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1.  Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results 
OBJECTIVES:
To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage.
METHODS:
From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up.
RESULTS:
A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days.
CONCLUSIONS:
CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.
doi:10.1038/ctg.2014.12
PMCID: PMC4218931  PMID: 25273155
2.  A Randomized Controlled Trial of Pretransplant Antiviral Therapy to Prevent Recurrence of Hepatitis C after Liver Transplantation 
Hepatology (Baltimore, Md.)  2013;57(5):1752-1762.
Hepatitis C virus (HCV) infection recurs in liver recipients who are viremic at transplantation. We conducted a randomized controlled trial to test the efficacy and safety of pre-transplant pegylated interferon alpha-2b plus ribavirin (Peg-IFN-a2b/RBV) for prevention of post-transplant HCV recurrence. Enrollees had HCV and were listed for liver transplantation, with either potential living donors or MELD upgrade for hepatocellular carcinoma. Patients with HCV genotypes (G) 1/4/6 (n=44/2/1) were randomized 2:1 to treatment (n=31) or untreated control (n=16); HCV G2/3 (n=32) were assigned to treatment. Overall, 59 were treated and 20 were not. PEGIFN alfa-2b, starting at 0.75 μg/kg/wk, and ribavirin (RBV), starting at 600 mg/d, were escalated as tolerated. Patients assigned to treatment versus control had similar baseline characteristics. Combined virologic response (CVR) included pre-transplant sustained VR (SVR12) and post-transplant VR (pTVR), defined as undetectable HCV RNA 12 weeks after end of treatment or transplant, respectively. In intent-to-treat analyses, 12 (19%) assigned to treatment and 1 (6%) assigned to control achieved CVR (p=0.29); per-protocol values were 13 (22%) and 0 (0%) (p=0.03). Among treated G1/4/6 patients, 23/30 received transplant of whom 22% had pTVR; among treated G2/3 patients 21/29 received transplant, of whom 29% had pTVR. pTVR was 0%, 18%, and 50% in patients treated for <8, 8–16, and >16 weeks, respectively (p=0.01). Serious adverse events (SAEs) occurred with similar frequency in treated versus untreated patients (68% vs. 55%, p=0.30) but the number of SAEs per patient was higher in the treated group (2.7 vs. 1.3, p=0.003).
Conclusion
Pretransplant treatment with PEGIFN/RBV prevents post-transplant recurrence of HCV in selected patients. Efficacy is higher with >16 weeks of treatment, but treatment is associated with increased risk of potentially serious complications.
doi:10.1002/hep.25976
PMCID: PMC3510348  PMID: 22821361
Peginterferon alfa-2b; Ribavirin; Cirrhosis; Waiting List; post-transplant virologic response
3.  Strategies for the Prevention of Recurrent Hepatitis B Virus Infection After Liver Transplantation 
Gastroenterology & Hepatology  2014;10(3):175-179.
Hepatitis B virus (HBV) infection is an international public health concern, and chronic infection can lead to the development of cirrhosis, liver failure, or hepatocellular carcinoma as well as the need for liver transplantation. The recurrence of HBV infection following liver transplantation was disproportionately high prior to the introduction of proper prophylactic treatment. Risk factors associated with the recurrence of HBV infection post-transplant include hepatitis B e antigen positivity, high levels of serum HBV DNA, and the presence of an antiviral drug-resistant strain prior to transplantation. The prevention of HBV recurrence began with the introduction of hepatitis B immunoglobulin (HBIG) in the early 1 990s. Nucleos(t)ide analog (NA) antiviral drugs were next to be introduced and, in combination with HBIG, are considered to be extremely effective for the prevention of recurrence. Because of concerns with HBIG, whether HBIG can be used for a short time or discontinued altogether is under debate. All of the NA antiviral drugs have been proven to be effective against HBV, at least in the pretransplant setting, and can be used safely posttransplant. Further investigation is still needed to standardize treatment in the posttransplant setting.
PMCID: PMC4014049  PMID: 24829544
Hepatitis B virus; hepatocellular carcinoma; liver transplantation; posttransplantation; risk factors; prevention
4.  Human immunodeficiency virus and nodular regenerative hyperplasia of liver: A systematic review 
World Journal of Hepatology  2014;6(1):55-63.
AIM: To investigate the diagnosis, pathogenesis, natural history, and management of nodular regenerative hyperplasia (NRH) in patients with human immunodeficiency virus (HIV).
METHODS: We performed a systematic review of the medical literature regarding NRH in patients with HIV. Inclusion criteria include reports with biopsy proven NRH. We studied the clinical features of NRH, in particular, related to its presenting manifestation and laboratory values. Combinations of the following keywords were implemented: “nodular regenerative hyperplasia”, “human immunodeficiency virus”, “noncirrhotic portal hypertension”, “idiopathic portal hypertension”, “cryptogenic liver disease”, “highly active antiretroviral therapy” and “didanosine”. The bibliographies of these studies were subsequently searched for any additional relevant publications.
RESULTS: The clinical presentation of patients with NRH varies from patients being completely asymptomatic to the development of portal hypertension – namely esophageal variceal bleeding and ascites. Liver associated enzymes are generally normal and synthetic function well preserved. There is a strong association between the occurrence of NRH and the use of antiviral therapies such as didanosine. The management of NRH revolves around treating the manifestations of portal hypertension. The prognosis of NRH is generally good since liver function is preserved. A high index of suspicion is required to make a identify NRH.
CONCLUSION: The appropriate management of HIV-infected persons with suspected NRH is yet to be outlined. However, NRH is a clinically subtle condition that is difficult to diagnose, and it is important to be able to manage it according to the best available evidence.
doi:10.4254/wjh.v6.i1.55
PMCID: PMC3953810  PMID: 24653794
Human immunodeficiency virus; Nodular regenerative hyperplasia; Ascites; Systematic review; Liver complications
5.  Feasibility of Completing an Accelerated Vaccine Series for Homeless Adults 
Journal of viral hepatitis  2009;16(9):666-673.
Homeless adults are at high risk for HBV infection. In addition to culturally-sensitive programs designed to enhance vaccination compliance, accelerated HBV vaccination (three doses over 21 days) have also been suggested to improve compliance among high-risk groups. In this paper, we examined predictors of completers of two of three doses of a HAV/HBV vaccine series, normally delivered over a six-month period, to simulate compliance with an accelerated series, dosed over four weeks. A convenience sample of 865 homeless adults were randomized into a nurse case-managed approach (NCMIT) versus standard programs with (SIT) and without tracking (SI). Each group was assessed for completion of two of the three dose HAV/HBV vaccine series as well as the full three dose vaccine series. Sixty-eight percent of the NCMIT participants completed the three dose vaccination series at 6 months compared to 61% of SIT participants and 54% of SI participants. Eighty-one percent of the NCMIT participants completed two of the vaccinations compared to 78% of SIT participants and 73% of SI participants. The NCMIT approach resulted in greater numbers of completers of two of three doses and of the full three dose vaccine series. Predictors of completers of two doses and the full three dose vaccine series are provided. A greater number of homeless persons completed two doses across the three groups compared to the three-dose vaccine series. The use of nurse case-management and tracking, coupled with an accelerated HAV/HBV vaccination schedule, may optimize vaccination compliance in homeless adults.
doi:10.1111/j.1365-2893.2009.01114.x
PMCID: PMC3780569  PMID: 19245384
HAV; HBV; HCV; homeless
6.  Severe Psychiatric Problems in Right Hepatic Lobe Donors for Living Donor Liver Transplantation 
Transplantation  2007;83(11):1506-1508.
Background
The morbidity and mortality from donation of a right hepatic lobe for living donor liver transplantation (LDLT) is an important issue for this procedure. We report the prevalence of severe psychiatric postoperative complications from the Adult-to-Adult Living Donor Liver Transplantation Cohort study (A2ALL), which was established to define the risks and benefits of LDLT for donors and recipients.
Methods
Severe psychiatric complications were evaluated in all donors from the A2ALL study who were evaluated between 1998 and February 2003.
Results
Of the 392 donors, 16 (4.1%) had one or multiple psychiatric complications, including three severe psychiatric complications (suicide, accidental drug overdose, and suicide attempt).
Conclusions
Despite extensive preoperative screening, some donors experience severe psychiatric complications, including suicide, after liver donation. Psychiatric assessment and monitoring of liver donors may help to understand and prevent such tragic events.
doi:10.1097/01.tp.0000263343.21714.3b
PMCID: PMC3762598  PMID: 17565325
Transplantation; Psychiatric; Morbidity; Liver
7.  Outcomes of Living Donor Liver Transplantation for Acute Liver Failure: The Adult-to-Adult Living Donor Liver Transplantation Cohort Study 
For acute liver failure (ALF), living donor liver transplantation (LDLT) may reduce waiting time and provide better timing compared to deceased donor liver transplantation (DDLT). However, there are concerns that a partial graft would result in reduced survival of critically ill LDLT recipients and that the rapid evolution of ALF would lead to selection of inappropriate donors. We report outcomes for ALF patients (and their donors) evaluated for LDLT between 1998 and April 2007 from the Adult-to-Adult Living Donor Liver Transplantation Cohort. Of the 1201 potential LDLT recipients, 14 had ALF, only 6 of whom had an identified cause. The median time from listing to first donor evaluation was 1.5 days, and the median time from evaluation to transplantation was 1 day. One patient recovered without liver transplant, 3 of 10 LDLT recipients died, and 1 of 3 DDLT recipients died. Five of the 10 living donors had a total of 7 posttransplant complications. In conclusion, LDLT is rarely performed for ALF, but in selected patients it may be associated with acceptable recipient mortality and donor morbidity.
doi:10.1002/lt.21500
PMCID: PMC3732478  PMID: 18756453
8.  Outcomes of Donor Evaluation in Adult-to-Adult Living Donor Liver Transplantation 
Hepatology (Baltimore, Md.)  2007;46(5):1476-1484.
The purpose of donor evaluation for adult-to-adult living donor liver transplantation (LDLT) is to discover medical conditions that could increase the donor postoperative risk of complications and to determine whether the donor can yield a suitable graft for the recipient. We report the outcomes of LDLT donor candidates evaluated in a large multicenter study of LDLT. The records of all donor candidates and their respective recipients between 1998 and 2003 were reviewed as part of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). The outcomes of the evaluation were recorded along with demographic data on the donors and recipients. Of the 1011 donor candidates evaluated, 405 (40%) were accepted for donation. The donor characteristics associated with acceptance (P < 0.05) were younger age, lower body mass index, and biological or spousal relationship to the recipient. Recipient characteristics associated with donor acceptance were younger age, lower Model for End-stage Liver Disease score, and shorter time from listing to first donor evaluation. Other predictors of donor acceptance included earlier year of evaluation and transplant center.
Conclusion
Both donor and recipient features appear to affect acceptance for LDLT. These findings may aid the donor evaluation process and allow an objective assessment of the likelihood of donor candidate acceptance.
doi:10.1002/hep.21845
PMCID: PMC3732162  PMID: 17668879
9.  Major Challenges Limiting Liver Transplantation in the United States 
Liver transplantation is the gold standard of care in patients with end-stage liver disease and those with tumors of hepatic origin in the setting of liver dysfunction. From 1988 to 2009, liver transplantation in the United States grew 3.7-fold from 1713 to 6320 transplants annually. The expansion of liver transplantation is chiefly driven by scientific breakthroughs that have extended patient and graft survival well beyond those expected 50 years ago. The success of liver transplantation is now its primary obstacle, as the pool of donor livers fails to keep pace with the growing number of patients added to the national liver transplant waiting list. This review focuses on three major challenges facing liver transplantation in the United States and discusses new areas of investigation that address each issue: 1) the need for an expanded number of useable donor organs, 2) the need for improved therapies to treat recurrent hepatitis C after transplantation and 3) the need for improved detection, risk stratification based upon tumor biology and molecular inhibitors to combat hepatocellular carcinoma.
doi:10.1111/j.1600-6143.2011.03587.x
PMCID: PMC3166424  PMID: 21672146
Liver transplantation; Donor organ shortage; Extended criteria donor; Split liver transplantation; Donation after cardiac death; Living donor liver transplantation; Hepatitis C; Hepatocellular carcinoma
10.  Outcomes in Hepatitis C Virus–Infected Recipients of Living Donor vs. Deceased Donor Liver Transplantation 
In this retrospective study of hepatitis C virus (HCV)–infected transplant recipients in the 9-center Adult to Adult Living Donor Liver Transplantation Cohort Study, graft and patient survival and the development of advanced fibrosis were compared among 181 living donor liver transplant (LDLT) recipients and 94 deceased donor liver transplant (DDLT) recipients. Overall 3-year graft and patient survival were 68% and 74% in LDLT, and 80% and 82% in DDLT, respectively. Graft survival, but not patient survival, was significantly lower for LDLT compared to DDLT (P = 0.04 and P = 0.20, respectively). Further analyses demonstrated lower graft and patient survival among the first 20 LDLT cases at each center (LDLT ≤20) compared to later cases (LDLT > 20; P = 0.002 and P = 0.002, respectively) and DDLT recipients (P < 0.001 and P = 0.008, respectively). Graft and patient survival in LDLT >20 and DDLT were not significantly different (P = 0.66 and P = 0.74, respectively). Overall, 3-year graft survival for DDLT, LDLT >20, and LDLT ≤20 were 80%, 79% and 55%, with similar results conditional on survival to 90 days (84%, 87% and 68%, respectively). Predictors of graft loss beyond 90 days included LDLT ≤20 vs. DDLT (hazard ratio [HR] = 2.1, P = 0.04), pretransplant hepatocellular carcinoma (HCC) (HR = 2.21, P = 0.03) and model for end-stage liver disease (MELD) at transplantation (HR = 1.24, P = 0.04). In conclusion, 3-year graft and patient survival in HCV-infected recipients of DDLT and LDLT >20 were not significantly different. Important predictors of graft loss in HCV-infected patients were limited LDLT experience, pretransplant HCC, and higher MELD at transplantation.
doi:10.1002/lt.20995
PMCID: PMC3155862  PMID: 17192908
11.  Effects of a Nurse-Managed Program on Hepatitis A and B Vaccine Completion Among Homeless Adults 
Nursing research  2009;58(1):13-22.
Background
Hepatitis B virus (HBV) infection constitutes a major health problem for homeless persons. Ability to complete an HBV vaccination series is complicated by the need to prioritize competing needs, such as addiction issues, safe places to sleep, and food, over health concerns.
Objectives
The objectives of this study were to evaluate the effectiveness of a nurse-case-managed intervention compared with that of two standard programs on completion of the combined hepatitis A virus (HAV) and HBV vaccine series among homeless adults and to assess socio-demographic factors and risk behaviors related to the vaccine completion.
Methods
A randomized, three-group, prospective, quasi-experimental design was conducted with 865 homeless adults residing in homeless shelters, drug rehabilitation sites, and outdoor areas in the Skid Row area of Los Angeles. The programs included (a) nurse-case-managed sessions plus targeted hepatitis education, incentives, and tracking (NCMIT); (b) standard targeted hepatitis education plus incentives and tracking (SIT); and (c) standard targeted hepatitis education and incentives only (SI).
Results
Sixty-eight percent of the NCMIT participants completed the three-series vaccine at 6 months, compared with 61% of SIT participants and 54% of SI participants. NCMIT participants had almost 2 times greater odds of completing vaccination than those of participants in the SI program. Completers were more likely to be older, to be female, to report fair or poor health, and not to have participated in a self-help drug treatment program. Newly homeless White adults were significantly less likely than were African Americans to complete the vaccine series.
Discussion
The use of vaccination programs incorporating nurse case management and tracking is critical in supporting adherence to completion of a 6-month HAV/HBV vaccine. The finding that White homeless persons were the least likely to complete the vaccine series suggests that programs tailored to address their unique cultural issues are needed.
doi:10.1097/NNR.0b013e3181902b93
PMCID: PMC3076026  PMID: 19092551
HAV/HBV vaccine completion; homeless adults; nurse case managed program; substance abuse
12.  Management of Hepatitis C Antiviral Therapy Adverse Effects 
Current Hepatitis Reports  2010;10(1):33-40.
Hepatitis C is one of the leading causes of liver disease in the United States, affecting more than 4 million individuals. The current treatment regimen involves pegylated interferon in combination with ribavirin. Although antiviral treatment has been associated with a greater than 50% sustained viral response rate, the adverse effects have proven to be detrimental to quality of life and therapy adherence, and consequently lead to lower sustained viral response rates. This article identifies the most frequently described complications associated with pegylated interferon and ribavirin. The active management of these complications is discussed, including both preventive and empiric treatments.
doi:10.1007/s11901-010-0078-7
PMCID: PMC3030745  PMID: 21423320
Hepatitis C virus; Pegylated interferon; Ribavirin; Side effects; Management
13.  Pegylated Interferon and Ribavirin Dosing Strategies to Enhance Sustained Virologic Response 
Current Hepatitis Reports  2010;9(3):147-154.
Hepatitis C virus (HCV) affects about 170 million people worldwide and is the most common chronic blood borne infection in the United States. Since the advent of blood screening protocols in the early 1990s, injection drug use has become the leading cause of infection. Hepatitis C can have both hepatic and nonhepatic manifestations of infection. Hepatic manifestations include hepatic fibrosis, cirrhosis, liver cancer, and liver failure. The standard treatment for chronic HCV is combination therapy with pegylated interferon-α and ribavirin. Although pegylated interferon and ribavirin has been used against HCV for close to a decade, advances in therapy have centered on doses and treatment durations. There has been increasing interest in applying on-treatment response or viral kinetics to predict antiviral response rates and shape therapeutic intervention. Protease inhibitors are a promising adjuvant to combination therapy, but their efficacy and safety are still under investigation.
doi:10.1007/s11901-010-0047-1
PMCID: PMC2895868  PMID: 20676191
Hepatitis C virus; Chronic hepatitis C; Pegylated interferon-α; Ribavirin; Viral kinetics; Protease inhibitors
14.  A comparison of hepatitis B viral markers of patients in different clinical stages of chronic infection 
Hepatology International  2010;4(2):516-522.
Purpose
Hepatitis B viral markers may be useful for predicting outcomes such as liver-related deaths or development of hepatocellular carcinoma. We determined the frequency of these markers in different clinical stages of chronic hepatitis B infection.
Methods
We compared baseline hepatitis B viral markers in 317 patients who were enrolled in a prospective study and identified the frequency of these tests in immune-tolerant (IT) patients, in inactive carriers, and in patients with either hepatitis B e antigen (HBeAg)-positive or HBeAg-negative chronic hepatitis or cirrhosis.
Results
IT patients were youngest (median age 27 years) and HBeAg-negative patients with cirrhosis were oldest (median age 58 years) (p = 0.03 to <0.0001). The male to female ratio was similar both in IT patients and in inactive carriers, but there was a male preponderance both in patients with chronic hepatitis and in patients with cirrhosis (p < 0.0001). The A1896 precore mutants were most prevalent in inactive carriers (36.4%) and HBeAg-negative patients with chronic hepatitis (38.8%; p < 0.0001), and the T1762/A1764 basal core promoter mutants were most often detected in HBeAg-negative patients with cirrhosis (65.1%; p = 0.02). Genotype A was detected only in 5.3% of IT patients, and genotype B was least often detected in both HBeAg-Positive patients with chronic hepatitis and cirrhosis (p = 0.03). The hepatitis B viral DNA levels were lowest in inactive carriers (2.69 log10 IU/mL) and highest in IT patients (6.80 log10 IU/mL; p = 0.02 to <0.0001). At follow-up, HBeAg-positive and HBeAg-negative patients with cirrhosis accounted for 57 of 64 (89.1%) liver-related deaths (p < 0.0001).
Conclusion
Differences in baseline hepatitis B viral markers were detected in patients in various clinical stages of hepatitis B virus infection. HBeAg-positive and HBeAg-negative patients with cirrhosis accounted for the majority of the liver-related fatalities.
doi:10.1007/s12072-010-9179-1
PMCID: PMC2896649  PMID: 20827410
HBeAg; Precore mutant; Basal core promoter mutant; Genotype; HBV DNA; Immune tolerant; Inactive carriers; Chronic hepatitis; Cirrhosis
15.  A comparison of hepatitis B viral markers of patients in different clinical stages of chronic infection 
Hepatology International  2010;4(2):516-522.
Purpose
Hepatitis B viral markers may be useful for predicting outcomes such as liver-related deaths or development of hepatocellular carcinoma. We determined the frequency of these markers in different clinical stages of chronic hepatitis B infection.
Methods
We compared baseline hepatitis B viral markers in 317 patients who were enrolled in a prospective study and identified the frequency of these tests in immune-tolerant (IT) patients, in inactive carriers, and in patients with either hepatitis B e antigen (HBeAg)-positive or HBeAg-negative chronic hepatitis or cirrhosis.
Results
IT patients were youngest (median age 27 years) and HBeAg-negative patients with cirrhosis were oldest (median age 58 years) (p = 0.03 to <0.0001). The male to female ratio was similar both in IT patients and in inactive carriers, but there was a male preponderance both in patients with chronic hepatitis and in patients with cirrhosis (p < 0.0001). The A1896 precore mutants were most prevalent in inactive carriers (36.4%) and HBeAg-negative patients with chronic hepatitis (38.8%; p < 0.0001), and the T1762/A1764 basal core promoter mutants were most often detected in HBeAg-negative patients with cirrhosis (65.1%; p = 0.02). Genotype A was detected only in 5.3% of IT patients, and genotype B was least often detected in both HBeAg-Positive patients with chronic hepatitis and cirrhosis (p = 0.03). The hepatitis B viral DNA levels were lowest in inactive carriers (2.69 log10 IU/mL) and highest in IT patients (6.80 log10 IU/mL; p = 0.02 to <0.0001). At follow-up, HBeAg-positive and HBeAg-negative patients with cirrhosis accounted for 57 of 64 (89.1%) liver-related deaths (p < 0.0001).
Conclusion
Differences in baseline hepatitis B viral markers were detected in patients in various clinical stages of hepatitis B virus infection. HBeAg-positive and HBeAg-negative patients with cirrhosis accounted for the majority of the liver-related fatalities.
doi:10.1007/s12072-010-9179-1
PMCID: PMC2896649  PMID: 20827410
HBeAg; Precore mutant; Basal core promoter mutant; Genotype; HBV DNA; Immune tolerant; Inactive carriers; Chronic hepatitis; Cirrhosis
16.  Refractory Ascites 
Gastroenterology & Hepatology  2009;5(9):647-656.
Refractory ascites is defined as ascites that does not recede or that recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment. To date, there is no approved medical therapy specifically for refractory ascites. Management of these patients is based upon procedures such as large-volume paracentesis and transjugular intrahepatic portosystemic shunts (TIPS), which temporarily alleviate symptoms but are not curative. These patients have a poor prognosis and are at risk for a series of complications that are associated with the condition or are secondary to therapy. The most common complications include spontaneous bacterial peritonitis, hepatic hydrothorax, spontaneous bacterial empyema, and umbilical hernia. The predicted survival rate is as low as 50% at 1 year, and prognosis worsens as patients present with comorbidities such as hepatorenal syndrome, renal failure, and hepatocellular carcinoma. The only curative treatment is liver transplantation, though current studies have shown that TIPS also increases survival.
PMCID: PMC2886420
Refractory ascites; paracentesis; TIPS; spontaneous bacterial peritonitis; spontaneous bacterial empyema
17.  An economic assessment of pre-vaccination screening for hepatitis A and B. 
Public Health Reports  2003;118(6):550-558.
OBJECTIVE: The availability of a single vaccine active against hepatitis A and B may facilitate prevention of both infections, but complicates the question of whether to conduct pre-vaccination screening. The authors examined the cost-effectiveness of pre-vaccination screening for several populations: first-year college students, military recruits, travelers to hepatitis A-endemic areas, patients at sexually transmitted disease clinics, and prison inmates. METHODS: Three prevention protocols were examined: (1) screen and defer vaccination until serology results are known; (2) screen and begin vaccination immediately to avoid a missed vaccination opportunity; and (3) vaccinate without screening. Data describing pre-vaccination immunity, vaccine effectiveness, and prevention costs borne by the health system (i.e., serology, vaccine acquisition, and administration) were derived from published literature and U.S. government websites. Using spreadsheet models, the authors calculated the ratio of prevention costs to the number of vaccine protections conferred. RESULTS: The vaccinate without screening protocol was most cost-effective in nine of 10 analyses conducted under baseline assumptions, and in 69 of 80 sensitivity analyses. In each population considered, vaccinate without screening was less costly than and at least equally as effective as screen and begin vaccination. The screen and defer vaccination protocol would reduce costs in seven populations, but effectiveness would also be lower. CONCLUSIONS: Unless directed at vaccination candidates with the highest probability of immunity, pre-vaccination screening for hepatitis A and B immunity is not cost-effective. Balancing cost reduction with reduced effectiveness, screen and defer may be preferred for older travelers and prison inmates.
PMCID: PMC1497596  PMID: 14563912

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