowledge this agent has not been previously reported to cause pancreatitis or acute kidney injury.

Case presentation

In this paper, we report the case of a 50-year-old man of Indian descent who presented with a six week history of diffuse abdominal pain, anorexia and weight loss following an eight week cycle of methandrostenolone use. At initial presentation, his lipase level was 785 U/L, bilirubin was 922 μmol/L and creatinine was 200 U/L while his aspartate aminotransferase and alanine aminotransferase levels were only mildly elevated at 61 U/L and 56 U/L respectively. His lipase peaked on day nine at >3000 U/L whilst his creatinine level was 299 U/L. Imaging was consistent with acute pancreatitis while a liver biopsy was consistent with intra-hepatic cholestasis and a kidney biopsy revealed evidence of acute tubular necrosis.

Conclusion

Both acute pancreatitis and acute kidney injury have rarely been reported with anabolic steroid use and they have not been previously reported to occur in the same patient. This case demonstrates some potentially new and serious adverse consequences occurring with the use of anabolic steroids, of which physicians need to be aware.

High-dose frequency beta-interferons increase the risk of liver test abnormalities in multiple sclerosis: a longitudinal study

BACKGROUND

Post-marketing studies and case reports have linked beta-interferon (IFNβ) treatment with liver enzyme abnormalities and liver injuries in patients with multiple sclerosis (MS). Few predictors of risk exist.

OBJECTIVE

We investigated the effect of IFNβ and other patient characteristics on levels of the liver enzyme, alanine aminotransferase (ALT).

METHOD

Repeated ALT test results were reviewed retrospectively for 1064 MS patients prescribed an IFNβ as their first immunomodulatory drug. Liver enzyme abnormality was defined as an ALT elevation twice the upper limit of normal (≥ 2 ULN). The Generalized Estimating Equation (GEE) was used to analyze the effect of age (≤ 35, >35-40, >40-45, >45 years), gender, disease duration, IFNβ product, and duration of treatment (≤ 5, >5-15, >15-40, >40 months) on de novo liver enzyme abnormality.

RESULTS

Over a mean treatment period of 38.7 months (SD=34.9), 12.4% (95/766) of MS patients developed de novo liver enzyme abnormality. Multivariable GEE results showed a dose frequency response effect of IFNβs on liver enzyme abnormality: OR=3.8(95% CI: 1.6-9.2) for IFNβ-1a 44 µg SC, and OR=3.4 (95% CI: 1.5-7.9) for IFNβ-1b 250 µg SC compared with the lower frequency IFNβ-1a 30 µg IM. Younger age (≤ 40 years), male gender, and ≤ 15 months of IFNβ exposure were also independent predictors.

CONCLUSION

A dose frequency response effect was observed, with high-frequency IFNβs having the greatest risk. The first 15 months of treatment, men, and younger patients were also associated with elevated risk. Regular ALT monitoring in MS patients appears prudent; long-term consequences of ALT elevations should be further investigated.

Multimodal therapy for hepatocellular carcinoma: a complementary approach to liver transplantation

OBJECTIVE

To evaluate the survival benefit of multimodal therapy for the treatment of HCC.

BACKGROUND

Orthotopic liver transplantation (OLT) is considered the treatment of choice for selected patients with hepatocellular carcinoma (HCC). However, donor organ shortages and patients whose HCCs exceed OLT criteria require consideration of alternate therapeutic options such as hepatic resection, radiofrequency ablation (RFA), ethanol injection (EI), transarterial chemoembolization (TACE), and chemotherapy (CTX). This study was performed to evaluate the survival benefit of multimodal therapy for treatment of HCC as complementary therapy to OLT.

METHODS

A retrospective review was conducted of HCC patients undergoing therapy following multidisciplinary review at our institution from 1996 . 2006 with a minimum of a 2 year patient follow-up. Data were available on 247/252 patients evaluated. Relevant factors at time of diagnosis included symptoms, hepatitis B (HBV) and C (HCV) status, antiviral therapy, Child-Pugh classification, portal vein patency, and TNM staging. Patients underwent primary treatment by hepatic resection, RFA, EI, TACE, CTX, or were observed (best medical management). Patients with persistent or recurrent disease following initial therapy were assessed for salvage therapy. Survival curves and pairwise multiple comparisons were calculated using standard statistical methods.

RESULTS

Mean overall survival was 76.8 months. Pairwise comparisons revealed significant mean survival benefits with hepatic resection (93.2 months), RFA (66.2 months), and EI (81.1 months), compared with TACE (47.4 months), CTX (24.9 months), or observation (31.4 months). Shorter survival was associated with symptoms, portal vein thrombus, or Child-Pugh class B or C. HCV infection was associated with significantly shorter survival compared with HBV infection. Antiviral therapy was associated with significantly improved survival in chronic HBV and HCV patients only with earlier stage disease.

CONCLUSION

Multimodal therapy is effective therapy for HCC and may be used as complementary treatment to OLT.

Chylous ascites: a late complication of intra-abdominal Mycobacterium avium complex immune reconstitution syndrome in HIV-infected patients

Chylous ascites related to Mycobacterium avium complex (MAC) in HIV-infected patients is rare, with only six cases reported in the English literature. We report a series of six cases from a single institution. During the past six years, chylous ascites was diagnosed in six (35%) of 17 AIDS patients, all of whom had previously been diagnosed with intra-abdominal MAC immune reconstitution syndrome (MAC-IRS). A review of medical records identified no other cases of chylous ascites among HIV-positive patients over the past 13 years (1994–2007), and the incidence was estimated at one in 2248 HIV-positive admissions. The ascitic fluid had a milky appearance and a median triglyceride level of 4.07 mmol/L (range 3.19–29.6 mmol/L) (360 mg/dL, range 282–2620 mg/dL). After a median follow-up of 20 months, five (83%) of six patients survived. Chylous ascites is a late complication of intra-abdominal MAC-IRS, and is usually associated with a favourable prognosis.