Thomas M. Shehab

Identification and management of hepatitis C patients in primary care clinics

OBJECTIVE:Previous survey-based research suggested that hepatitis C patients receive suboptimal care in primary care settings. The aim of our study was to define the actual level of care hepatitis C patients receive in primary care clinics.METHODS:Medical records of 229 hepatitis C antibody-positive (group 1), 229 hepatitis C antibody-negative (group 2), and 229 patients not tested for hepatitis C antibody (group 3) were reviewed to assess the indications for hepatitis C testing and the subsequent management and referral of hepatitis C antibody-positive patients diagnosed in primary care clinics. In addition, the compliance of primary care physicians with hepatitis C screening and testing guidelines was assessed.RESULTS:Only 16% of group 1 and 10% of group 2 patients were tested for hepatitis C based on physician-identified risk factors. Only 1% of group 3 patients had documented discussion of hepatitis C risk factors during their initial visit with a primary care physician. The majority of hepatitis C antibody-positive patients was appropriately evaluated in primary care clinics, and most (77%) hepatitis C RNA-positive patients with elevated liver enzymes were referred for subspecialty care. Of the 59 patients who underwent liver biopsy, 40% had bridging fibrosis or cirrhosis.CONCLUSIONS:Hepatitis C testing is rarely initiated in primary care clinics based on physician-identified risk factors. Interventions should be developed to optimize early diagnosis of hepatitis C as significant liver disease may be present despite the absence of symptoms.

Acute liver failure due to hepatic involvement by hematologic malignancy

Infiltration of the liver by secondary malignancies is a rare cause of acute liver failure. Acute liver failure caused by malignant infiltration is associated with almost 100% mortality and is typically diagnosed postmortem. Richters transformation is a well-recognized complication of chronic lymphocytic leukemia. This transformation is the progression of chronic lymphocytic leukemia to a high-grade lymphoma. We describe the case of a 64-year-old man with a history of chronic lymphocytic leukemia who presented with acute liver failure. Liver biopsy revealed hepatic infiltration by a high-grade lymphoma. The patient responded to chemotherapy with normalization of hepatic function and remained disease-free after eight months. This case represents the first report of Richters transformation presenting as acute liver failure. It also represents the fourth reported case of a patient with acute liver failure secondary to involvement by a hematopoietic malignancy that was successfully recognized and treated.

Knowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years.

OBJECTIVES:Over 2 million people in the United States are infected with hepatitis C, and there has been an explosion in knowledge regarding this disease in the last decade. Internal medicine residents must be able to identify patients at risk for hepatitis C and institute appropriate diagnostic testing and referral of these patients.METHODS:A survey regarding hepatitis C risk factors and the management of hepatitis C patients was administered on three occasions over 15 months (time 0, 1 month, and 15 months) to members of a large university-based internal medicine residency.RESULTS:During the study period 59 residents completed all three surveys. Less than half of the residents (39%) ask patients about hepatitis C risk factors. Only 58% reported that they would refer a hepatitis C antibody positive patient with elevated liver enzymes to a subspecialist on the initial survey. The residents who did not refer patients cited low response rates, high side-effect profiles, and the high cost of therapy as reasons for not referring the patient. There was significant improvement (58% vs 78%, p < 0.01) in the rate of patient referral during the 15-month study period but no substantial improvement in the other knowledge deficits.CONCLUSIONS:The knowledge base of the internal medicine residents about hepatitis C screening and management is suboptimal. New, more effective hepatitis C education programs for internal medicine residents should be initiated.

Helicobacter pylori-associated gastric MALT lymphoma in liver transplant recipients

Background. Immunosuppressed transplant recipients are at increased risk of developing several forms of malignancy. The aim of this study is to report the clinical presentation, treatment, and outcome of four liver transplant recipients with Helicobacter pylori–associated gastric mucosae-associated lymphoid tissue (MALT) lymphoma. Methods. The medical records of four liver transplant recipients with gastric MALT lymphoma were reviewed. In situ hybridization for Epstein-Barr–encoded ribonucleic acid was performed on formalin-fixed tissues. Results. All four subjects presented with abdominal symptoms at a mean of 6.1 years posttransplant. Ulcerative lesions biopsied at endoscopy demonstrated early-stage gastric MALT lymphoma with associated Helicobacter pylori gastritis. In situ hybridization revealed no evidence of Epstein-Barr virus infection in examined tissues. Antibiotic eradication of Helicobacter pylori lead to disease remission in three subjects with a mean follow-up of 21 months, and one subject failed to respond to antibiotics and radiation therapy and died from metastatic gastric adenocarcinoma. Conclusions. Early-stage, low-grade gastric MALT lymphoma that was associated with Helicobacter pylori gastritis responded to antibiotic therapy with a sustained clinical remission in three of four treated subjects. If other studies confirm a higher than expected incidence of gastric MALT lymphoma in immunosuppressed transplant recipients with Helicobacter pylori infection, screening and treating Helicobacter pylori infection in selected transplant patients may prove beneficial.

Effectiveness of interferon α-2b and ribavirin combination therapy in the treatment of naive chronic hepatitis C patients in clinical practice

BACKGROUND & AIMS Studies in many diseases have shown that efficacy in clinical trials often does not translate into effectiveness in clinical practice. The aims of this study were to determine the rate of sustained virological response (SVR) and the factors associated with SVR in therapy naive chronic hepatitis C patients treated with interferon alpha-2b and ribavirin combination therapy at a university outpatient clinic. METHODS The medical records of 153 consecutive chronic hepatitis C patients treated between June 1998 and May 2001 were reviewed. RESULTS The mean subject age was 44 years, 64% were men, 85% were white, 56% had HCV genotype 1, and 21% had cirrhosis on biopsy. The overall SVR rate was 42% (29% in genotype 1/4; 65% in genotype 2/3). Side effects resulted in interferon or ribavirin dose reductions in 22% of patients and premature termination of treatment in 10%. The SVR rate was significantly higher in the 102 patients who received >80% of the recommended dose and duration of therapy compared with the 51 patients who did not (53% vs. 20%, P = 0.00008). HCV genotype, subject race, and adherence were independently associated with SVR (P < 0.01). Although the incidence of side effects and medication adherence was similar in blacks and whites, adherent blacks had a significantly lower SVR rate (14% vs. 58%, P < 0.01). CONCLUSIONS Despite the inclusion of a broader spectrum of patients and less frequent monitoring, combination antiviral therapy in our treatment-naive chronic hepatitis C patients was of similar efficacy to that reported in large multicenter trials. In addition, our data show that medication adherence is an important predictor of SVR in an academic clinical practice.

Management of Clostridium difficile Infection : Survey of Practices and Compliance with National Guidelines Among Primary Care Physicians

Guidelines Among Primary Care Physicians • Author(s): Gayle L. Byker, MD; Marie T. Dinh, MD; Naresh T. Gunaratnam, MD; Eileen A. Robinson, MPH; Thomas M. Shehab, MD; Anurag N. Malani, MD Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 4 (April 2009), pp. 397-399 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/596200 . Accessed: 14/05/2014 19:20

Original contributionKnowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years1

Knowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years

High-dose peginterferon α-2a sustained virologic and biochemical response in chronic hepatitis C infection with cirrhosis

P a t i e n t s 271 patients (mean age 47 y, 72% men) with chronic HCV infection and biopsy-proven liver cirrhosis or bridging fibrosis. Inclusion criteria were an abnormal serum aminotransferase level twice in the previous 6 months and a liver biopsy in the previous year. Exclusion criteria were other liver diseases, decompensated cirrhosis, HIV infection, psychiatric conditions, seizure disorders, severe cardiac disease, retinopathy, cancer, low neutrophil or platelet counts, or an α-fetoprotein level > 100 ng/mL. The intention-totreat analysis included all patients.

The Endocrinologist's Version of the Betty Crocker™ Cookbook

Abstract Endocrine and Metabolic Testing Manual. Third Edition By Robert F. Dons. Boca Raton, CRC, 1998,

Current practice patterns of primary care physicians in the management of patients with hepatitis C

79.95 (304 pages), ISBN 0-8493-76060-8