Implementation of a Hepatocellular Carcinoma Surveillance Program in a Community-Based Integrated Health System in Patients With Hepatitis C Cirrhosis

INTRODUCTION

Underutilization of hepatocellular cancer (HCC) surveillance has been reported, although data evaluating interventions to improve surveillance are sparse. We assessed the effect of a population-based HCC surveillance program on HCC surveillance utilization and outcomes.

METHODS

In this retrospective cohort study, we assessed preinclusion and postinclusion HCC surveillance patterns among 597 patients with hepatitis C virus cirrhosis enrolled in a program at an integrated health system between 2013 and 2020. Adequate surveillance was defined as at least 5 surveillance studies within 36 months pre-enrollment and postenrollment; a secondary outcome was proportion of time covered by surveillance over 36 months. Tumor size, stage, and receipt of curative therapy were compared between HCC detected on the first imaging examination (prevalent HCC) and surveillance-detected HCC (incident HCC). We performed Kaplan-Meier analysis and multivariable competing risk analysis to characterize the association between surveillance and mortality.

RESULTS

The surveillance program significantly improved surveillance completion (77.6% vs 5.0%, P < 0.001) and proportion time covered (80.9% vs 15.8%, P < 0.001). Compared with prevalent HCC, surveillance-detected cases were more likely unifocal (77.8% vs 44.8%, P < 0.001), early-stage (85.2% vs 44.8%, P < 0.001), with smaller maximum diameter (median 2.3 vs 3.2 cm), and more likely to undergo curative therapy (92.5% vs 72.4% P = 0.010). Survival was improved compared with prevalent cases hazard ratio (HR) 0.23 (0.11-0.51) after adjusting for age and Model for End Stage Liver Disease score.

DISCUSSION

Implementation of a population-based program resulted in significant improvement in HCC surveillance use and clinical outcomes among patients with hepatitis C virus cirrhosis. These findings may inform similar interventions by other healthcare systems.

Primary Care Utilization, Preventative Screening, and Control of Metabolic Syndrome in Metabolic Dysfunction-Associated Steatohepatitis Liver Transplant Recipients

OBJECTIVES

Patients with pre-transplant metabolic dysfunction-associated steatohepatitis (MASH) are at high risk of metabolic syndrome (MetS) after liver transplant. While many patients are co-managed by a transplant team, most preventative screening and MetS management may occur in the primary care setting. We aimed to evaluate primary care utilization by MASH liver transplant recipients as well as MetS screening and control.

METHODS

We conducted a retrospective chart review that included adults who underwent liver transplant for MASH or cryptogenic cirrhosis at a single institution from January 2010 to December 2016, had available primary care data, and at least 36-months of follow-up post-transplant. Measures included primary care utilization, adherence to screening guidelines, and control of MetS. We used Fischer's exact test to explore the association of primary care utilization with screening and control.

RESULTS

A total of 37 patients met inclusion criteria with 366 visits reviewed. The median time to first visit was 68 days post-transplant and patients had a median of 9 total visits. Few patients met screening guidelines for diabetes (8.1%) or hyperlipidemia (10.8%). The percentage of patients with control of obesity, hypertension, diabetes, and hyperlipidemia decreased over the 36-month follow-up period. Primary care utilization was not associated with adherence to screening recommendations for diabetes (P = .141) or hyperlipidemia (P = .103). Higher primary care utilization was not associated with control of hypertension (P = .107), diabetes (P = .871), or hyperlipidemia (P = .999).

CONCLUSION

More research is needed to investigate barriers to screening and management of MetS conditions in this high-risk patient population in the primary care setting as well as to optimize post-transplant care coordination.

AFP-L3 and DCP are superior to AFP in predicting waitlist dropout in HCC patients: Results of a prospective study

In patients with HCC awaiting liver transplantation (LT), there is a need to identify biomarkers that are superior to AFP in predicting prognosis. AFP-L3 and des-gamma-carboxyprothrombin (DCP) play a role in HCC detection, but their ability to predict waitlist dropout is unknown. In this prospective single-center study commenced in July 2017, 267 HCC patients had all 3 biomarkers obtained at LT listing. Among them, 96.2% received local-regional therapy, and 18.8% had an initial tumor stage beyond Milan criteria requiring tumor downstaging. At listing, median AFP was 7.0 ng/mL (IQR 3.4-21.5), median AFP-L3 was 7.1% (IQR 0.5-12.5), and median DCP was 1.0 ng/mL (IQR 0.2-3.8). After a median follow-up of 19.3 months, 63 (23.6%) experienced waitlist dropout, while 145 (54.3%) received LT, and 59 (22.1%) were still awaiting LT. Using Cox proportional hazards analysis, AFP-L3≥35% and DCP≥7.5 ng/mL were associated with increased waitlist dropout, whereas AFP at all tested cutoffs, including ≥20,≥ 100, and≥250 ng/mL was not. In a multivariable model, AFP-L3≥35% (HR 2.25, p =0.04) and DCP≥7.5 ng/mL (HR 2.20, p =0.02) remained associated with waitlist dropout as did time from HCC diagnosis to listing ≥ 1 year and increasing MELD-Na score. Kaplan-Meier probability of waitlist dropout within 2 years was 21.8% in those with AFP-L3<35% and DCP<7.5 ng/mL, 59.9% with either AFP-L3 or DCP elevated, and 100% for those with both elevated ( p <0.001). In this prospective study, listing AFP-L3% and DCP were superior to AFP in predicting waitlist dropout with the combination of AFP-L3≥35% and DCP≥7.5 ng/mL associated with a 100% risk of waitlist dropout, thus clearly adding prognostic value to AFP alone.

Application of Shape Memory and Self-Healable Polymers/Composites in the Biomedical Field: A Review

Shape memory-assisted self-healing polymers have drawn attention over the past few years owing to their interdisciplinary and wide range of applications. Self-healing and shape memory are two approaches used to improve the applicability of polymers in the biomedical field. Combining both these approaches in a polymer composite opens new possibilities for its use in biomedical applications, such as the "close then heal" concept, which uses the shape memory capabilities of polymers to bring injured sections together to promote autonomous healing. This review focuses on using shape memory-assisted self-healing approaches along with their respective affecting factors for biomedical applications such as tissue engineering, drug delivery, biomaterial-inks, and 4D printed scaffolds, soft actuators, wearable electronics, etc. In addition, quantification of self-healing and shape memory efficiency is also discussed. The challenges and prospects of these polymers for biomedical applications have been summarized.

In Vitro Evaluation of marginal adaptation of polyether ether ketone and zirconia copings

Background

Polyether ether ketone (PEEK) has emerged as a new thermoplastic material with potential applications as a restorative material. Aim: This study aimed to evaluate the marginal adaptation of PEEK copings compared to zirconia copings using field emission scanning electron microscopy.

Materials and Methods

A freshly extracted maxillary central incisor was prepared for a full-coverage restoration following standard principles of tooth preparation. The tooth was sent to a laboratory for fabrication of samples using computer-aided design and manufacturing (CAD/CAM). Twenty samples of polyether ether ketone (PEEK) copings (group A) and 20 of zirconia copings were fabricated (group B). The copings were scanned under a field emission scanning electron microscope and measurements were taken at four distinct points. The marginal adaptation over the buccal, lingual, mesial, and distal margins for both groups was evaluated. One-way analysis of variance (ANOVA) and independent t test were applied.

Results

Our findings indicate that PEEK showed better marginal adaptation than zirconia at all measurement points. The mean marginal gap value of the PEEK group was 33.99 ± 8.81 μm and of the zirconia group was 56.21 ± 15.07 μm. On comparing marginal adaptation among the mesial, distal, buccal, and lingual aspects, PEEK showed better adaptation on all four margins, with the best adaptation on the buccal margin that had the lowest mean gap value of 29.27 ± 6.07 μm. The zirconia group adapted best at the distal margin, with a lowest mean gap value of 53.58 ± 15.25 μm (P ≤ 0.05).

Conclusion

PEEK copings had better marginal adaptation and fit compared to zirconia copings. It may have applications as a restorative material in fixed prostheses.

Abstract P567: Cardiovascular Health Awareness and Risk Assessment in Schoolteachers in Calcutta, India

Background: Cardiovascular disease (CVD) is the leading cause of death in India, surpassing all infectious causes. Early awareness of CVD and its risk factors and adoption of heart healthy lifestyle practices are crucial to reducing the impact of CVD in the community.

Objective: To assess schoolteachers’ awareness of CVD and to compare the calculated ten-year risk of heart attack, stroke, and death by the Atherosclerotic Cardiovascular Disease (ASCVD) model to the observed event rates.

Methods: We surveyed 4,150 schoolteachers out of 5,321 (78% response rate) from 400 schools in Calcutta during 2019 using a questionnaire assessing their awareness of CVD in five domains: prevalence, spectrum of CVD, its nature, risk factors, and benefits of a heart healthy lifestyle. The study population was stratified by risk tertile of their 10-year calculated ASCVD score.

Results: Awareness about cardiovascular health among schoolteachers (male 41%, mean age 44 years) was low: 33 (mean score out of maximum 100), varying in different domains as shown below.

Although most (86%) were at mild risk for CVD with ASCVD scores below five, nine percent had moderate risk, and five percent had high risk of CVD. There was no significant association between their risk score and their awareness of CVD health (correlation coefficient r = - 0.022, 95% confidence interval - 0.052, 0.009).

Conclusions: Cardiovascular health awareness among schoolteachers in Calcutta is suboptimal, many of whom are at risk for CVD. Awareness of the disease, detection of risk factors at an early stage, and adoption of a healthy lifestyle may help reduce CVD in this community.

Models to Predict Development or Recurence of Hepatocellular Carcinoma (HCC) in Patients with Advanced Hepatic Fibrosis

Purpose of Review

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death in the United States (U.S.).¹ The purpose of this review is to highlight published models that predict development of HCC and estimate risk of HCC recurrence after treatments.

Recent Findings

There have been several models created for both de novo HCC and HCC recurrence, with the more recent models using a combination of age, sex, decompensation, and laboratory values (platelet count, albumin, bilirubin), and liver disease etiology to predict both 5 and 10-year HCC incidence. For chronic hepatitis C, sustained virologic response has been a useful component of understanding HCC risk reduction. BMI and diabetes have been utilized in non-alcoholic fatty liver disease (NAFLD) models to predict HCC risk. For HCC recurrence after treatment (for both surgical resection and liver transplant), tumor size and number, vascular invasion, alpha-fetoprotein (AFP) and neutrophil to lymphocyte ratio (NLR) are all components of HCC recurrence risk models.

Summary

Although numerous HCC risk prediction models have been established over the last several years, challenges remain including how to best incorporate these models into clinical practice, improve surveillance for NAFLD-HCC development, and determine timing and duration of post-resection recurrence surveillance.

Cancer in People with and without Hepatitis C Virus Infection: Comparison of Risk Before and After Introduction of Direct-Acting Antivirals

BACKGROUND

Chronic hepatitis C virus (HCV) infection is a leading cause of liver cancer. The association of HCV infection with extrahepatic cancers, and the impact of direct-acting antiviral (DAA) treatment on these cancers, is less well known.

METHODS

We conducted a cohort study in a healthcare delivery system. Using electronic health record data from 2007 to 2017, we determined cancer incidence, overall and by type, in people with HCV infection and by DAA treatment status. All analyses included comparisons with a reference population of people without HCV infection. Covariate-adjusted Poisson models were used to estimate incidence rate ratios.

RESULTS

2,451 people with HCV and 173,548 people without HCV were diagnosed with at least one type of cancer. Compared with people without HCV, those with HCV were at higher risk for liver cancer [adjusted incidence rate ratio (aIRR) = 31.4, 95% confidence interval (CI) = 28.9-34.0], hematologic cancer (aIRR = 1.3, 95% CI = 1.1-1.5), lung cancer (aIRR = 1.3, 95% CI = 1.2-1.5), pancreatic cancer (aIRR = 2.0, 95% CI = 1.6-2.5), oral/oropharynx cancer (aIRR = 1.4, 95% CI = 1.1-1.8), and anal cancer (aIRR = 1.6, 95% CI = 1.1-2.4). Compared with people without HCV, the aIRR for liver cancer was 31.9 (95% CI = 27.9-36.4) among DAA-untreated and 21.2 (95% CI = 16.8-26.6) among DAA-treated, and the aIRR for hematologic cancer was 1.5 (95% CI = 1.1-2.0) among DAA-untreated and 0.6 (95% CI = 0.3-1.2) among DAA-treated.

CONCLUSIONS

People with HCV infection were at increased risk of liver cancer, hematologic cancer, and some other extrahepatic cancers. DAA treatment was associated with reduced risk of liver cancers and hematologic cancers.

IMPACT

DAA treatment is important for reducing cancer incidence among people with HCV infection.

Microstructural, electrical and biological activity in [Formula: see text] ceramic composites designed for tissue engineering applications

The article investigates electrically active ceramic composite of [Formula: see text] (HAP) and [Formula: see text] (BST) for biomedical applications. The study is a systematic blend of the materials science aspect of composites with a special focus on the dielectric and biological properties and their relationships. The article emphasized primarily extracting the dielectric constant ([Formula: see text] of the specimens (that lay in the range of 3-65) and related them to microstructural properties like the grain size and at.% of BST. A broad outlook on the importance of [Formula: see text] in determining the suitability of bioceramics for clinical applications is presented. Bioactivity analysis of the specimens led to probing the surface charges (that were negative), and it was found crucial to the growth of dense apatite layers. Furthermore, the cytocompatibility of the specimens displayed cell viability above 100% for Day 1, which increased substantially for Day 3. To reveal other biological properties of the composites, protein adsorption studies using bovine serum albumin (BSA) and fetal bovine serum (FBS) was carried out. Electrostatic interactions govern the adsorption, and the mathematical dependence on surface charges is linear. The protein adsorption is also linearly correlated with the [Formula: see text], intrinsic to the biomaterials. We delve deeper into protein-biomaterials interactions by considering the evolution of the secondary structure of BSA adsorbed into the specimens. Based on the investigations, 20 at.% HAP-80 at.% BST (20H-80B) was established as a suitable composite comprising the desired features of HAP and BST. Such explorations of electrical and biological properties are interesting for modulating the behavior of bioceramic composites. The results project the suitability of 20H-80B for designing electrically active smart scaffolds for the proposed biomedical applications and are expected to incite further clinical trials.

Performance study of a sterilization box using a combination of heat and ultraviolet light irradiation for the prevention of COVID-19

SARS-CoV-2 virus and other pathogenic microbes are transmitted to the environment through contacting surfaces, which need to be sterilized for the prevention of COVID-19 and related diseases. In this study, a prototype of a cost-effective sterilization box is developed to disinfect small items. The box utilizes ultra violet (UV) radiation with heat. For performance assessment, two studies were performed. First, IgG (glycoprotein, a model protein similar to that of spike glycoprotein of SARS-COV-2) was incubated under UV and heat sterilization. An incubation with UV at 70 °C for 15 min was found to be effective in unfolding and aggregation of the protein. At optimized condition, the hydrodynamic size of the protein increased to ~171 nm from ~5 nm of the native protein. Similarly, the OD₂₈₀ values also increased from 0.17 to 0.78 indicating the exposure of more aromatic moieties and unfolding of the protein. The unfolding and aggregation of the protein were further confirmed by the intrinsic fluorescence measurement and FTIR studies, showing a 70% increase in the β-sheets and a 22% decrease in the α-helixes of the protein. The designed box was effective in damaging the protein's native structure indicating the effective inactivation of the SARS-COV-2. Furthermore, the incubation at 70 °C for 15 min inside the chamber resulted in 100% antibacterial efficacy for the clinically relevant E.coli bacteria as well as for bacteria collected from daily use items. It is the first detailed performance study on the efficacy of using UV irradiation and heat together for disinfection from virus and bacteria.

Evolving multidisciplinary treatment of squamous cell carcinoma of the head and neck in India✰

In this article, we highlight the evolution of a multimodal approach in the overall management of squamous cell carcinoma of the head and neck (SCCHN) in India; present advances in technology (newer surgical techniques), novel medical and radiotherapy (RT) approaches; review their roles for an integrated approach for treating SCCHN and discuss the current role of immunotherapy in SCCHN. For locally advanced (LA) SCCHN, the multidisciplinary approach includes surgery followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy. Improved surgical techniques of reconstruction and voice-preservation are being implemented. Advanced forms of high-precision conformal techniques like intensity-modulated radiotherapy are used to deliver highly conformal doses to tumors, sparing the surrounding normal tissue. Compared with RT alone, novel CT regimens and targeted therapeutic agents have the potential to improve locoregional control and survival and reduce treatment-induced toxicities. Several clinical trials have demonstrated efficacy, safety, and quality of life benefits of adding cetuximab to RT regimens in LASCCHN. Studies have also suggested a cetuximab-related laryngeal preservation benefit. At progression, platinum-based CT combined with cetuximab (a monoclonal anti-epidermal growth factor receptor antibody) is the only validated option available as the first-line therapy. Thus, an integrated multidisciplinary approach plays a key role in maximizing patient outcomes, reduction in treatment related morbidities that consequently impact quality of life of survivors.

Chain-End Modifications and Sequence Arrangements of Antimicrobial Peptoids for Mediating Activity and Nano-Assembly

Poly(N-substituted glycine) "peptoids" are an interesting class of peptidomimics that can resist proteolysis and mimic naturally found antimicrobial peptides (AMPs), which exhibit wide spectrum activity against bacteria. This work investigates the possibility of modifying peptoid AMP mimics (AMPMs) with aliphatic lipid "tails" to generate "lipopeptoids" that can assemble into micellar nanostructures, and evaluates their antimicrobial activities. Two families of AMPMs with different distributions of hydrophobic and cationic residues were employed-one with a uniform repeating amphiphilicity, the other with a surfactant-like head-to-tail amphiphilicity. To further evaluate the interplay between self-assembly and activity, the lipopeptoids were variously modified at the AMPM chain ends with a diethylene glycol (EG₂) and/or a cationic group (Nlys-Nlys dipeptoid) to adjust amphiphilicity and chain flexibility. Self-assembly was investigated by critical aggregation concentration (CAC) fluorescence assays and dynamic light scattering (DLS). The structure of a key species was also verified by small-angle X-ray scattering (SAXS) and cryo-electron microscopy (cryo-EM). To screen for antibacterial properties, we measured the minimum inhibitory concentrations (MIC) against S. aureus, E. coli, and P. aeruginosa. We found that certain combinations of lipid tail and AMPM sequences exhibit increased antibacterial activity (i.e., decreased MICs). Perhaps counter-intuitively, we were particularly interested in increased MICs in combination with low CACs. Concealing antimicrobial interactions due to packing of AMPMs in nano-assemblies could pave the way to AMPMs that may be "inert" even if unintentionally released and prevent microbes from gaining resistance to the lipopeptoids. Overall, incorporation of EG₂ significantly improved lipopeptoids packing while the hydrophobic tail length was found to have a major influence over the MIC. One particular sequence, which we named C₁₅-EG₂-(kss)₄, exhibited a very low CAC of 34 μM (0.0075 wt.%) and a significantly increased MIC above values for the unmodified AMPM. With the sequence design trends uncovered from this study, future work will focus on discovering more species such as C₁₅-EG₂-(kss)₄ and on investigating release mechanisms and the potency of the released lipopeptoids.

Life Expectancy of Insured People With and Without Hepatitis C Virus Infection, 2007-2017

Among 25 291 and 4 921 830 people with and without hepatitis C, life expectancy at age 20 increased 1.8 years and 0.3 years from the interferon to interferon-free era, respectively. Increases were highest for racial and/or ethnic minority groups with hepatitis C.

Prevalence of Spontaneous Clearance of Hepatitis C Virus Infection Doubled From 1998 to 2017

Strategic planning for hepatitis C virus (HCV) screening and treatment requires up-to-date information on the prevalence of HCV spontaneous clearance. Published estimates of HCV spontaneous clearance range from 15% to 60%.^1-3 We conducted an observational study over 20 years to evaluate trends in the prevalence of HCV spontaneous clearance. Our goals were to estimate the proportion of HCV-antibody-positive patients who were viremic, and to identify factors associated with viremia, thus facilitating prediction of the number of patients needing treatment.

Hepatitis C treatment uptake and response among human immunodeficiency virus/hepatitis C virus-coinfected patients in a large integrated healthcare system

U.S. guidelines recommend that patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) be prioritized for HCV treatment with direct-acting antiviral agents (DAAs), but the high cost of DAAs may contribute to disparities in treatment uptake and outcomes. We evaluated DAA initiation and effectiveness in HIV/HCV-coinfected patients in a U.S.-based healthcare system during October 2014-December 2017. Of 462 HIV/HCV-coinfected patients, 276 initiated DAAs (70% cumulative proportion treated over three years). Lower likelihood of DAA initiation was observed among patients with Medicare (government-sponsored insurance) versus commercial insurance (adjusted rate ratio [aRR] = 0.62, 95% CI = 0.46-0.84), patients with drug abuse diagnoses (aRR = 0.72, 95% CI = 0.54-0.97), patients with CD4 cell count <200 cells/µl versus ≥500 (aRR = 0.45, 95% CI = 0.23-0.91), and patients without prior HCV treatment (aRR = 0.68, 95% CI = 0.48-0.97). There were no significant differences in DAA initiation by age, gender, race/ethnicity, socioeconomic status, HIV transmission risk, alcohol use, smoking, fibrosis level, HIV RNA levels, antiretroviral therapy use, hepatitis B infection, or number of outpatient visits. Ninety-five percent of patients achieved sustained virologic response (SVR). We found little evidence of sociodemographic disparities in DAA initiation among HIV/HCV-coinfected patients, and SVR rates were high. Efforts are needed to increase DAA uptake among coinfected Medicare enrollees, patients with drug abuse diagnoses, patients with low CD4 cell count, and patients receiving first-time HCV treatment.

Femtosecond phase-transition in hard x-ray excited bismuth

The evolution of bismuth crystal structure upon excitation of its A_1g phonon has been intensely studied with short pulse optical lasers. Here we present the first-time observation of a hard x-ray induced ultrafast phase transition in a bismuth single crystal at high intensities (~10¹⁴ W/cm²). The lattice evolution was followed using a recently demonstrated x-ray single-shot probing setup. The time evolution of the (111) Bragg peak intensity showed strong dependence on the excitation fluence. After exposure to a sufficiently intense x-ray pulse, the peak intensity dropped to zero within 300 fs, i.e. faster than one oscillation period of the A_1g mode at room temperature. Our analysis indicates a nonthermal origin of a lattice disordering process, and excludes interpretations based on electron-ion equilibration process, or on thermodynamic heating process leading to plasma formation.

No Difference in Effectiveness of 8 vs 12 Weeks of Ledipasvir and Sofosbuvir for Treatment of Hepatitis C in Black Patients

BACKGROUND & AIMS

Treatment with the combination of ledipasvir and sofosbuvir for 12 weeks has been approved by the Food and Drug Administration for patients with genotype 1 hepatitis C virus (HCV) infection; some patients can be treated with an 8-week course. Guidelines recommend a 12-week treatment course for black patients, but studies have not compared the effectiveness of 8 vs 12 weeks in black patients who are otherwise eligible for an 8-week treatment regimen.

METHODS

We conducted an observational study of Kaiser Permanente Northern California members with HCV genotype 1 infection who were eligible for 8 weeks of treatment with ledipasvir and sofosbuvir (treatment-naïve, no cirrhosis, no HIV infection, level of HCV RNA <6 million IU/mL) and were treated for 8 or 12 weeks from October 2014 through December 2016. We used χ² analyses to compare sustained virologic response 12 weeks after the end of treatment (SVR12) among patients treated for 8 vs 12 weeks, and adjusted Poisson models to identify factors associated with receipt of 12 weeks of therapy among patients eligible for 8 weeks.

RESULTS

Of 2653 patients eligible for 8 weeks of treatment with ledipasvir and sofosbuvir, 1958 (73.8%) received 8 weeks of treatment and 695 (26.2%) received 12 weeks; the proportions of patients with SVR12 were 96.3% and 96.3%, respectively (P = .94). Among 435 black patients eligible for the 8-week treatment regimen, there was no difference in the proportions who achieved an SVR12 following 8 vs 12 weeks' treatment (95.6% vs 95.8%; P = .90). Male sex, higher transient elastography or FIB-4 scores, higher INR and level of bilirubin, lower level of albumin, obesity, diabetes, and ≥15 alcohol drinks consumed/week were independently associated with receiving 12 weeks of treatment among patients eligible for the 8-week treatment regimen, but were not associated with reduced SVR12 after 8 weeks of treatment.

CONCLUSION

In an observational study of patients who received ledipasvir and sofosbuvir treatment for HCV genotype 1 infection, we found that contrary to guidelines, 8-week and 12-week treatment regimens do not result in statistically significant differences in SVR12 in black patients. Patient characteristics were associated with receipt of 12-week regimens among patients eligible for 8 weeks, but were not associated with reduced SVR12 after 8 weeks. Shorter treatment courses might therefore be more widely used without compromising treatment effectiveness.

Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population

OBJECTIVES

The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation.

METHODS

We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation.

RESULTS

Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007).

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

Recent advances in conventional and contemporary methods for remediation of heavy metal-contaminated soils

Remediation of heavy metal-contaminated soils has been drawing our attention toward it for quite some time now and a need for developing new methods toward reclamation has come up as the need of the hour. Conventional methods of heavy metal-contaminated soil remediation have been in use for decades and have shown great results, but they have their own setbacks. The chemical and physical techniques when used singularly generally generate by-products (toxic sludge or pollutants) and are not cost-effective, while the biological process is very slow and time-consuming. Hence to overcome them, an amalgamation of two or more techniques is being used. In view of the facts, new methods of biosorption, nanoremediation as well as microbial fuel cell techniques have been developed, which utilize the metabolic activities of microorganisms for bioremediation purpose. These are cost-effective and efficient methods of remediation, which are now becoming an integral part of all environmental and bioresource technology. In this contribution, we have highlighted various augmentations in physical, chemical, and biological methods for the remediation of heavy metal-contaminated soils, weighing up their pros and cons. Further, we have discussed the amalgamation of the above techniques such as physiochemical and physiobiological methods with recent literature for the removal of heavy metals from the contaminated soils. These combinations have showed synergetic effects with a many fold increase in removal efficiency of heavy metals along with economic feasibility.

Surface Functionalization of Ti6Al4V via Self-assembled Monolayers for Improved Protein Adsorption and Fibroblast Adhesion

Although metallic biomaterials find numerous biomedical applications, their inherent low bioactivity and poor osteointegration had been a great challenge for decades. Surface modification via silanization can serve as an attractive method for improving the aforementioned properties of such substrates. However, its effect on protein adsorption/conformation and subsequent cell adhesion and spreading has rarely been investigated. This work reports the in-depth study of the effect of Ti6Al4V surface functionalization on protein adsorption and cell behavior. We prepared self-assembled monolayers (SAMs) of five different surfaces (amine, octyl, mixed [1:1 ratio of amine:octyl], hybrid, and COOH). Synthesized surfaces were characterized by Fourier transform infrared-attenuated total reflection (FTIR-ATR) spectroscopy, contact angle goniometry, profilometry, and field emission scanning electron microscopy (FESEM). Quantification of adsorbed mass of bovine serum albumin (BSA) and fibronectin (FN) was determined on different surfaces along with secondary structure analysis. The adsorbed amount of BSA was found to increase with an increase in surface hydrophobicity with the maximum adsorption on the octyl surface while the reverse trend was detected for FN adsorption, having the maximum adsorbed mass on the COOH surface. The α-helix content of adsorbed BSA increased on amine and COOH surfaces while it decreased for other surfaces. Whereas increasing β-turn content of the adsorbed FN with the increase in the surface hydrophobicity was observed. In FN, RGD loops are located in the β-turn and consequently the increase in Δ adhered cells (%) was predominantly increased with the increasing Δ β-turn content (%). We found hybrid surfaces to be the most promising surface modifier due to maximum cell adhesion (%) and proliferation, larger nuclei area, and the least cell circularity. Bacterial density increased with the increasing hydrophobicity and was found maximum for the amine surface (θ = 63 ± 1°) which further decreased with the increasing hydrophobicity. Overall, modified surfaces (in particular hybrid surface) showed better protein adsorption and cell adhesion properties as compared to unmodified Ti6Al4V and can be potentially used for tissue engineering applications.

Safety and efficacy of current direct-acting antiviral regimens in kidney and liver transplant recipients with hepatitis C: Results from the HCV-TARGET study

Data outside of clinical trials with direct-acting antiviral regimens with or without ribavirin as treatment of chronic hepatitis C virus in solid organ transplant recipients are limited. Liver transplant (LT), kidney transplant (KT), and dual liver kidney (DLK) transplant recipients from the Hepatitis C Therapeutic Registry and Research Network database, a multicenter, longitudinal clinical care treatment cohort, treated with direct-acting antiviral regimens between January 1, 2014, and February 15, 2016, were included to assess safety and efficacy. Included were 443 posttransplant patients (KT = 60, LT = 347, DLK = 36); 42% had cirrhosis, and 54% had failed prior antiviral therapy. Most had genotype (GT) 1 (87% with 52% GT1a, 27% GT1b, and 8% GT1 no subtype) and were treated with sofosbuvir (SOF)/ledipasvir ± ribavirin (85%) followed by SOF + daclatasvir ± ribavirin (9%) and ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (6%). Rates of sustained virologic response (SVR) at 12 weeks were available on 412 patients, and 395 patients (95.9%) achieved SVR at 12 weeks: 96.6%, 94.5%, and 90.9% among LT, KT, and DLK transplant recipients, respectively. Ribavirin did not influence SVR rates and was more often used in those with higher BMI, higher estimated glomerular filtration rate and lower creatinine. Female gender, baseline albumin ≥3.5 g/dL, baseline total bilirubin ≤1.2 mg/dL, absence of cirrhosis, and hepatic decompensation predicted SVR at 12 weeks. Six episodes of acute rejection (n = 2 KT, 4 LT) occurred, during hepatitis C virus treatment in 4 and after cessation of treatment in 2.

CONCLUSION

In a large prospective observational cohort study, direct-acting antiviral therapy with SOF/ledipasvir, ombitasvir/paritaprevir/ritonavir + dasabuvir, and SOF plus daclatasvir was efficacious and safe in LT, KT, and DLK transplant recipients; ribavirin did not influence SVR, and graft rejection was rare. (Hepatology 2017;66:1090-1101).

Publisher's Note: Relativistic breather-type solitary waves with linear polarization in cold plasmas [Phys. Rev. E 91, 033102 (2015)]

This corrects the article DOI: 10.1103/PhysRevE.91.033102.

Safety and efficacy of sofosbuvir-containing regimens in hepatitis C-infected patients with impaired renal function

BACKGROUND & AIMS

Renal clearance is the major elimination pathway for sofosbuvir (SOF). We assessed the safety and efficacy of SOF-containing regimens in patients with varying baseline estimated glomerular filtration rate (eGFR).

METHODS

HCV-TARGET database is a multicentre, longitudinal 'real-world' treatment cohort.

RESULTS

A total of 1789 patients [genotypes 1 (72%), 2 (17%) 3 (9%), 4-6 (2%)] had baseline eGFR determination: 73 with eGFR≤45 (18 with eGFR≤30, 5 on dialysis) were compared to 1716 with eGFR>45 ml/min/1.73 m(2) . Patients with baseline eGFR≤45 vs. >45 differed in being female (55% vs. 36%), age ≥65 years (24% vs. 16%), Black race (22% vs. 12%), having cirrhosis with decompensation (73% vs. 24%) and being post-transplant (49% vs. 10%), all P < 0.05. All patients with eGFR≤45 were treated with SOF 400 mg/day (including those on haemodialysis) and had median starting ribavirin (RBV) dose of 800 mg (IQR: 400-1200). Sustained virologic response (SVR) frequencies were similar across eGFR groups, ranging from 82-83%. Patients with eGFR ≤45 more frequently experienced anaemia, worsening renal function and serious AEs (all P < 0.05), and these associations persisted when limiting analysis to RBV-free regimens. Patients with baseline eGFR≤30 and eGFR 31-45 had similar frequencies of efficacy and safety outcomes.

CONCLUSIONS

Sustained viral clearance was achieved in 83% of patients with renal impairment (eGFR ≤45 ml/min/1.73 m(2) ) treated with SOF-containing regimens. However, these patients had higher rates of anaemia, worsening renal dysfunction and serious adverse events regardless of use of RBV. Patient with renal impairment require close monitoring and should be treated by providers extensively experienced with SOF-containing regimens.

Current Management of Hepatitis C Virus: Regimens for Peri-Liver Transplant Patients

Chronic hepatitis C virus (HCV) infection currently remains the leading indication for liver transplant in the United States. However, recurrent HCV infection after transplant is universal in those who enter transplant with viremia resulting in reduced posttransplant graft and patient survival rates, caused in large part by progressive recurrent HCV disease. Therefore, successful treatment of HCV in the peri-transplant period, either before or after transplant, is paramount in ensuring improved posttransplant outcomes. This article reviews the experience to date treating HCV in wait-listed patients and liver transplant recipients and the unique challenges encountered when treating this population.

Safety and Efficacy of Simeprevir/Sofosbuvir in Hepatitis C-Infected Patients With Compensated and Decompensated Cirrhosis

Risks and benefits of simeprevir plus sofosbuvir (SIM+SOF) in patients with advanced cirrhosis are unknown. We assessed the safety and sustained virological responses (SVR) of SIM+SOF with and without ribavirin (RBV) in patients with Child-Pugh (CP)-B/C versus CP-A cirrhosis and compared to matched untreated controls. This study was of a multicenter cohort of adults with hepatitis C virus genotype 1 and cirrhosis treated with SIM+SOF with/without RBV for 12 weeks. Controls were matched on treatment center, age, CP class, and Model for End-Stage Liver Disease (MELD) score. Of 160 patients treated with SIM+SOF with/without RBV, 35% had CP-B/C and 64% had CP-A, with median baseline MELD 9 (interquartile range, 8-11). Sustained virological response at week 12 (SVR12) was achieved by 73% of CP-B/C versus 91% of CP-A (P < 0.01). CP-B/C versus CP-A had more early treatment discontinuations (11% vs. 1%), adverse events (AEs) requiring hospitalization (22% vs. 2%), infections requiring antibiotics (20% vs. 1%), and hepatic decompensating events (20% vs. 3%; all P < 0.01). There were 2 deaths: 1 CP-B/C (liver related) and 1 CP-A (not liver related). In multivariate analysis, CP-B/C independently predicted lack of SVR12 (odds ratio, 0.27; 95% confidence interval: 0.08-0.92). In comparing SIM+SOF-treated patients versus matched untreated controls, AEs requiring hospitalization (9% vs. 13%; P = 0.55), infections (8% vs. 6%; P = 0.47), and events of decompensation (9% vs. 10%; P = 0.78) occurred at similar frequency.

CONCLUSIONS

SIM+SOF with/without RBV has lower efficacy and higher rates of AEs in patients with CP-B/C cirrhosis, compared to CP-A. Frequency of adverse safety outcomes were similar to matched untreated controls, suggesting that safety events reflect the natural history of cirrhosis and are not related to treatment.

Kidney Failure and Liver Allocation: Current Practices and Potential Improvements

In February 2002, the United Network for Organ Sharing implemented a system for prioritizing candidates for liver transplantation that was based on the risk of 90-day mortality as determined by the Model for End-Stage Liver Disease (MELD) score. As the MELD score is driven in part by serum creatinine as a marker of kidney function, the prevalence of kidney dysfunction and failure in patients with end-stage liver disease at the time of listing and at transplantation has steadily risen. In this review, we discuss current practices in liver transplantation in patients with kidney dysfunction focusing briefly on the decision to perform simultaneous liver-kidney transplantation. We then discuss pitfalls to the current practices of liver transplantation in patients with kidney dysfunction. We conclude by discussing potential improvements to current practices including the use of the MELD-Na score, alternatives to creatinine and creatinine-based equation for estimating kidney function, and the use of intraoperative kidney replacement therapy during liver transplantation.

Telaprevir- and Boceprevir-based Triple Therapy for Hepatitis C in Liver Transplant Recipients With Advanced Recurrent Disease: A Multicenter Study

BACKGROUND

Antiviral treatment with sustained virologic response (SVR) improves survival in liver transplant (LT) recipients, and is especially relevant to patients with advanced recurrent hepatitis C virus (HCV). We assessed the safety and efficacy of protease inhibitor-based triple therapy in patients with recurrent advanced fibrosis and cholestatic hepatitis.

METHODS

The LT recipients with genotype 1 HCV and advanced fibrosis (F3-4/4) or cholestatic hepatitis treated with telaprevir- or boceprevir-based triple therapy at 6 centers (CRUSH-C consortium) were retrospectively assessed. The primary endpoints were SVR at 12 weeks (SVR12) and safety.

RESULTS

Forty-five patients with advanced fibrosis and 9 with cholestatic hepatitis (74% men, 57% genotype 1a, 63% previous nonresponders) were included. SVR12 occurred in 51% with advanced fibrosis and 44% with cholestatic hepatitis. Extended rapid virologic response was highly predictive of SVR12. Hispanic ethnicity (odds ratio, 0.16; P = 0.03), previous null/partial response (0.24; P = 0.02), IL28B genotype CC (7.0; P = 0.02), albumin (3.87; P = 0.03), platelet count (1.01; P = 0.02), and steroid use (0.21; P = 0.03) were associated with SVR12. Six (11%) patients died, and hepatic decompensation occurred in 22% with advanced fibrosis and 33% with cholestatic hepatitis. Albumin (0.02; P = 0.001), encephalopathy (12.0; P = 0.04) and Hispanic ethnicity (odds ratio, 6.17; P = 0.01) were associated with death or decompensation.

CONCLUSIONS

For LT recipients with recurrent advanced HCV and at greatest need of cure, protease inhibitor-based triple therapy achieved approximately 50% SVR12. However, there is significant risk of serious adverse events, arguing for earlier intervention. The availability of treatments with better efficacy and safety is of particular importance for posttransplant patients with advanced disease.

Relativistic breather-type solitary waves with linear polarization in cold plasmas

Linearly polarized solitary waves, arising from the interaction of an intense laser pulse with a plasma, are investigated. Localized structures, in the form of exact numerical nonlinear solutions of the one-dimensional Maxwell-fluid model for a cold plasma with fixed ions, are presented. Unlike stationary circularly polarized solitary waves, the linear polarization gives rise to a breather-type behavior and a periodic exchange of electromagnetic energy and electron kinetic energy at twice the frequency of the wave. A numerical method based on a finite-differences scheme allows us to compute a branch of solutions within the frequency range Ωmin<Ω<ωpe, where ωpe and Ωmin are the electron plasma frequency and the frequency value for which the plasma density vanishes locally, respectively. A detailed description of the spatiotemporal structure of the waves and their main properties as a function of Ω is presented. Small-amplitude oscillations appearing in the tail of the solitary waves, a consequence of the linear polarization and harmonic excitation, are explained with the aid of the Akhiezer-Polovin system. Direct numerical simulations of the Maxwell-fluid model show that these solitary waves propagate without change for a long time.

An evaluation of dental prosthetic status and prosthetic needs among eunuchs (trans genders) residing in bhopal city, madhya pradesh, India: a cross-sectional study

BACKGROUND

Eunuchs are considered as the most vulnerable, frustrated, and insecure community. The accessibility to medical and dental facilities for the eunuchs is nearly nonexistent. Due to these reasons, they might be at a high risk of developing severe dental problems like tooth loss.

AIM

The present cross-sectional study aimed to evaluate the dental prosthetic status and prosthetic needs among eunuchs residing in Bhopal city, Madhya Pradesh, India.

SUBJECTS AND METHODS

On the basis of convenient nonprobability snowball sampling technique, all the self-identified eunuchs residing in the city of Bhopal along with a matched control consisting of cross section of the general population residing in the same locality was examined to evaluate the prosthetic status and prosthetic needs of the population. All the obtained data were entered into a personal computer on Microsoft excel sheet and analyzed using the software; Statistical Package for Social Science version 20. Data comparison was done by applying Chi-square test.

RESULTS

A total of 639 subjects comprised of 207 eunuchs, 218 males and 214 females. Among all participants, 2.8% (18/639) were having prosthesis. The overall prosthetic status among males was 3.2% (7/218) followed by 2.9% (6/207) eunuchs and 2.3% (5/214) females. However, need for multi-unit and combination of one and more unit prosthesis for upper and lower jaws was higher in males compared to females and eunuchs, but the difference was not statistically significant.

CONCLUSION

The findings of this study clearly demonstrate a high unmet need for prosthetic care among the population surveyed.

Modeling relativistic soliton interactions in overdense plasmas: a perturbed nonlinear Schrödinger equation framework

We investigate the dynamics of localized solutions of the relativistic cold-fluid plasma model in the small but finite amplitude limit, for slightly overcritical plasma density. Adopting a multiple scale analysis, we derive a perturbed nonlinear Schrödinger equation that describes the evolution of the envelope of circularly polarized electromagnetic field. Retaining terms up to fifth order in the small perturbation parameter, we derive a self-consistent framework for the description of the plasma response in the presence of localized electromagnetic field. The formalism is applied to standing electromagnetic soliton interactions and the results are validated by simulations of the full cold-fluid model. To lowest order, a cubic nonlinear Schrödinger equation with a focusing nonlinearity is recovered. Classical quasiparticle theory is used to obtain analytical estimates for the collision time and minimum distance of approach between solitons. For larger soliton amplitudes the inclusion of the fifth-order terms is essential for a qualitatively correct description of soliton interactions. The defocusing quintic nonlinearity leads to inelastic soliton collisions, while bound states of solitons do not persist under perturbations in the initial phase or amplitude.

A US multicenter study of hepatitis C treatment of liver transplant recipients with protease-inhibitor triple therapy

BACKGROUND & AIMS

NS3/4A protease inhibitors, boceprevir or telaprevir, combined with peginterferon and ribavirin was the standard treatment for HCV genotype 1 and remains the only available direct antiviral drug based therapy in some countries. Efficacy and safety data in liver transplant recipients are limited.

METHODS

This was a retrospective cohort study of 81 patients with genotype 1 HCV treated with boceprevir (10%) or telaprevir (90%) plus peginterferon and ribavirin at 6 US transplant centers (53% stage 3-4/4 fibrosis, 57% treatment experienced). The primary end point was undetectable HCV RNA 12 weeks after treatment completion (SVR12).

RESULTS

The intent-to-treat SVR12 rate was 63% (51/81). Patients with an extended rapid virologic response, (undetectable HCV RNA at 4 and 12 weeks after starting boceprevir or telaprevir), had a higher rate of SVR12 than all other patients (85% vs. 15%, p<0.001). Adverse effects were common; 21% of patients experienced hemoglobin <8g/dl and 57% required blood transfusions during the first 16 weeks. Twenty seven percent were hospitalized and 9% died; all were liver-related.

CONCLUSIONS

The addition of boceprevir or telaprevir to peginterferon and ribavirin yields SVR12 of 63% in liver transplant recipients with genotype 1 recurrent HCV, despite a high prevalence of advanced fibrosis and prior non-response to peginterferon and ribavirin. Rapid virologic response predicted a high likelihood of SVR. Despite a doubling of SVR rates, poor tolerability and high rates of adverse events were frequent and pose barriers to its widespread application.

Telaprevir or boceprevir triple therapy in patients with chronic hepatitis C and varying severity of cirrhosis

BACKGROUND

Risks and benefits of protease inhibitor (PI) (telaprevir or boceprevir) triple therapy in hepatitis C virus (HCV)-infected patients with mildly decompensated cirrhosis, including those wait-listed for liver transplantation (LT), are incompletely known.

AIM

To assess virological responses and safety of PI triple therapy in patients with mildly decompensated Child-Pugh (CP) CP ≥6 vs. compensated (CP = 5) cirrhosis.

METHODS

Multicentre cohort of 160 adults with cirrhosis treated with peginterferon/ribavirin (peg-IFN/RBV) plus telaprevir (69%) or boceprevir (31%), comparing outcomes between those with CP = 5 and CP ≥6.

RESULTS

Patients, 47% with CP ≥6 cirrhosis (CP range 6-10), received PI triple therapy for a targeted duration of 48 weeks. The cohort was median age 59 years, 32% female, 59% genotype 1a, 35% previous null/partial responders. Sustained virological response at 12 weeks (SVR12) was achieved by 35% of patients with CP ≥6 vs. 54% of those with CP = 5 (P = 0.02). CP = 5, achievement of rapid virological response and genotype 1b/other, independently predicted SVR12. Compared to those with CP = 5, patients with CP ≥6 had more peg-IFN dose reductions, eltrombopag use, transfusions and hospitalisations to manage adverse events (all P < 0.05). Overall, 67 (42%) discontinued treatment early. Nine wait-listed patients were treated for a median of 97 days (IQR 60-160) prior to liver transplantation and five achieved post-LT SVR.

CONCLUSIONS

In the presence of mild decompensation (Child-Pugh ≥6), SVR12 rates with protease inhibitor triple therapy are significantly reduced and adverse events increased. Thus, treatment with protease inhibitor triple therapy, if judged as necessary, should be undertaken with close monitoring and awareness of the significant risks.

Renal transplantation across ABO barrier

In India, patients without a compatible blood group donor are usually excluded from renal transplantation. For young patients, it is a difficult therapeutic choice to stay on long-term dialysis. We describe the case of a 19-year-old male patient who had blood group O +ve and had no compatible donor in the family. His mother was B +ve and was willing to donate. The patient had an initial anti-B antibody titer of 1:512 and underwent antibody depletion with plasmapheresis (11 sessions) and intravenous immunoglobulin (IVIG) 100 mg/kg after every plasmapheresis. He also received rituximab 500 mg for 3 days prior to transplant and was induced with basiliximab. At the time of transplant, his anti-B titers were <1:8. Post-operatively, he required four sessions of plasmapheresis and IVIG as his titers rebounded to 1:64. The titers then spontaneously subsided to <1:16 and have stayed at the same level for 6 months post-transplant. The patient continues to have normal renal function with a creatinine of 1.4 mg/dl% and has had no episodes of rejection.

Need for a national epilepsy control program

This article briefly outlines the proposed national epilepsy control program. The content of the article is based on four meetings held by invitation of the Ministry of Health. Invitees by ministry – Drs. D. C. Jain, M. Gourie Devi, V. Saxena, S. Jain, P. Satish. Chandra, M. Gupta, K. Bala, V. Puri, K. S. Anand, S. Gulati, S. Johri, P. S. Chandra, M. Behari, K. Radhakrishnan, D. Bachani. Presentations were made by Dr. M. Tripathi.The program will involve all neurologists across the country in teaching and training at state levels and a central monitoring committee.

Knowledge, attitude and practice of epilepsy in Uttarakhand, India

Objectives:

This study was conducted to find out knowledge, attitude and practice (KAP) of epilepsy among 12^th-class students in Uttarakhand state. Secondly data of Uttarakhand was compared with KAP study from other parts of the country.

Materials and Methods:

All 12^th-class students studying in six schools of randomly selected 36 villages in Chakrata block of Dehradun district of Uttarakhand state were provided a printed questionnaire having answer as “yes or no”. This questionnaire used was used previously by various authors and validated for KAP analysis. These filled questionnaires were collected by village health workers and medical officer.

Results:

This study conducted on 219, 12^th-class students revealed that epilepsy was heard by 98%, 74.9% thought epilepsy a mental disease and 4.8% believed that it is contagious. Negative attitude showed as nearly 2/3^rd students stated that epilepsy is hindrance in marriage and occupation. Nearly 41% would use onion or shoe for terminating seizure attack. Ayurvedic treatment was preferred over allopathic drugs.

Conclusions:

Study on 12^th-class students of Uttarakhand revealed poor knowledge, attitude and practice for epilepsy and needs special education program to dispel these misconceptions.

Recipient-donor race mismatch for African American liver transplant patients with chronic hepatitis C

African American (AA) recipient-donor race mismatch has been associated with graft loss and mortality, but studies of an association between race mismatch and hepatitis C virus (HCV) disease severity are lacking. HCV-infected adults from 4 US centers who underwent liver transplantation for the first time (n = 1093) were followed for a median of 3.05 years to determine the rates of advanced HCV disease (bridging fibrosis or cirrhosis) and graft failure; 11% of the patients were AA. The unadjusted cumulative rate of advanced fibrosis was higher in AAs than non-AAs (56% and 40% at 4 years, respectively, (P < 0.01), and 59% and 56% for AA recipient-donor-matched patients and AA recipient-donor-mismatched patients, respectively (P = 0.89). In adjusted models, both AA recipient race [hazard ratio (HR) = 1.47, 95% CI = 1.06-2.03, P = 0.02] and AA recipient-donor mismatch (versus match; HR = 1.48, 95% CI = 1.03-2.12, P = 0.03) were significant predictors of advanced fibrosis; other independent predictors were donor age (HR = 1.21, P < 0.01) and cytomegalovirus infection (HR = 1.55, P < 0.01). The 4-year unadjusted cumulative rates for HCV-associated graft loss were 10% and 17% for non-AAs and AAs, respectively (P < 0.01), and 0% and 21% for AA recipient-donor-matched patients and AA recipient-donor-mismatched patients, respectively (P < 0.01). In adjusted models, AA recipient-donor-mismatched patients had a 62% higher rate of graft loss than non-AA recipients (HR = 1.62, 95% CI = 1.14-2.29, P < 0.01), and AA recipient-donor-matched patients had a 76% lower rate of graft loss/mortality (HR = 0.24, 95% CI = 0.06-0.97, P = 0.05). In conclusion, AA recipient-donor-mismatched patients who are infected with HCV are at high risk for advanced HCV disease and HCV-related graft loss and constitute a patient group that will benefit from new therapeutic strategies for preventing graft loss.

Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - A single-center experience

OBJECTIVE

To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010.

MATERIALS AND METHODS

Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center.

RESULTS

The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%.

CONCLUSION

Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

Comparison of azathioprine with mycophenolate mofetil in a living donor kidney transplant programme

There are conflicting data regarding the comparative efficacy of mycophenolate mofetil (MMF) versus azathioprine (AZA) as maintenance immunosuppressive agent in kidney transplantation. The data are even less in combination with tacrolimus (TAC) in living donor kidney transplantation. A total of 205 living donor kidney transplants, on TAC-based triple drug immunosuppression were included in the study. A total of 113 patients received AZA and rest 92 were on MMF based protocol. TAC levels were monitored and graft biopsy was done whenever rejection was suspected. The outcomes were evaluated in terms acute rejection (AR) episodes at 1 year, infections, renal function, graft loss, and death between two groups. The study group comprised 163 males (79.5%) and 42 (20.5%) females. The mean age of patients was 42.4±11.8 years in the AZA group and 39.4 ±13.4 in the MMF group (P=0.09). The mean duration of follow-up was 491.7±240.7 and 478.8±334.4 days respectively in the AZA and MMF groups (P=0.75). Thirty-seven of 92 (40.2%) patients in the MMF group and 70/113 (61.9%) patients in the AZA group received IL-2 RAb induction (P=0.002). 32 patients (15.6 %) developed AR within a year. The incidence of AR was similar in patients who received MMF (12/92, 13%) and those who received AZA (20/113, 17.5%), (P=0.36). There was no difference in the incidence of AR in the subgroup of patients who received IL-2 RAb compared to those who did not receive induction in the two groups (5/37 vs. 7/55 in the MMF group and 10/70 vs. 10/43 in the AZA group, P=0.72). The incidence of infections was similar in the two groups (19/92, 20.6% vs. 25/113, 22.1%, P=0.79). Three patients developed CMV disease, of which two were in the MMF group. Graft loss occurred in 7/205 (3.4%) and death in 8/205 (3.9%) patients. Six of eight patients who died had functioning grafts. The rate of graft loss (3/92 vs. 4/113, P=0.97) and death (5/92 vs. 3/113, P=0.27) was similar in two groups. The overall patient survival was 94.5% and death censored graft survival was 97.4%. Cost comparison suggests AZA to be 6-10 times cheaper than MMF. This study suggests that, in tacrolimus-based immunosuppression, azathioprine may be as good as MMF as maintenance immunosuppressive drug in living donor kidney transplantation. It is also a more cost-effective immunosuppression.