Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
Современное лечение ВИЧ: лечение ВИЧ у пациентов с вирусными гепатитами.Conte...hivlifeinfo
Современное лечение ВИЧ: лечение ВИЧ у пациентов с вирусными гепатитами.Contemporary Management of HIV. Managing HIV in Viral Hepatitis Coinfection.2016
In this downloadable slideset, David L. Wyles, MD, and Program Director Eric S. Daar, MD, review key data and optimal approaches for ART management in patients with HIV and viral hepatitis coinfection.
Format: Microsoft PowerPoint (.ppt)
File size: 1.85 MB
Estudios que evaluaron el tratamiento actual de la hepatitis C, los cuales fueron presentados en el consenso de viena en abril de 2015.
Forman parte de EASL guidelines HCV 2015.
Discussion of the current medications of chronic hepatitis treatment in the Egyptian market as well as our protocol of management in the Viral Hepatitis Treatment Centers in Egypt. Discussion of the latest recommendations of AASLD/IDSA and EASL are presented
Современное лечение ВИЧ: лечение ВИЧ у пациентов с вирусными гепатитами.Conte...hivlifeinfo
Современное лечение ВИЧ: лечение ВИЧ у пациентов с вирусными гепатитами.Contemporary Management of HIV. Managing HIV in Viral Hepatitis Coinfection.2016
In this downloadable slideset, David L. Wyles, MD, and Program Director Eric S. Daar, MD, review key data and optimal approaches for ART management in patients with HIV and viral hepatitis coinfection.
Format: Microsoft PowerPoint (.ppt)
File size: 1.85 MB
Estudios que evaluaron el tratamiento actual de la hepatitis C, los cuales fueron presentados en el consenso de viena en abril de 2015.
Forman parte de EASL guidelines HCV 2015.
Clinical Impact of New HIV Data From the 2016 Comorbidities-Adverse Drug Reac...hivlifeinfo
In this downloadable slideset, expert faculty members Todd T. Brown, MD, PhD, and Jordan E. Lake, MD, MSc, review key studies presented at the 2016 Comorbidities/Adverse Drug Reactions Workshop.
Format: Microsoft PowerPoint (.ppt)
File size: 1.37 MB
Date posted: 10/14/2016
Susanna Naggie, M.D., M.H.S., of Duke Clinical Research Center, presents "HIV/HCV Co-Infection: The Journey of a Special Population" at AIDS Clinical Rounds
This lecture is about Treatment of HCV Genotype 4 presented by Dr. Tamer Elbaz, Assistant professor of Hepatology & Gastroenterology, Cairo University.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
https://www.facebook.com/AMTH.IM
https://www.facebook.com/events/1072758396145209/
http://www.no4c.com
Современное лечение ВИЧ : АРТ как профилактика.Contemporary Management of HIV...hivlifeinfo
Contemporary Management of HIV. Antiretroviral Therapy As Prevention.2016
In this downloadable slideset, Kenneth Mayer, MD, and Program Director Eric S. Daar, MD, review key data and optimal approaches for pre- and post-exposure prophylaxis in patients at risk for HIV infection.
Format: Microsoft PowerPoint (.ppt)
File size: 2.13 MB
Аллопуринол и прогрессирование ХБП и кардиоваскулярные события. РКИ / Allopur...hivlifeinfo
Allopurinol and Progression of CKD and Cardiovascular Events- Long-term Follow-up of a Randomized Clinical Trial.Am J Kidney Dis. 2015 Apr
Background:Asymptomatic hyperuricemia increases renal and cardiovascular (CV) risk. We previously
conducted a 2-year, single-blind, randomized, controlled trial of allopurinol treatment that showed improved
estimated glomerular filtration rate and reduced CV risk.
Study Design:Post hoc analysis of a long-term follow-up after completion of the 2-year trial.
Setting & Participants:113 participants (57 in the allopurinol group and 56 in the control group) initially
followed up for 2 years and 107 participants followed up to 5 additional years.
Intervention: Continuation of allopurinol treatment, 100 mg/d, or standard treatment.
Outcome:Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or$50%
decrease in estimated estimated glomerular filtration rate) and CV events (defined as myocardial infarction,
coronary revascularization or angina pectoris, congestive heart failure, cerebrovascular disease, and peripheral vascular disease).
Results:During initial follow-up, there were 2 renal and 7 CV events in the allopurinol group compared with
6 renal and 15 CV events in the control group. In the long-term follow-up period, 12 of 56 participants taking
allopurinol stopped treatment and 10 of 51 control participants received allopurinol. During long-term follow-up,
an additional 7 and 9 participants in the allopurinol group experienced a renal or CV event, respectively, and an
additional 18 and 8 participants in the control group experienced a renal or CV event, respectively. Thus,
during the initial and long-term follow-up (median, 84 months), 9 patients in the allopurinol group had a
renal event compared with 24 patients in the control group (HR, 0.32; 95% CI, 0.15-0.69; P50.004;
adjusted for age, sex, baseline kidney function, uric acid level, and renin-angiotensin-aldosterone system
blockers). Overall, 16 patients treated with allopurinol experienced CV events compared with 23 in the
control group (HR, 0.43; 95% CI, 0.21-0.88;P50.02; adjusted for age, sex, and baseline kidney function).
Limitations:Small sample size, single center, not double blind, post hoc follow-up and analysis.
Conclusions: Long-term treatment with allopurinol may slow the rate of progression of kidney disease and
reduce CV risk.
Best Practices in the Management of HCV. 2015hivlifeinfo
In this downloadable slideset, Andrew J. Muir, MD, reviews the evidence informing current guidance and best practices on treating patients with hepatitis C.
Format: Microsoft PowerPoint (.ppt)
File size: 1.97 MB
Современное лечение ВИЧ: новые парадигмы в АРТ / Contemporary Management of H...hivlifeinfo
Набор слайдов c рассмотрением важных вопросов об АРТ первого ряда, арв-препаратами пролонгированного действия и схемами АРТ с двумя препаратами, акцент в публикации на роль новых стратегий.
HIV Alert:ART Considerations for Aging Patients.2018hivlifeinfo
In this downloadable slideset, Eric S. Daar, MD, and David A. Wohl, MD, provide expert recommendations for older patients with HIV, both in terms of ART selection and general management.
Format: Microsoft PowerPoint (.ppt)
File size: 545 KB
Date posted: 2/12/2018
Clinical Impact of New HIV Data From the 2016 Comorbidities-Adverse Drug Reac...hivlifeinfo
In this downloadable slideset, expert faculty members Todd T. Brown, MD, PhD, and Jordan E. Lake, MD, MSc, review key studies presented at the 2016 Comorbidities/Adverse Drug Reactions Workshop.
Format: Microsoft PowerPoint (.ppt)
File size: 1.37 MB
Date posted: 10/14/2016
Susanna Naggie, M.D., M.H.S., of Duke Clinical Research Center, presents "HIV/HCV Co-Infection: The Journey of a Special Population" at AIDS Clinical Rounds
This lecture is about Treatment of HCV Genotype 4 presented by Dr. Tamer Elbaz, Assistant professor of Hepatology & Gastroenterology, Cairo University.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
https://www.facebook.com/AMTH.IM
https://www.facebook.com/events/1072758396145209/
http://www.no4c.com
Современное лечение ВИЧ : АРТ как профилактика.Contemporary Management of HIV...hivlifeinfo
Contemporary Management of HIV. Antiretroviral Therapy As Prevention.2016
In this downloadable slideset, Kenneth Mayer, MD, and Program Director Eric S. Daar, MD, review key data and optimal approaches for pre- and post-exposure prophylaxis in patients at risk for HIV infection.
Format: Microsoft PowerPoint (.ppt)
File size: 2.13 MB
Аллопуринол и прогрессирование ХБП и кардиоваскулярные события. РКИ / Allopur...hivlifeinfo
Allopurinol and Progression of CKD and Cardiovascular Events- Long-term Follow-up of a Randomized Clinical Trial.Am J Kidney Dis. 2015 Apr
Background:Asymptomatic hyperuricemia increases renal and cardiovascular (CV) risk. We previously
conducted a 2-year, single-blind, randomized, controlled trial of allopurinol treatment that showed improved
estimated glomerular filtration rate and reduced CV risk.
Study Design:Post hoc analysis of a long-term follow-up after completion of the 2-year trial.
Setting & Participants:113 participants (57 in the allopurinol group and 56 in the control group) initially
followed up for 2 years and 107 participants followed up to 5 additional years.
Intervention: Continuation of allopurinol treatment, 100 mg/d, or standard treatment.
Outcome:Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or$50%
decrease in estimated estimated glomerular filtration rate) and CV events (defined as myocardial infarction,
coronary revascularization or angina pectoris, congestive heart failure, cerebrovascular disease, and peripheral vascular disease).
Results:During initial follow-up, there were 2 renal and 7 CV events in the allopurinol group compared with
6 renal and 15 CV events in the control group. In the long-term follow-up period, 12 of 56 participants taking
allopurinol stopped treatment and 10 of 51 control participants received allopurinol. During long-term follow-up,
an additional 7 and 9 participants in the allopurinol group experienced a renal or CV event, respectively, and an
additional 18 and 8 participants in the control group experienced a renal or CV event, respectively. Thus,
during the initial and long-term follow-up (median, 84 months), 9 patients in the allopurinol group had a
renal event compared with 24 patients in the control group (HR, 0.32; 95% CI, 0.15-0.69; P50.004;
adjusted for age, sex, baseline kidney function, uric acid level, and renin-angiotensin-aldosterone system
blockers). Overall, 16 patients treated with allopurinol experienced CV events compared with 23 in the
control group (HR, 0.43; 95% CI, 0.21-0.88;P50.02; adjusted for age, sex, and baseline kidney function).
Limitations:Small sample size, single center, not double blind, post hoc follow-up and analysis.
Conclusions: Long-term treatment with allopurinol may slow the rate of progression of kidney disease and
reduce CV risk.
Best Practices in the Management of HCV. 2015hivlifeinfo
In this downloadable slideset, Andrew J. Muir, MD, reviews the evidence informing current guidance and best practices on treating patients with hepatitis C.
Format: Microsoft PowerPoint (.ppt)
File size: 1.97 MB
Современное лечение ВИЧ: новые парадигмы в АРТ / Contemporary Management of H...hivlifeinfo
Набор слайдов c рассмотрением важных вопросов об АРТ первого ряда, арв-препаратами пролонгированного действия и схемами АРТ с двумя препаратами, акцент в публикации на роль новых стратегий.
HIV Alert:ART Considerations for Aging Patients.2018hivlifeinfo
In this downloadable slideset, Eric S. Daar, MD, and David A. Wohl, MD, provide expert recommendations for older patients with HIV, both in terms of ART selection and general management.
Format: Microsoft PowerPoint (.ppt)
File size: 545 KB
Date posted: 2/12/2018
This downloadable slideset summarizes key studies selected by Andrew J. Muir, MD, David R. Nelson, MD, and Norah Terrault, MD, MPH, regarding the use of investigational agents for treating hepatitis C presented at the 2015 Annual Meeting of the European Association for the Study of the Liver.
Format: Microsoft PowerPoint (.ppt)
File size: 1.99 MB
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pharynx and Clinical Correlations BY Dr.Rabia Inam Gandapore.pptx
Sat 0855-hepatitis-c-update- -park
1. 5/23/2014
1
Hepatitis C
‘ An Update’
Alnoor Ramji
Gastroenterology & Hepatology
Clinical Associate Professor
Division of Gastroenterology
University Of British Columbia
St. Paul’s Hospital Site
ramji_a@hotmail.com
Fax: 604-689-2004
Company Name Relationship
Abbvie Investigator, consultant
BI Investigator, Consultant
BMS Investigator, Consultant,
Gilead Sci. Inc Investigator, Consultant, Speaker
Hoffman LaRoche Investigator, Consultant, Speaker
Nursing Support
Janssen (J. & J.) Investigator, Consultant, Speaker
Novartis Investigator
Merck & Co. Investigator, Consultant, Speaker
Nursing Support
Vertex Pharmaceuticals Investigator, Consultant, Speaker
Disclosures
2. 5/23/2014
2
Disclosure of Commercial Support
• This program has NOT received financial support.
• This program has NOT received in-kind support.
• Potential for conflict(s) of interest:
– As prior slide, nil else.
Mitigating Potential Bias
• The presentation was reviewed by an external reviewer for
any biases.
4. 5/23/2014
4
Estimated 170 Million Persons With
HCV Infection Worldwide
• 3-4 million newly infected each yr worldwide
World Health Organization 2008. Available at: http://www.who.int/ith/es/index.html. Accessed October 28, 2009.
> 10%
2.5%-10%
1%-2.50%
Prevalence of infection
NA
1a, 1b
2a, 2b,
3a
1a, 1b
2a, 2b, 2c,
3a
4
5a
1b
1b,
6
1b,
3a
1b,
3a
3b
4
Fang et al. Clin Liver Dis. 1997.
HCV Infection:
Worldwide Genotype Distribution
1a, 1b,
2b, 3a
2a
5. 5/23/2014
5
9
HCC: hepatocellular carcinoma.
1. Remis RS. Final Report. PublicHealth Agency of Canada. 2007. Available from: http://www.phac-aspc.gc.ca/sti-its-surv-epi/model/pdf/model07-eng.pdf.
Canadian Burden of HCV
Modeled Non-exclusive Burden of HCV and Sequelae in Canada1
HCC: hepatocellular carcinoma.
1. Remis RS. Final Report. PublicHealth Agency of Canada. 2007. Available from: http://www.phac-aspc.gc.ca/sti-its-surv-epi/model/pdf/model07-eng.pdf.
10
HIV: human immunodeficiencyvirus
1. Ly et al. Ann Intern Med. 2012;156:271-278
Importance of Screening
and Treating HCV
HCV-related mortality exceeds mortality from HCV1
6. 5/23/2014
6
111. Seeff LB. Hepatology 2002;36(Suppl 1):S35-46; 2. Sherman et al. Curr Oncol. 2011;18:228-40; 3. Consensus recommendationsof the Steering Committee.
Natural History of HCV
HCV exposureHCV exposure
Chronic infectionChronic infection
Cirrhosis
20-30 yrs following infection
Cirrhosis
20-30 yrs following infection
Liver failure or decompensationLiver failure or decompensation Hepatocellular carcinoma3Hepatocellular carcinoma3
Acute infectionAcute infection60-75% are asymptomatic60-75% are asymptomatic
50-85% of patients50-85% of patients
>20% of patients3>20% of patients3
1-4% of
patients/yr
1-4% of
patients/yr
Liver transplant, deathLiver transplant, death
4% of
patients/yr3
4% of
patients/yr3
Progression To Cirrhosis
Progression to cirrhosis: based on inflammation of initial biopsy.
Yano. Hepatology 1996
7. 5/23/2014
7
• 312 patients with initially compensated cirrhosis of viral aetiology
Cirrhotic patients at risk of serious
morbidity
Benvegnù L, et al. Gut 2013; 53: 744‒9
Patients at risk
HCC 312 311 310 303 297 268 226 189 153 129 94 65 45 27 11 5
Variceal bleeding 312 312 312 309 301 269 237 190 163 131 97 71 44 29 13 7
Ascites 312 311 312 305 296 259 223 181 152 125 93 60 48 30 15 9
Encephalopathy 312 312 312 309 300 270 235 192 161 127 95 65 43 30 13 7
Cumulativerisk(%)
Years of follow-up
HCC
Variceal bleeding
Ascites
Portal-systemic encephalopathy
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
14
*Other modes of transmission include sexual, occupational, nosocomial and vertical transmission.
IDU: injection drug use.
1. Remis RS. Final Report. PublicHealth Agency of Canada. 2007. Available from: http://www.phac-aspc.gc.ca/sti-its-surv-epi/model/pdf/model07-eng.pdf.
HCV Prevalence
According to Exposure
8. 5/23/2014
8
15
CDC: Centers for Disease Control and Prevention
1. Hepatitis C: Proposed Expansion of Testing Recommendations, 2012. Available from:
http://www.cdc.gov/nchhstp/newsroom/docs/HCV-TestingFactSheetNoEmbargo508.pdf;
2. Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm?s_cid=rr6104a1_w.
CDC Recommendations
(August 2012)
*** InCanada : CLF suggests 1945-1975
→ One-time testing during a yearly checkup or as a part of insurance
blood work
In the US, >75% of adults with chronic hepatitisC are baby boomers
• 73.4% of HCV-related deaths were in persons 45-64 years of age
Screening of those born between 1945-19651,2
Virological tests to confirm
HCV infection
• Anti-HCV
• HCV-RNA
• HCV genotype
Bloodwork
• CBC
• Liver enzyme & function tests:
• ALT,AST, GGT, alkaline phosphatase,
bilirubin, INR (or PT), albumin
• NormalALT is not a contraindication to
treatment (⅓ have normal test results)2
• Creatinine
16
ALT : alanine aminotransferase; AST : aspartate transaminase;CBC: complete blood count; GGT: gamma-glutamyl transferase;HAV: hepatitisA virus; HAV-AB: hepatitisA antibody; HB: hepatitis
B; HBsAG:hepatitis B surface antigen; HBsAb: hepatitisB surface antibody; HIV: human immunodeficiencyvirus; INR: Internationalnormalized ratio; PT: Prothrombin time
1. Myers et al. Can Gastroenterol.2012;26(6):359-75; 2. Pinette et al. Public Health Agency of Canada. Available from: http://www.phac-aspc.gc.ca/hepc/pubs/pdf/hepc_guide-eng.pdf.
Evaluation:
LaboratoryTesting1,2
Abdominal ultrasound
• Test for cirrhosis and exclude
hepatocellular carcinoma
Tests to rule out coinfections
• Hepatitis A (HAV-Ab)
• Hepatitis B (HBsAg, HBsAb)
• HIV (Anti-HIV)
Tests to exclude
other causes of liver disease
9. 5/23/2014
9
Adapted from the US Food and Drug Administration, Antiviral Drugs Advisory Committee Meeting,
April 27-28, 2011, Silver Spring, MD.
SVR(%)
IFN
6 mos
PegIFN/ RBV
12 mos
IFN
12 mos
IFN/RBV
12 mos
PegIFN
12 mos
2001
1998
2011
Standard
IFN
RBV
PegIFN
1991
DAAs
PegIFN/
RBV/
DAA
IFN/RBV
6 mos
6
16
34
42
39
55
70+
0
20
40
60
80
100
The Advancing Present
2014
90
PegIFN/
RBV/
DAA
Or DAA+RBV
Impact of SVR on All-Cause Mortality by
Genotype
• VA clinical case registry (N=16,864)
• SVR associated with improved survival among HCV
genotypes 1, 2 and 3
BackusL, et al. 61st AASLD; Boston,MA; October 29-November 2, 2010; Abst. 213.
G: Genotype
HR: Hazard Ratio
CI: Confidence Interval
G1 HR
(95% CI)
P
value
G2 HR
(95% CI)
P
value
G3 HR
(95% CI)
P
value
Unadjusted
0.45
(0.39-0.52)
<0.001
0.50
(0.38-0.65)
<0.001
0.30
(0.22-0.40)
<0.001
Adjusted
0.67
(0.56-0.79)
<0.001 0.63
(0.45-0.86)
0.004
0.45
(0.32-0.65)
<0.001
10. 5/23/2014
10
0
20
40
60
80
100
SVR(%)
PegIFN/RBV
BOC or TVR +
PegIFN/RBV
38-44
67-81
Poordad F, et al. N Engl J Med. 2011;364:1195-1206.
Jacobson IM, et al. N Engl J Med. 2011;364:2405-2416.
The Present: SVR Rates With Boceprevir or
Telaprevir in Genotype 1 Treatment-Naive Patients
Triple Therapy for upto 48 Weeks
F0-2 F3-4
52-62
11. 5/23/2014
11
Adverse Event Arm 1 (PR48); n=363 (%) Arm 2 (RGT); n=368 (%) Arm 3 (BOC/PR48); n=366 (%)
Fatigue 59 52 57
Headache 42 45 43
Nausea 40 46 42
Anemia 29 49 49
Dysgeusia 18 37 43
Chills 28 36 33
Pyrexia 32 33 30
Insomnia 32 31 32
Alopecia 27 20 28
Decreased Appetite 25 26 24
Pruritis 26 23 25
Neutropenia 21 25 25
Influenza Like Illness 25 23 22
Myalgia 26 21 24
Rash 22 24 23
Irritability 24 22 22
Depression 21 23 19
Diarrhea 19 19 23
Dry Skin 18 18 22
Dyspnea 16 18 22
Dizziness 15 21 17
Most Common Treatment-Related Adverse Events*
*Reported in >20% of patients in any treatment arm and listed by decreasing overall frequency
85% of patients have
treatment shortened to 24
weeks total
Virologic Outcomes
Jacobson I, et al. EASL 2013. Abstract 1425. Reproduced with permission.
18/
31
n/
N =
5/
17
188/
229
80
60
40
20
0
100
HCVRNAUndetectable(%)
No cirrhosis Cirrhosis
82
53
58
29
SMV + P/R P/R
60/
113
Virologic Response to Simeprevir (2nd gen. protease
Inh.) + PEG-INF + Ribavirin x 24 weeks Treatment:
Genotype 1
12. 5/23/2014
12
Virologic Response to Sofosbuvir (Nuc. Inh.) + PEG-INF
+ Ribavirin x 12 weeks Treatment: Genotype 1
Lawitz E, et al. EASL 2013. Abstract 1411. Reproduced with permission.
SVR12(%)
92
80
100
80
60
40
20
0
No
Cirrhosis
Cirrhosis
252/273 43/54
SVR According to
Fibrosis Level
SVR12(%)
89
96
100
100
80
60
40
20
0
GT 1 GT 4 GT 5,6
261/292 27/28 7/7
SVR According to
Genotype
n/N =
0
20
40
60
80
100
SVR(%)
PegIFN/RBV
X 24 wks
70-80%
97%
Poordad F, et al. N Engl J Med. 2011;364:1195-1206.
Jacobson IM, et al. N Engl J Med. 2011;364:2405-2416.
Virologic Response to PEG-INF + RBV vs. Sofosbuvir
+ RBV (all-oral) in Genotype 2 and 3 Treatment-
Naive Patients
Geno 2
SOF+RBV
X 12 wks
92-94%
Geno 3
SOF+RBV
X 24 wks
Gane E, et al. J Hepatol. 2013;58(suppl 1):S3. Abstract 5.
Lawitz E, et al. N Engl J Med. 2013;368:1878-1887.
14. 5/23/2014
14
Hepatitis C: Summary
• HCV is common
• Screening for HCV is imperative
– ‘baby-boomers’ and immigrants
• Viral eradication / cure in 70-90%
• Viral eradication has a mortality benefit
15. 5/23/2014
15
Hepatitis C
‘ An Update’
Alnoor Ramji
Gastroenterology & Hepatology
Clinical Associate Professor
Division of Gastroenterology
University Of British Columbia
St. Paul’s Hospital Site
ramji_a@hotmail.com
Fax: 604-689-2004
