It can be accessed through: http://www.georgiadotyfund.org
The link is:
http://www.georgiadotyfund.org/HepCHIVHEALTHMagazine.pdf
Be forewarned that it is a long download. A little over 5 MB's so those with
dial up will have to WAIT quite awhile. Sorry but worth the wait!
Acoustic liver biopsy using endoscopic ultrasound.
Andanappa HK, Dai Q, Korimilli A, Panganamamula K, Friedenberg F, Miller L.
Section of Gastroenterology, Department of Medicine, Temple University Hospital,
3401 N Broad Street, Philadelphia, PA 19140, USA.
BACKGROUND: Transabdominal ultrasound cannot be used to quantitate fibrosis in
patients with cirrhosis because of variability in the abdominal wall thickness
and variability in the components of the abdominal wall (fat versus muscle).
Endoscopic ultrasound through the gastric wall is always at a constant distance,
approximately 3 mm, away from the liver when the transducer is just below the
gastroesophageal junction, thereby eliminating this variability. PURPOSE: To
differentiate between cirrhotic and noncirrhotic liver using endoluminal
ultrasound. METHODS: Eleven patients without known liver disease and eight
patients with cirrhosis underwent endoscopic ultrasound using an Olympus linear
ultrasound scope. The gain, contrast, frequency, and acoustic power were kept
constant on the Aloka ultrasound processor. Videotaped images of the liver were
recorded and then digitized on Image-Pro Plus software. The brightness of the
image was adjusted to a standard brightness for each image and an area of
interest was chosen using Photoshop 7.0. Vessels and artifacts were eliminated
digitally and a histogram was produced using Photoshop to quantitate the pixel
density for the area of interest from 0 (black) to 255 (white). Approximately
250,000 pixels were evaluated for each subject. The mean +/- standard deviation
(SD) pixel density of the noncirrhotic subjects was evaluated against the
cirrhotic patients using a Student unpaired t-test. RESULTS: The mean
echogenecity in patients with cirrhosis was 116.85 and the mean echogenecity in
patients without cirrhosis was 92.75 (P < 0.002). The mean standard deviation of
the pixel density in patients with cirrhosis was 19.08 and the mean standard
deviation of the pixel density in patients without cirrhosis was 13.25 (P <
0.0004). Using these criteria the subjects with cirrhosis were segregated from
the noncirrhotic subjects (normal subjects and the subjects with steatosis) with
100% sensitivity and 100% specificity.
CONCLUSION: A new method of evaluating the liver parenchyma (acoustic liver
biopsy) that takes advantage of the proximity of the endoscopic ultrasound
transducer to the liver and uses commercial image analysis technology that is
inexpensive and widely available was developed. This is a preliminary study of
this new technology, which demonstrates that endoscopic ultrasound, can be
standardized in order to image, analyze, and compare the mean echogenecity and
mean standard deviation of the pixel density in the liver in order to
distinguish cirrhotic patients from patients without cirrhosis.
PMID: 18270828 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/18270828
Barbers aware of hepatitis
Nazia Hameed
ISLAMABAD: A study to assess the knowledge, attitude and practices of
barbers and street dentists regarding hepatitis and modes of its transmission
has revealed that 70 percent of those practicing in large cities were aware that
used instruments (scissors, blades and extraction forceps) could transmit
hepatitis, revealed Dr Rubina.
She said in large cities, 81% of barbers were aware that hepatitis was a
disease, 63% knew it could spread through blood and blood products and 70% had
the knowledge that used instruments could transmit hepatitis.
While in small cities, she said, 29% knew that hepatitis was a disease,
23% that used instruments could transmit hepatitis and 22% were aware of the
fact that it could spread through blood and blood products.
In rural areas, she said, 18% were aware of hepatitis, 1% knew it could
spread through blood and blood products and 15% were aware that used instruments
could transmit hepatitis.
Regarding attitude of most of the barbers, the survey revealed that most
of them were not concerned about the health hazards posed by this disease to
their clients, did not recognize the need for special precautions and using
separate instruments while dealing with these patients, and 85% did not want to
change their profession for the risk involved in it.
The survey also revealed that most of the barbers were satisfied with
their practice of cleaning the instruments with Dettol and not aware of the fact
that Dettol was not effective as Virucidal against Hepatitis B&C.
Dr Rubina said that the awareness level of the urban barbers and dentist
was observed better than to their rural co-professionals'; however, their
attitudes and practices were found similar. One factor for this unconcern for
the health risks was undoubtedly the cost involved in ensuring sterilization,
she said. Clients would most likely not agree to bear the increased cost of the
procedure and hence, in an effort not to loose their customer base, operational
costs are being kept low at the expense of likely transmission of Hepatitis, she
added. The survey has brought out useful information, which can guide the policy
makers to design and implement a cost-effective plan for prevention and control
of Hepatitis in Pakistan.
http://thepost.com.pk/IsbNewsT.aspx?dtlid=166069&catid=17
Now experts say cannabis should be legal
Published Date: 10 June 2008
By David Maddox
Scottish Political Correspondent
CANNABIS should be legalised and taxed, an influential Scottish think tank
recommended yesterday, just weeks after the Government hardened its attitude
towards the drug, reclassifying it as a class B substance.
The Scottish Futures Forum yesterday published a report on drugs and alcohol in
Scotland, saying one way to tackle the problem of addiction to harder drugs was
to tax and regulate cannabis.
Forum chairman Frank Pignatelli said studies of San Francisco, where cannabis is
illegal, and the Netherlands, where it is decriminalised, showed that the idea
is worth considering because it breaks the link with class A drugs. In the
Netherlands, only 17 per cent of cannabis sellers were also selling drugs such
as crack, cocaine and heroin, while in San Francisco it was more than 50 per
cent.
The idea was one of several aimed at halving drug addiction in Scotland by 2025.
This included introducing shooting galleries, where heroin addicts can go and
take drugs in supervised surroundings, as revealed in yesterday's Scotsman.
The forum's vice-chairman, Tom Wood, former deputy chief constable of Lothian
and Borders, said that there are "no easy options" and insisted that a different
and sometimes uncomfortable approach was needed to tackle Scotland's drug
problems.
He said: "Where we are now is living in a country where there is one of the
highest prevalences for drugs.
"We're living in a country where we have the highest drug death rate, we're
living in a country which has one of the highest hep C rates in Europe. So we're
hardly in a good place now. A lot of the things we've done in the past clearly
have not worked and so we have to move, and I think we are moving in the right
direction, but we have to move quite radically."
Just last month the Home Office announced it was reclassifying cannabis to class
B, reversing a decision in 2004 to lower it to class C.
The decision was made because stronger forms of cannabis such as skunk are
becoming more readily available and there is new evidence linking the drug to
psychiatric problems.
Both the Home Office and the Scottish Government have made it clear that they do
not support the idea of legalisation.
The community safety minister Fergus Ewing, who last week unveiled a new drugs
strategy, welcomed upgrading cannabis to class B.
There were two failed efforts to open cannabis cafés in Edinburgh. Scottish
Socialist Party member Kevin Williamson almost bankrupted himself trying to open
one in Haymarket and Paul Stewart was forced to quit for Amsterdam after being
fined for selling cannabis at his café Purple Haze in Leith.
The forum's suggestion has been welcomed by the Legalise Cannabis Alliance UK,
which claimed Scotland is leading the way on the issue.
Don Barnard, a spokesman, said: "The Scots seem to have been taking a more
mature view and I hope the recommendation is taken seriously."
The idea has also been backed by the Greens. Patrick Harvie, MSP, said: "The
current approach to criminalising drug users has been one of the most obvious
failures of social policy over the last 50 years, and the Futures Forum should
be thanked for their efforts to move the debate on. We broadly welcome their
report."
But the Scottish Tory leader Annabel Goldie, who persuaded the SNP to produce a
drugs strategy as part of a deal on supporting its budget, described the forum's
report as "flawed".
She added: "The taxing and regulation of cannabis is akin to legalisation. This
will not decrease use of this extremely harmful substance. Fortunately the
long-term consequences of cannabis usage are now universally acknowledged and
there is a consensus at Westminster that the damaging downgrading of cannabis to
a class C substance should be reversed."
http://news.scotsman.com/latestnews/Now-experts-say-cannabis-should.4167260.jp
Teenager cycling to raise awareness for Hepatitis B
By Michelle Paynter - bio | email
HARDEEVILLE, SC (WTOC) - A Florida teenager is braving the heat and bicycling
his way up the east coast and making a stop in the Low Country.
It's all to raise awareness for Hepatitis B, a disease that attacks the liver.
17-year-old John Ellis was diagnosed with Hepatitis B two years ago.
Ellis left his hometown of Pensacola last Monday and will end up in Philadelphia
by June 23. He and his friend are averaging about 60 miles a day on their bikes.
They stopped for a breather outside of Hardeeville this morning.
Ellis said he hopes this tour will make a difference. "I don't just want to sit
around and fight for myself, Hepatitis B has effected a lot of people," he said.
Doctors told Ellis he will eventually need a liver transplant. Statistics show
one out of every 20 Americans is infected with Hepatitis B.
http://www.wtoc.com/global/story.asp?s=8453616
Active and Recovering Injection Drug Users Can Benefit from Hepatitis C
Treatment if They Maintain Good Adherence
By Liz Highleyman
Because hepatitis C virus (HCV) can be transmitted via shared needles and other
drug-injection equipment, a high proportion of active and former injection drug
users (IDUs) have chronic hepatitis C.
Traditionally, some experts have felt that IDUs - particularly those who
continue active drug use - are unsuitable for interferon-based therapy because
they tend to be difficult to treat and have poor outcomes. Recent research,
however, contradicts this belief, and National Institutes of Health (NIH)
consensus guidelines state that IDUs, especially those on methadone maintenance
or similar opiate substitution therapy, should not be routinely denied
treatment.
As reported at the Digestive Disease Week 2008 conference last month in San
Diego, Olga Anagnostou and colleagues evaluated hepatitis C treatment adherence
and response rates among IDUs and investigated factors influencing outcomes.
The study included 104 IDUs with chronic hepatitis C who received combination
therapy with conventional or pegylated interferon plus ribavirin between 2000
and 2007. Most (77) were men and the mean age was 37 years (range 19-58 years);
34 had HCV genotypes 1 or 4, while 57 had genotype 3. Seven had histological
evidence of cirrhosis, but none had decompensated liver disease.
Among the participants, 45 (43.3%) were receiving maintenance opiate
substitution treatment, 39 (37.5%) injected drugs in the past, and 20 (13%)
continued active injection drug use.
Treatment adherence, end-of-treatment response (ETR), and sustained virological
response (SVR) 24 weeks after completion of therapy were assessed and correlated
with patient characteristics.
Results
. 30 of the 104 participants (28.8%) discontinued anti-HCV treatment
prematurely, after a mean of 3 months.
. 13 participants (12.5%) discontinued therapy due to major side effects
and 17 (16.3%) did so due to personal decision.
. By subgroup, 76% of past users, 65% of active users, and 60% of those
on methadone maintenance completed anti-HCV therapy (a non-significant
difference).
. Multivariate analysis including age, sex, active or past drug use,
substitution treatment, HCV genotype, duration of therapy, and current alcohol
consumption did not reveal any significant association with adherence.
. Among the 74 patients who completed interferon-based therapy, 47
(64.4%) achieved SVR, while another 13 (17.6%) experienced ETR with subsequent
viral relapse.
. There was no significant difference in SVR rates between past users
(57.9%), active users (71.4%), and individuals on methadone maintenance (71.4%).
. In a multivariate analysis, younger age and male sex were associated
with SVR.
"Our data clearly suggest that, as long as [IDU] patients with chronic hepatitis
C keep adherent, chronic hepatitis C therapy is effective," the investigators
concluded.
"Active drug users and patients on substitution maintenance treatment do not
differ from past users in terms of SVR and compliance to hepatitis C treatment,"
they continued. "SVR in those patients is similar [to] that expected in the
general chronic hepatitis C population."
Therefore, the researchers recommended, "[IDUs] with chronic hepatitis C
infection -- especially when they are on substitution treatment -- should not be
excluded from treatment."
6/10/08
Reference
O Anagnostou, S Manolakopoulos, M Deutsch, and others. Drug Users with chronic
hepatitis C who are adherent to antiviral treatment will finally benefit from
therapy. Digestive Disease Week (DDW) 2008. San Diego, CA. May 17-22, 2008.
Abstract S1013.
http://www.hivandhepatitis.com/2008icr/ddw/docs/061008_c.html
Selected Hepatitis C Patients with Decompensated Cirrhosis Can Benefit from
Interferon-based Therapy prior to Liver Transplantation
By Liz Highleyman
Many clinicians are reluctant to use interferon-based therapy to treat chronic
hepatitis C patients with decompensated cirrhosis (liver failure) due to the
risk of severe adverse events. Such patients, however, may be in the most dire
need of treatment as they await liver transplantation.
As reported at the Digestive Disease Week 2008 conference last month in San
Diego, Alexandra Retana and John Wong performed a systemic review of prior
studies looking at the risks and benefits of antiviral therapy for decompensated
hepatitis C patients.
The researchers searched the Medline and Web of Science databases for entries
published between 1990 and 2007 using the subject headings "hepatitis C,"
"cirrhosis," "antiviral agents," "preoperative management," and "adverse
effects." They also looked at bibliographies of related articles.
The analysis included randomized controlled trials, observational case control
studies, and cohort studies involving hepatitis C patients on transplant waiting
lists with at least 1 episode of decompensation or signs of decompensated
cirrhosis (for example, bleeding esophageal varices or ascites).
Results
. The investigators identified 4 cohort studies and 1 case control study
with 255 patients (70% men, mean age 62 years; average Child-Pugh score
7.4-11.9).
. Patients were treated with either:
. Conventional interferon monotherapy (1-5 MU daily or 1.5-3 MU thrice
weekly);
. Conventional interferon plus ribavirin (3 MU daily and 400-800
mg/day, respectively);
. Pegylated interferon monotherapy (0.5 mcg/kg/week);
. Pegylated interferon plus ribavirin (1 mcg/kg/week and 600-800
mg/day, respectively).
. Patients were treated either for 24-48 weeks or until transplantation.
. The overall end-of-treatment response rate was 45% and the overall
sustained virological response (SVR) rate was 23%.
. The overall relapse rate was 52%.
. Among patients who had undetectable HCV RNA by PCR at the time of
transplantation, the recurrence rate was 39%.
. The most commonly reported adverse effects were leukopenia or
neutropenia (low white blood cell count) at 46%, thrombocytopenia (low platelet
count) at 38%, and anemia (low hemoglobin and/or red blood cell count) at 35%.
. The treatment-related mortality rate was 3.8%.
. 30% of patients required dose reductions due to adverse effects and 24%
discontinued treatment.
. In the study with an untreated control arm, control subjects had a
higher adverse event rate (88% vs 59%) and a higher mortality rate (32% vs 16%,
all in patients without SVR).
Based on these findings, the researchers concluded that "antiviral therapy in
carefully selected patients with advanced cirrhosis may be attempted and
potentially beneficial, but is likely to be associated with frequent adverse
effects."
6/10/08
Reference
AK Retana and JB Wong. Pre-transplant antiviral treatment of hepatitis C with
decompensated cirrhosis: a systematic review of risks and benefits. Digestive
Disease Week (DDW) 2008. San Diego, CA. May 17-22, 2008. Abstract S1011.
http://www.hivandhepatitis.com/2008icr/ddw/docs/061008_a.html
Herbal Product Stevioside Inhibits HCV Replication and Curcumin Suppresses
Fibrogenic Cell Activity in Laboratory Studies
By Liz Highleyman
Given the suboptimal response rate and difficult side effects associated with
standard interferon-based therapy for chronic hepatitis C virus (HCV) infection,
many patients have used various alternative and complementary therapies, and
researchers have assessed several such agents in laboratory and clinical
studies.
At the Digestive Disease Week 2008 conference last month in San Diego,
researchers reported on 2 plant-derived therapies that may have the potential to
inhibit HCV and improve liver fibrosis.
Stevioside
In the first study, Kazuhisa Yuasa and colleagues assessed the in vitro anti-HCV
activity of stevioside, an agent derived from the leaves of the Stevia
rebaudiana plant that is used as a natural non-caloric sweetener.
Stevioside has been reported to have anti-inflammatory and antioxidant
properties, as well as an antiviral effect on rotavirus. According to background
information provided the investigators, some chronic hepatitis C patients who
regularly use stevioside have exhibited decreased HCV RNA or undetectable viral
load in the absence of interferon-based therapy.
In the present study, the researchers evaluated the antiviral effect of
stevioside on HCV replication using HCV replicon systems. They used ORN/C-5B/KE
cells supporting genome-length HCV RNA encoding the luciferase reporter gene,
and O cells replicating the genome-length HCV RNA in a real-time transcription
polymerase chain reaction analysis.
Both cell systems were exposed to several concentrations of sterilized
stevioside. The investigators assessed cytotoxicity, effect on signal
transduction pathways, and anti-HCV activity (with and without interferon).
Results
. A diluted solution of stevioside demonstrated no cytotoxicites to
either ORN/C-5B/KE cells or O cells.
. In both replicon systems, diluted stevioside suppressed HCV RNA in a
dose-dependent manner.
. A 1000 times diluted stevioside solution inhibited HCV replication by
about 30%.
. The same solution activated interferon-stimulated response element and
2-5A synthesizing enzyme gene promoter, but not the NF-kappa-?B gene promoter.
. Exposure to stevioside and interferon in combination produced an
additive, but not a synergistic antiviral effect.
"We showed [the] anti-HCV effect of stevioside and the additive anti-HCV effect
by combination of stevioside with interferon in vitro, and the activation of
interferon signal was considered as one of the mechanism[s]," the investigators
stated.
Thus, they concluded that, "stevioside is a possible antiviral agent for
hepatitis C virus infection," and they plan to conduct a pilot study of the
safety and efficacy of stevioside therapy for patients with chronic hepatitis C.
Curcumin
Looking at another herbal therapy, Anping Chen and colleagues presented 3
laboratory studies assessing at the effect of curcumin on hepatic stellate
cells.
Curcumin is the main component of the curry spice turmeric, derived from the
Curcuma longa plant. Prior research indicates that it has antioxidant,
anti-inflammatory, and anti-tumor properties. Hepatic stellate cells produce
extracellular matrix proteins such as collagen that are responsible for liver
fibrosis.
In the first study, the investigators found that curcumin promotes peroxisome
proliferator-activated receptor-gamma (PPAR-gamma) gene expression and
suppresses expression of the low-density lipoprotein (LDL) cholesterol receptor
gene, which in turn lowers the level of intracellular cholesterol and thereby
reduces the stimulatory effect of LDL on hepatic stellate cell activation.
In the second study, the researchers demonstrated that curcumin diminished the
activating effect of oxidized LDL on stellate cells by suppressing LOX-1 gene
expression, again via PPAR-gamma activation. Conversely, pre-treating the cells
with a PPAR-gamma antagonist (PD68235) eliminated the inhibitory effect of
curcumin.
Finally, the investigators showed that by increasing oxidative stress, insulin
stimulates hepatic stellate cell proliferation and collagen production. But
curcumin suppressed insulin-induced stellate cell activation by interrupting the
insulin signaling pathway and reducing oxidative stress, via the same PPAR-gamma
mechanism.
Hyperlipidemia (elevated blood lipid levels), obesity, and insulin resistance
are features of the metabolic syndrome, which is associated with liver steatosis
(accumulation of fat in hepatocytes). Steatosis is linked to fibrosis in
individuals with non-alcoholic fatty liver disease, as well as those with
chronic hepatitis C. Further, steatosis and insulin resistance are factors
associated with poor response to interferon-based anti-HCV therapy.
The results of these laboratory studies suggest that curcumin or related agents
that work by a similar mechanism might reduce fibrosis associated with
hyperlipidemia or insulin resistance in individuals with or without hepatitis C.
6/10/08
References
K Yuasa, K Sato, A Naganuma, and others. Stevioside as a possible antiviral
agent for hepatitis C virus infection. Digestive Disease Week (DDW) 2008. San
Diego, CA. May 17-22, 2008. Abstract S1943.
Q Kang and A Chen. Curcumin suppresses LDL receptor gene expression, leading to
the inhibition of cholesterol/LDL-induced hepatic stellate cell activation.
Digestive Disease Week (DDW) 2008. San Diego, CA. May 17-22, 2008. Abstract
S1584.
Q Kang, A Chen, and JL Mehta. Curcumin inhibits ox-LDL-activated hepatic
stellate cells in vitro by suppressing gene expression of lectin-like
oxidized-LDL receptor via activation of peroxisome proliferator-activated
receptor-gamma. Digestive Disease Week (DDW) 2008. San Diego, CA. May 17-22,
2008. Abstract S1896.
J Lin and A Chen. Curcumin Suppresses Insulin-induced hepatic stellate cell
activation by interrupting insulin signaling and attenuating oxidative stress.
Digestive Disease Week (DDW) 2008. San Diego, CA. May 17-22, 2008. Abstract
M1576.
http://www.hivandhepatitis.com:80/2008icr/ddw/docs/061008_b.html
SILIBININ IS A POTENT ANTIVIRAL AGENT IN CHRONIC HEPATITIS C NOT RESPONDING TO
ANTIVIRAL COMBINATION THERAPY
Reported by Jules Levin
43rd EASL
April 23-27, 2008-05-01Milan, Italy
Peter Ferenci, Thomas M. Scherzer,
Harald Hofer, Katharina Staufer, Petra Munda
Internal Medicine 3
Medical University of Vienna
AUSTRIA
This study was supported by an unrestricted research grant by ROCHE Austria,
Silibinin was provided by ROTTAPHARM-MADAUS free of charge
AUTHOR SUMMARY
iv. silibinin has potent antiviral activity against HCV
This effect is dose dependent, and independent of peginterferon/ribavirin
iv. silibinin was well tolerated
oral administration of silymarin was ineffective
AUTHOR CONCLUSIONS
iv. silibinin may be useful for treatment of nonresponders to
peginterferon/ribavirin
the optimal dose and duration of silibinin therapy remains to be studied
Studies of the pharmacokinetics of silibinin are mandatory
The mechanism of action is unknown
Silymarin
Silymarin is a potentially useful drug for treatment of liver diseases
-- Clinical studies not conclusive
--mode of action
antioxidant/free radical scavenger
antifibrotic
Hepatoprotective (Amanita phalloides)
Study 1
Decrease of oxidative stress by high dose silibinin Đ improved efficacy of
interferon?
Pedigreed nonresponders
Full dose peginterferon/RBV for at least 12 weeks
-- < 2log drop week 12
-- HCV-RNA pos.at week 24
Click on link for slides: http://www.natap.org/2008/EASL/EASL_57.htm
Treatment of Chronic Hepatitis C with Telaprevir (TVR) in Combination with
Peginterferon Alfa-2a with or without Ribavirin: Interim Results of the PROVE2
Study - (05/02/08)
a.. SILIBININ IS A POTENT ANTIVIRAL AGENT IN CHRONIC HEPATITIS C NOT
RESPONDING TO ANTIVIRAL COMBINATION THERAPY - (05/02/08)
b.. Results of a Safety, Tolerability and Pharmacokinetic Phase I Study of
VCH-916, a Novel Polymerase Inhibitor for HCV, Following Single Ascending Doses
in Healthy Volunteers - (05/02/08)
Preclinical Pharmacokinetic and ADME Characterization of VCH-916, a Novel
Non-Nuclesoside HCV NS5B Polymerase Inhibitor - (05/02/08)
Interim Results from HCV SPRINT-1: RVR/EVR from Phase 2 Study of Boceprevir Plus
Peginterferon alfa-2b/Ribavirin in Treatment-Naive Subjects with Genotype-1 CHC
- (04/30/08)
a.. RANDOMIZED DOUBLE BLIND PLACEBO-CONTROLLED TRIAL OF NITAZOXANIDE IN THE
TREATMENT OF PATIENTS WITH CHRONIC HEPATITIS C GENOTYPE 4 - (05/16/08)
b.. EVALUATION OF A 4 WEEK LEAD-IN PHASE WITH NITAZOXANIDE PRIOR TO
NITAZOXANIDE+PEGINTERFERON IN TREATING CHRONIC HEPATITIS C - (05/16/08)
POTENT ANTIVIRAL ACTIVITY OF THE HCV NUCLEOSIDE POLYMERASE INHIBITOR, R7128, IN
COMBINATION WITH PEG-IFN a-2a AND RIBAVIRIN - (05/06/08)
High end-of-treatment response (84%) after 4 weeks of R1626, peginterferon
alfa-2a (40KD) and ribavirin followed by a further 44 weeks of peginterferon
alfa-2a and ribavirin- (05/06/08)
a.. HCV Protease Inhibitor Telaprevir, PROVE1 Study: final results of a phase
2 study with peginterferon plus ribaviron in treatment-naive patients with
hepatitis C - (04/25/08)
b.. A Study of Telaprevir (TVR) with Peginterferon Alfa-2a (P) and Ribavirin
(R) in Subjects with Well-Documented Prior PR Null Response, Non-Response or
Relapse: Preliminary Results - (04/25/08)
Federal action could stop unneeded surgeries, experts say
By Andrew Conte and Luis Fabregas
TORONTO -- Federal rules need to change to protect patients from receiving
unnecessary liver transplants, leading surgeons said at the American Transplant
Congress here.
"We are concerned," said Dr. Elizabeth A. Pomfret, chairman of the liver and
intestinal organ transplantation committee of the United Network for Organ
Sharing, the federally funded agency that manages the nation's transplant
system. "The new challenge is, can we improve upon the current allocation
system? I think it's very possible that we could."
The Tribune-Review in March reported hundreds of patients each year undergo
liver transplants when they have better odds of living at least a year by
waiting. Often, these people near the bottom of the waiting list receive organs
that were rejected for thousands of sicker patients.
Crediting the Trib with highlighting the problem, UNOS officials are reviewing
the practice and are expected to address the issue at the liver committee
meeting next month.
At last week's transplant congress, a gathering of about 4,500 surgeons,
scientists and other medical professionals discussed the problem and proposed
changes.
Too often, centers perform transplants for the wrong reasons, said Dr. Richard
Rohrer, chief of transplant surgery at Tufts-New England Medical Center.
"There is a huge amount of self-interest," Rohrer said. "There are marketplace
incentives to do these transplants. It's not about the science anymore."
They discussed changes focused on systems for ranking patients and giving out
organs.
Rankings are based on a score called MELD, for Model End-stage Liver Disease,
that predicts whether patients on the waiting list will die within three months
but says little about their life expectancies after surgery.
The system could be changed to favor recipients who have more years to gain from
an organ, said Pomfret, a transplant surgeon at the Lahey Clinic Medical Center
in Burlington, Mass.
The so-called net benefit of a transplant -- the number of years a transplant
recipient could expect to gain from surgery -- could be determined in part by
looking at objective, measurable medical criteria such as the recipient's
disease and age, Pomfret said.
Columbia University researchers have studied a change that would include the
odds of dying within three months after transplant as well as waiting list
mortality.
The review "will allow us to look at low-MELD transplants and figure out if it
makes sense to do them," said Pomfret, adding that she expects some centers will
fight changes to the MELD allocation system.
"There are some centers that will oppose this because they have financial
incentives" to do transplants on low-MELD patients, she said. "That's just a
reality."
Allocation policies need to be revamped, surgeons said.
Too much variation exists among the 11 UNOS regions, said Dr. Russell H.
Wiesner, a liver doctor at the Mayo Clinic in Rochester, Minn. Surgeons in some
regions unnecessarily move people up the list. And, the lack of broader sharing
rules allows less critically ill patients to get organs in some places before
the sickest ones in others.
Patients with low scores can apply to a regional review board for extra points
if they have symptoms such as severe itching, brain disorders or swelling that
are not reflected in their blood work. Those in the region that includes New
York are more likely to be transplanted with the exception points than those in
Pennsylvania or any other region.
Instead, UNOS should create a national review board so that decisions are
standardized across the country, Wiesner said.
"The regional review boards don't work," Wiesner said. "It's a tit for tat. I
hear this all the time."
Under federal allocation policies, geography plays a role in how long patients
wait for livers.
When an organ becomes available, it is offered first to the sickest patients in
that city and then in the region -- but then it is offered to patients lower on
the list, instead of the sickest patients in the next region. An organ could go
to someone near the bottom of the waiting list in Pittsburgh before a dying
patient in Cleveland, because it's in a different region.
That process could be changed to one with wider sharing or one based on donor
density rather than state lines.
Andrew Conte can be reached at andrewconte@... or 412-320-7835. Luis
Fabregas can be reached at lfabregas@... or 412-320-7998.
http://www.pittsburghlive.com/x/pittsburghtrib/news/cityregion/s_571657.html