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Sulkowski MS, Martinez A, Tyson GL, Scholz K, Franco RA, Kohli A, Julius SF, Deming P, Fink SA, Lynch K, Roytman M, Stainbrook TR, Turner MD, Viera-Briggs M, Ramers CB. Leveraging opportunities for treatment/user simplicity (LOTUS): Navigating the current treatment landscape for achieving hepatitis C virus elimination among persons who inject drugs. J Viral Hepat 2024. [PMID: 38433561 DOI: 10.1111/jvh.13927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/09/2024] [Accepted: 01/28/2024] [Indexed: 03/05/2024]
Abstract
All-oral, direct-acting antivirals can cure hepatitis C virus (HCV) in almost all infected individuals; yet, many individuals with chronic HCV are not treated, and the incidence of acute HCV is increasing in some countries, including the United States. Strains on healthcare resources during the COVID-19 pandemic negatively impacted the progress toward the World Health Organization goal to eliminate HCV by 2030, especially among persons who inject drugs (PWID). Here, we present a holistic conceptual framework termed LOTUS (Leveraging Opportunities for Treatment/User Simplicity), designed to integrate the current HCV practice landscape and invigorate HCV treatment programs in the setting of endemic COVID-19: (A) treatment as prevention (especially among PWID), (B) recognition that HCV cure may be achieved with variable adherence with evidence supporting some forgiveness for missed doses, (C) treatment of all persons with active HCV infection (viremic), regardless of acuity, (D) minimal monitoring (MinMon) during treatment, and (E) rapid test and treat (TnT). The objective of this article is to review the current literature supporting each LOTUS petal; identify remaining gaps in knowledge or data; define the remaining barriers facing healthcare providers; and review evidence-based strategies for overcoming key barriers.
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Affiliation(s)
- Mark S Sulkowski
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Kathleen Scholz
- Central Outreach Wellness Centers, Pittsburgh, Pennsylvania, USA
| | - Ricardo A Franco
- The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Anita Kohli
- Arizona Liver Health, Chandler, Arizona, USA
| | | | - Paulina Deming
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | | | - Keisa Lynch
- University of Utah Health, Salt Lake City, Utah, USA
| | - Marina Roytman
- University of California San Francisco, Fresno, California, USA
| | | | | | | | - Christian B Ramers
- University of California San Diego, San Diego, California, USA
- Family Health Centers of San Diego, San Diego, California, USA
- San Diego State University School of Public Health
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2
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Talal AH, Dharia A, Kapadia SN, Tyson GL, Birch S, Zerzan-Thul J, Sullivan D, Britton E, Wethington E, Gonzalez CJ, Fliss M, Mizroch B, McCall F, Lloyd AR, Shapiro MF, Franco R. Hepatitis C Virus Elimination Programs in Louisiana and Washington: Importance of Screening and Surveillance Systems. J Public Health Manag Pract 2024; 30:208-212. [PMID: 37594263 PMCID: PMC10833194 DOI: 10.1097/phh.0000000000001808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
The US government has established a national goal of hepatitis C virus (HCV) elimination by 2030. To date, most HCV elimination planning and activity have been at the state level. Fifteen states presently have publicly available HCV elimination plans. In 2019, Louisiana and Washington were the first states to initiate 5-year funded HCV elimination programs. These states differ on motivation for pursuing HCV elimination and ranking on several indicators. Simultaneously, however, they have emphasized several similar elimination components including HCV screening promotion through public awareness, screening expansion, surveillance enhancement (including electronic reporting and task force development), and harm reduction. The 13 other states with published elimination plans have proposed the majority of the elements identified by Louisiana and Washington, but several have notable gaps. Louisiana's and Washington's comprehensive plans, funding approaches, and programs provide a useful framework that can move states and the nation toward HCV elimination.
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Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Shashi N. Kapadia
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Gia L. Tyson
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Susan Birch
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Judy Zerzan-Thul
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Donna Sullivan
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Elizabeth Britton
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Elaine Wethington
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Christopher J. Gonzalez
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Mary Fliss
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Brandon Mizroch
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Frederic McCall
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Audrey R. Lloyd
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Martin F. Shapiro
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
| | - Ricardo Franco
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York (Drs Talal and Dharia); Divisions of Infectious Diseases (Dr Kapadia) and General Internal Medicine (Drs Gonzalez and Shapiro), Weill Cornell Medicine, New York, New York; Louisiana Department of Health, New Orleans, Louisiana (Drs Tyson, Mizroch, and McCall and Ms Britton); Washington State Healthcare Authority, Olympia, Washington (Drs Sullivan and Zerzan-Thul and Mss Birch and Fliss); Cornell University, Ithaca, New York (Dr Wethington); and Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Drs Lloyd and Franco)
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Kruse R, Kramer JR, Tyson GL, Duan Z, Chen L, El-Serag HB, Kanwal F. Clinical outcomes of hepatitis B virus coinfection in a United States cohort of hepatitis C virus-infected patients. Hepatology 2014; 60:1871-8. [PMID: 25065513 PMCID: PMC4245372 DOI: 10.1002/hep.27337] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 07/24/2014] [Indexed: 12/19/2022]
Abstract
UNLABELLED The effect of hepatitis B virus (HBV) coinfection in patients with hepatitis C virus (HCV) remains unclear. We used the National Veterans Affairs HCV Clinical Case Registry to identify patients with confirmed HCV viremia during 1997-2005. We defined HBV coinfection as a positive test for hepatitis B surface antigen, HBV DNA, or hepatitis B e antigen. We defined cirrhosis and hepatocellular carcinoma (HCC) based on the validated ICD-9 codes and determined mortality through the end of 2009. We performed Cox proportional hazard regression analyses to examine the effect of HBV coinfection stratified by HBV DNA status (positive or negative) on the risk of cirrhosis, HCC, and death adjusting for patients' age, gender, race, human immunodeficiency virus (HIV) infection, alcohol or drug use, Deyo Score, and antiviral treatment. Among 99,548 patients with HCV infection, 1,370 patients (1.4%) had HBV coinfection. Of the coinfected patients, 677 (49.4%) patients had at least one HBV DNA test done and 303 patients (44.7%) tested positive for HBV DNA. The incidence rates of cirrhosis, HCC, and death were significantly higher in patients with HBV coinfection and detectable HBV DNA compared to HCV monoinfection (36.8, 6.9, and 41.7 versus 17.4, 3.6, and 31.4 per 1,000 person-years, respectively; P < 0.05 for all comparisons). After adjustment for demographic, clinical, and treatment factors, patients with detectable HBV DNA had a significantly higher risk for cirrhosis (hazard ratio [HR] = 1.89 95% confidence interval [CI] = 1.46-2.45), HCC (HR = 2.12, 95% CI = 1.26-3.60), and death (HR = 1.62, 95% CI = 1.33-1.99) compared to HCV monoinfected patients. There were no differences in the risk of cirrhosis, HCC, or overall mortality between coinfected patients with undetectable HBV DNA and those with HCV monoinfection (HR = 1.18, 95% CI = 0.90-1.55; 1.54, 95% CI = 0.93-2.56; 1.08, 95% CI = 0.88-1.33, respectively). CONCLUSION We found that while only a small number of HCV patients were coinfected with HBV, patients with documented HBV viremia were at a significantly higher risk for cirrhosis, HCC, and overall death than HCV monoinfected patients. Absence of HBV replication was associated with a clinical course similar to that of HCV monoinfected patients.
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Affiliation(s)
- Robert Kruse
- Interdepartmental Program in Translational Biology and Molecular Medicine,
Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center
| | - Gia L. Tyson
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor
College of Medicine, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College
of Medicine, Houston, TX
| | - Zhigang Duan
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center,Section of Health Services Research, Department of Medicine, Baylor College
of Medicine, Houston, TX
| | - Liang Chen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center,Section of Health Services Research, Department of Medicine, Baylor College
of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor
College of Medicine, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College
of Medicine, Houston, TX
| | - Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt),
Michael E. DeBakey Veterans Affairs Medical Center,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor
College of Medicine, Houston, TX,Section of Health Services Research, Department of Medicine, Baylor College
of Medicine, Houston, TX,Interdepartmental Program in Translational Biology and Molecular Medicine,
Baylor College of Medicine, Houston, Texas
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Tyson GL, Kramer JR, Duan Z, Davila JA, Richardson PA, El-Serag HB. Prevalence and predictors of hepatitis B virus coinfection in a United States cohort of hepatitis C virus-infected patients. Hepatology 2013; 58:538-45. [PMID: 23505059 PMCID: PMC3729715 DOI: 10.1002/hep.26400] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 02/26/2013] [Indexed: 12/21/2022]
Abstract
UNLABELLED There are sparse epidemiologic data on coinfection of hepatitis B (HBV) and hepatitis C (HCV) in the United States. Therefore, the aim of this study was to determine the prevalence and predictors of HBV coinfection in a large U.S. population of HCV patients. We used the National Veterans Affairs HCV Clinical Case Registry to identify patients tested for HCV during 1997-2005. Patients were categorized based on HCV exposure (any two +HCV tests or one test with a diagnostic code), HCV infection (+RNA or genotype), HBV exposure (any +HBV test, excluding +HBsAb only), and HBV infection (+HBsAg, HBV DNA, or HBeAg). The prevalence of HBV exposure among patients with HCV exposure and that of HBV infection among patients with HCV infection were determined. Multivariate logistic regression evaluated potential demographic and clinical predictors of HBV coinfection. Among 168,239 patients with HCV exposure, 58,415 patients had HBV exposure for a prevalence of 34.7% (95% confidence interval [CI] 34.5-35.0). Among 102,971 patients with HCV infection, 1,431 patients had HBV coinfection for a prevalence of 1.4% (95% CI 1.3-1.5). Independent associations with HBV coinfection compared with HCV monoinfection were age ≤ 50 years, male sex, positive HIV status, history of hemophilia, sickle cell anemia or thalassemia, history of blood transfusion, cocaine and other drug use; there was decreased risk in patients of Hispanic ethnicity. CONCLUSION This is the largest cohort study in the U.S. on the prevalence of HBV coinfection in HCV patients. Among veterans with HCV, exposure to HBV is common (~35%), but HBV coinfection is relatively low (1.4%). Several possible risk factors were identified.
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Affiliation(s)
- Gia L. Tyson
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jennifer R. Kramer
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Zhigang Duan
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jessica A. Davila
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Peter A. Richardson
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX,Sections of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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5
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Davila JA, Kramer JR, Duan Z, Richardson PA, Tyson GL, Sada YH, Kanwal F, El-Serag HB. Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: effect of patient and nonpatient factors. Hepatology 2013; 57:1858-68. [PMID: 23359313 PMCID: PMC4046942 DOI: 10.1002/hep.26287] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 11/27/2012] [Indexed: 01/01/2023]
Abstract
UNLABELLED The delivery of treatment for hepatocellular carcinoma (HCC) could be influenced by the place of HCC diagnosis (hospitalization versus outpatient), subspecialty referral following diagnosis, as well as physician and facility factors. We conducted a study to examine the effect of patient and nonpatient factors on the place of HCC diagnosis, referral, and treatment in Veterans Administration (VA) hospitals in the United States. Using the VA Hepatitis C Clinical Case Registry, we identified hepatitis C virus (HCV)-infected patients who developed HCC during 1998-2006. All cases were verified and staged according to Barcelona Clinic Liver Cancer (BCLC) criteria. The main outcomes were place of HCC diagnosis, being seen by a surgeon or oncologist, and treatment. We examined factors related to these outcomes using hierarchical logistic regression. These factors included HCC stage, HCC surveillance, physician specialty, and facility factors, in addition to risk factors, comorbidity, and liver disease indicators. Approximately 37.2% of the 1,296 patients with HCC were diagnosed during hospitalization, 31.0% were seen by a surgeon or oncologist, and 34.3% received treatment. Being seen by a surgeon or oncologist was associated with surveillance (adjusted odds ratio [aOR] = 1.47; 95% CI: 1.20-1.80) and varied by geography (1.74;1.09-2.77). Seeing a surgeon or oncologist was predictive of treatment (aOR = 1.43; 95% CI: 1.24-1.66). There was a significant increase in treatment among patients who received surveillance (aOR = 1.37; 95% CI: 1.02-1.71), were seen by gastroenterology (1.65;1.21-2.24), or were diagnosed at a transplant facility (1.48;1.15-1.90). CONCLUSION Approximately 40% of patients were diagnosed during hospitalization. Most patients were not seen by a surgeon or oncologist for treatment evaluation and only 34% received treatment. Only receipt of HCC surveillance was associated with increased likelihood of outpatient diagnosis, being seen by a surgeon or oncologist, and treatment.
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Affiliation(s)
- Jessica A Davila
- Houston VA Health Services Research Center of Excellence, Section of Health Services Research, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
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6
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Tyson GL, Duan Z, Kramer JR, Davila JA, Richardson PA, El-Serag HB. Level of α-fetoprotein predicts mortality among patients with hepatitis C-related hepatocellular carcinoma. Clin Gastroenterol Hepatol 2011; 9:989-94. [PMID: 21820396 PMCID: PMC3200479 DOI: 10.1016/j.cgh.2011.07.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 07/15/2011] [Accepted: 07/25/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) can result from hepatitis C virus (HCV)-related liver disease and is the fastest-growing cause of cancer-related death in the United States. α-fetoprotein (AFP) has been used as a prognostic factor for HCC, but the value of AFP as a prognostic factor for HCV-related HCC in the United States is unknown. We investigated whether higher levels of AFP at the time of diagnosis are associated with increased mortality of patients with HCV-related HCC. METHODS In a retrospective study, we collected data from a cohort of HCV-infected veterans, identifying incident HCC cases from October 1, 1998, to January 1, 2007 (n = 1480 patients). The mean serum levels of AFP, obtained within 60 days before to 30 days after HCC diagnosis, were determined for 1064 patients and categorized as less than 10 ng/mL (18%), 10 to less than 100 ng/mL (30%), 100 to less than 1000 ng/mL (22%), or 1000 ng/mL or more (29%). Cox proportional hazard models were used to associate serum levels of AFP with mortality, adjusting for demographic features, clinical factors, and treatment. RESULTS The median survival times were significantly lower among patients with higher levels of AFP: 709 days for patients with less than 10 ng/mL, 422 days for patients with 10 to less than 100 ng/mL, 208 days for patients with 100 to less than 1000 ng/mL, and 68 days for patients with 1000 ng/mL or more. In the multivariate analysis, increased levels of AFP (10 to <100, 100 to <1000, and ≥1000) were associated significantly with increased mortality, compared with a serum AFP level of less than 10; hazard ratios were 1.50, 2.23, and 4.35, respectively. CONCLUSIONS Serum AFP level at the time of diagnosis with HCV-related HCC is an independent predictor of mortality.
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Affiliation(s)
- Gia L. Tyson
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Michael E. DeBakey Veterans Affairs Medical Center and Sections of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Zhigang Duan
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jennifer R. Kramer
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jessica A. Davila
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Peter A. Richardson
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Houston VA Health Services Research and Development Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, TX
- Michael E. DeBakey Veterans Affairs Medical Center and Sections of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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Abstract
Cholangiocarcinoma (CC) is the second most common primary hepatic malignancy after hepatocellular cancer. CC accounts for approximately 10%-25% of all hepatobiliary malignancies. There are considerable geographic and demographic variations in the incidence of CC. There are several established risk factors for CC, including parasitic infections, primary sclerosing cholangitis, biliary-duct cysts, hepatolithiasis, and toxins. Other less-established potential risk factors include inflammatory bowel disease, hepatitis C virus, hepatitis B virus, cirrhosis, diabetes, obesity, alcohol drinking, tobacco smoking, and host genetic polymorphisms. In studies where the distinction between intra- and extrahepatic CC was used, some potential risk factors seem to have a differential effect on CC, depending on the site. Therefore, the consistent use of a more refined classification would allow a better understanding of risk factors for CC.
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Affiliation(s)
- Gia L Tyson
- Section of Gastroenterology at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX 77030, USA
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