Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

[email protected]

On Twitter @richpizzi

The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

[email protected]

On Twitter @richpizzi

The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

[email protected]

On Twitter @richpizzi

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

LAKE BUENA VISTA, FLA. – Many clinicians dread discussing a screening test that suggests patients have not been compliant with their scheduled pain medication. Nevertheless, Edwin A. Salsitz, MD, said, those tests should be embraced for their value.

“Every single body that publishes guidelines regarding the use of opioids for chronic pain calls for the use of specimen testing. It is a standard of care,” reported Dr. Salsitz, medical director of office-based opioid therapy at Mount Sinai Beth Israel in New York.

“Urine drug testing is being performed for the patient, not to the patient, and it should increase, not decrease communication,” Dr. Salsitz said at the meeting. Most of all, “just because a urine test is positive, don’t dismiss the patient. That is not the point.”

Among biologic specimens used to monitor compliance with treatment plans, urine is the one most commonly performed, according to Dr. Salsitz, but it is not the only one. A growing number of centers are moving to saliva tests, he said, and those have several advantages. For example, collection of specimens is easier and opportunities for cheating are reduced.

Hair specimens pose an even lower risk of cheating, and they have a much longer drug detection window. Relative to blood and saliva specimens, which become positive almost immediately after drug exposures but lose validity within 24-48 hours, hair specimens do not become positive for days but still can prove positive for drugs months after exposure. Urine samples, which do not become positive for several hours after a drug exposure, typically remain reliable for several days.

Urine testing remains the most widely used screening tool and also the focus of most efforts to cheat, Dr. Salsitz said. He said an Internet search for strategies used to cheat on urine drug testing would generate pages of recommendations. For men, options include a prosthetic penis that permits cheating even for observed urine samples. Strapped to the body, the lifelike prosthetic includes a place to store a sample of urine that can be excreted by the prosthetic into a collection receptacle. This type of sophisticated effort to “game the system” can be a challenge when managing patients most intent on noncompliance.

For periodic drug screening at his own center, Dr. Salsitz reported that he often uses point-of-care urine testing. Although he conceded that those kits, which employ a dipstick technology similar to pregnancy tests, are not as reliable as laboratory analyses of urine samples, they are relatively inexpensive and provide immediate results. However, laboratory testing still may be needed if the patient denies drug use after a positive result or if a more comprehensive analysis of drug exposures is needed.

“I would not make a major clinical decision on the basis of point-of-care testing alone,” Dr. Salsitz reported. Indeed, he expressed caution about relying on specimen screening alone when other reasons exist to be concerned about noncompliance.

“It is unwise to accept at face value a urinary drug test report that seems to support an impression of clinical stability if, in fact, there is other clinical evidence to the contrary,” Dr. Salsitz said.

Successful screening strategies for noncompliance require an objective, nonjudgmental, and systematic approach, Dr. Salsitz said. Implementing a uniform policy common for all patients reduces the risk of conveying a sense of distrust. Indeed, uniform testing circumvents bias that could, for example, permit well-liked patients to avoid detection of noncompliance.

“In one study, reliance on aberrant behavior alone to trigger urine drug testing was estimated to miss almost half of those using drugs problematically,” Dr. Salsitz reported. However, he noted that the same study suggested that urine screening by itself also was insufficient. Rather, he said, “Monitoring urine and behavior identified more patients with inappropriate drug taking than either alone.”

Emphasizing that biologic specimen screening is “just a tool” in managing chronic pain patients on opioids, Dr. Salsitz reported several cases where he verified false-positive results with a point-of-care urine test using his own specimen, thereby validating claims made to him by patients. In one case, results were positive after he consumed a poppy bagel. “When the patient stopped eating poppy seed bagels, he stopped having positive tests,” Dr. Salsitz reported. In another case, a positive result occurred after consuming a commercially available tea made with coca leaves.

Dr. Salsitz reports that he has no relevant financial relationships to disclose. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

AGA Resource
Through the HCV Clinical Service Line, AGA offers tools to help you become more efficient, understand quality standards and improve the process of care for patients. Visit http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c to learn more.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

AGA Resource
Through the HCV Clinical Service Line, AGA offers tools to help you become more efficient, understand quality standards and improve the process of care for patients. Visit http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c to learn more.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

AGA Resource
Through the HCV Clinical Service Line, AGA offers tools to help you become more efficient, understand quality standards and improve the process of care for patients. Visit http://www.gastro.org/patient-care/conditions-diseases/hepatitis-c to learn more.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log₁₀ copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log₁₀ IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log₁₀ U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

A Chinese study found a robust relationship between Helicobacter pylori infection and chronic hepatitis B. This is especially true during hepatitis B virus progression.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

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