Publications by authors named "Chris Estes"

33 Publications

Global prevalence of hepatitis C virus in women of childbearing age in 2019: a modelling study.

Lancet Gastroenterol Hepatol 2021 03 28;6(3):169-184. Epub 2021 Jan 28.

Center for Disease Analysis Foundation, Lafayette, CO, USA. Electronic address:

Background: Treatment for infection with hepatitis C virus (HCV) during pregnancy has not yet been approved; however, interventions specifically targeting women, especially those of childbearing age (15-49 years), could prevent vertical transmission and community spread. To assess the impact of such interventions, improved prevalence estimates in this group are needed. We aimed to estimate the global prevalence of viraemic HCV in 2019 among women of childbearing age.

Methods: In this modelling study, we used previously developed models for 110 countries inputted with country-specific demographic and HCV epidemiology data. We did a literature review, searching PubMed, Embase, and grey literature for studies published between Jan 1, 2000, and June 30, 2018, reporting HCV antibody or viraemic prevalence in women of childbearing age. Studies from the literature review and studies in models were compared by use of a data quality scoring system and models were updated, as appropriate, when a better study was identified. We used these HCV disease burden models to calculate the 2019 prevalence of viraemic HCV in women of childbearing age. In countries without a model, prevalence was extrapolated by Global Burden of Disease (GBD) region.

Findings: An estimated 14 860 000 (95% uncertainty interval [UI] 9 667 000-18 282 000) women aged 15-49 years had HCV infection worldwide in 2019, corresponding to a viraemic prevalence of 0·78% (95% UI 0·62-0·86). Globally, HCV prevalence increased with age, rising from 0·25% (95% UI 0·20-0·27) in women aged 15-19 years to 1·21% (0·97-1·34) in women aged 45-49 years. China (16% of total infections) and Pakistan (15%) had the greatest numbers of viraemic infections, but viraemic prevalence was highest in Mongolia (5·14%, 95% CI 3·46-6·28) and Burundi (4·91%, 3·80-18·75). Of the countries with 500 cases or more, viraemic prevalence was lowest in Chile (0·07%, 95% UI 0·04-0·12). Among the GBD regions, eastern Europe had the highest viraemic prevalence (3·39%, 95% UI 1·88-3·54). By WHO region, the Eastern Mediterranean region had the highest viraemic prevalence (1·75%, 95% UI 1·26- 1·90).

Interpretation: Most research on HCV disease burden among women aged 15-49 years focuses on pregnant women. Using modelling, this analysis provides global and national estimates of HCV prevalence in all women of childbearing age. These data can inform preconception test-and-treat strategies to reduce vertical transmission and total disease burden.

Funding: Gilead Sciences, John C Martin Foundation, private donors.
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http://dx.doi.org/10.1016/S2468-1253(20)30359-9DOI Listing
March 2021

Impact of COVID-19 on global HCV elimination efforts.

J Hepatol 2021 01 7;74(1):31-36. Epub 2020 Aug 7.

Gastroenterology and Hepatology Unit, Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.

Background & Aims: Coronavirus disease 2019 (COVID-19) has placed a significant strain on national healthcare systems at a critical moment in the context of hepatitis elimination. Mathematical models can be used to evaluate the possible impact of programmatic delays on hepatitis disease burden. The objective of this analysis was to evaluate the incremental change in HCV liver-related deaths and liver cancer, following a 3-month, 6-month, or 1-year hiatus in hepatitis elimination programs.

Methods: Previously developed models were adapted for 110 countries to include a status quo or 'no delay' scenario and a '1-year delay' scenario assuming significant disruption in interventions (screening, diagnosis, and treatment) in the year 2020. Annual country-level model outcomes were extracted, and weighted averages were used to calculate regional (WHO and World Bank Income Group) and global estimates from 2020 to 2030. The incremental annual change in outcomes was calculated by subtracting the 'no-delay' estimates from the '1-year delay' estimates.

Results: The '1-year delay' scenario resulted in 44,800 (95% uncertainty interval [UI]: 43,800-49,300) excess hepatocellular carcinoma cases and 72,300 (95% UI: 70,600-79,400) excess liver-related deaths, relative to the 'no-delay' scenario globally, from 2020 to 2030. Most missed treatments would be in lower-middle income countries, whereas most excess hepatocellular carcinoma and liver-related deaths would be among high-income countries.

Conclusions: The impact of COVID-19 extends beyond the direct morbidity and mortality associated with exposure and infection. To mitigate the impact on viral hepatitis programming and reduce excess mortality from delayed treatment, policy makers should prioritize hepatitis programs as soon as it becomes safe to do so.

Lay Summary: COVID-19 has resulted in many hepatitis elimination programs slowing or stopping altogether. A 1-year delay in hepatitis diagnosis and treatment could result in an additional 44,800 liver cancers and 72,300 deaths from HCV globally by 2030. Countries have committed to hepatitis elimination by 2030, so attention should shift back to hepatitis programming as soon as it becomes appropriate to do so.
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http://dx.doi.org/10.1016/j.jhep.2020.07.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411379PMC
January 2021

Burden of nonalcoholic fatty liver disease in Canada, 2019-2030: a modelling study.

CMAJ Open 2020 Apr-Jun;8(2):E429-E436. Epub 2020 Jun 9.

Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo.

Background: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) account for a growing proportion of liver disease cases, and there is a need to better understand future disease burden. We used a modelling framework to forecast the burden of disease of NAFLD and NASH for Canada.

Methods: We used a Markov model to forecast fibrosis progression from stage F0 (no fibrosis) to stage F4 (compensated cirrhosis) and subsequent progression to decompensated cirrhosis, hepatocellular carcinoma, liver transplantation and liver-related death among Canadians with NAFLD from 2019 to 2030. We used historical trends for obesity prevalence among adults to estimate longitudinal changes in the number of incident NAFLD cases.

Results: The model projected that the number of NAFLD cases would increase by 20% between 2019 and 2030, from an estimated 7 757 000 cases to 9 305 000 cases. Increases in advanced fibrosis cases were relatively greater, as the number of model-estimated prevalent stage F3 cases would increase by 65%, to 357 000, and that of prevalent stage F4 cases would increase by 95%, to 195 000. Estimated incident cases of hepatocellular carcinoma and decompensated cirrhosis would increase by up to 95%, and the number of annual NAFLD-related deaths would double, to 5600.

Interpretation: Increasing rates of obesity translate into increasing NAFLD-related cases of cirrhosis and hepatocellular carcinoma and related mortality. Prevention efforts should be aimed at reducing the incidence of NAFLD and slowing fibrosis progression among those already affected.
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http://dx.doi.org/10.9778/cmajo.20190212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286622PMC
February 2021

Assessment of Treatment Strategies to Achieve Hepatitis C Elimination in Canada Using a Validated Model.

JAMA Netw Open 2020 05 1;3(5):e204192. Epub 2020 May 1.

British Columbia Centre for Disease Control, Vancouver, Canada.

Importance: Achievement of the World Health Organization (WHO) target of eliminating hepatitis C virus (HCV) by 2030 will require an increase in key services, including harm reduction, HCV screening, and HCV treatment initiatives in member countries. These data are not available for Canada but are important for informing a national HCV elimination strategy.

Objective: To use a decision analytical model to explore the association of different treatment strategies with HCV epidemiology and HCV-associated mortality in Canada and to assess the levels of service increase needed to meet the WHO elimination targets by 2030.

Design, Setting, And Participants: Study participants in this decision analytical model included individuals with hepatitis C virus infection in Canada. Five HCV treatment scenarios (optimistic, very aggressive, aggressive, gradual decrease, and rapid decrease) were applied using a previously validated Markov-type mathematical model. The optimistic and very aggressive treatment scenarios modeled a sustained annual treatment of 10 200 persons and 14 000 persons, respectively, from 2018 to 2030. The aggressive, gradual decrease, and rapid decrease scenarios assessed decreases in treatment uptake from 14 000 persons to 10 000 persons per year, 12 000 persons to 8500 persons per year, and 12 000 persons to 4500 persons per year, respectively, between 2018 and 2030.

Main Outcomes And Measures: Hepatitis C virus prevalence and HCV-associated health outcomes were assessed for each of the 5 treatment scenarios with the goal of identifying strategies to achieve HCV elimination by 2030.

Results: An estimated mean 180 142 persons (95% CI, 122 786-196 862 persons) in Canada had chronic HCV infection at the end of 2017. The optimistic and gradual decrease scenarios estimated a decrease in HCV prevalence from 180 142 persons to 37 246 persons and 37 721 persons, respectively, by 2030. Relative to 2015, this decrease in HCV prevalence was associated with 74%, 69%, and 69% reductions in the prevalence of decompensated cirrhosis, hepatocellular carcinoma, and liver-associated mortality, respectively, leading to HCV elimination by 2030. More aggressive treatment uptake (very aggressive scenario) could result in goal achievement up to 3 years earlier than 2030, although a rapid decrease in the initiation of treatment (rapid decrease scenario) would preclude Canada from reaching the HCV elimination goal by 2030.

Conclusions And Relevance: The study findings suggest that Canada could meet the WHO goals for HCV elimination by 2030 by sustaining the current national HCV treatment rate during the next decade. This target will not be achieved if treatment uptake is allowed to decrease rapidly.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.4192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203608PMC
May 2020

Modelling NAFLD disease burden in four Asian regions-2019-2030.

Aliment Pharmacol Ther 2020 04 4;51(8):801-811. Epub 2020 Mar 4.

Lafayette, CO, USA.

Background: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) account for an increasing proportion of liver disease in the Asia-Pacific region. Many areas in the region are experiencing epidemics of metabolic syndrome among rapidly ageing populations.

Aims: To estimate using modelling the growth in NAFLD populations, including cases with significant fibrosis that are most likely to experience advanced liver disease and related mortality.

Methods: A disease progression model was used to summarise and project fibrosis progression among the NAFLD populations of Hong Kong, Singapore, South Korea and Taiwan. For each area, changes in the adult prevalence of obesity was used to extrapolate long-term trends in NAFLD incidence.

Results: In the areas studied, prevalent NAFLD cases were projected to increase 6%-20% during 2019-2030, while prevalent NASH cases increase 20%-35%. Incident cases of hepatocellular carcinoma are projected to increase by 65%-85%, while incident decompensated cirrhosis cases increase 65%-100% by 2030. Likewise, NAFLD-related mortality is projected to increase between 65% and 100% from 2019 to 2030. NAFLD disease burden is expected to increase alongside rising trends in metabolic syndrome and obesity among populations in the region. This leads to more cases of advanced liver disease and associated mortality.

Conclusions: Preventing the growth of diabetic and obese populations will be a key factor in reducing ongoing increases in NAFLD-related disease burden in the Asia-Pacific region.
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http://dx.doi.org/10.1111/apt.15673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7154715PMC
April 2020

Nonalcoholic fatty liver disease burden: Australia, 2019-2030.

J Gastroenterol Hepatol 2020 Sep 26;35(9):1628-1635. Epub 2020 Feb 26.

School of Medicine, University of Sydney, Sydney, New South Wales, Australia.

Background And Aim: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) account for a large and growing proportion of liver disease burden globally. The burden of NAFLD/NASH manifests in increasing levels of advanced liver disease and primary liver cancer in Australia. A Markov model was used to forecast NAFLD burden in Australia through 2030.

Methods: A model was used to estimate fibrosis progression, primary liver cancer, and liver deaths among the Australian NAFLD population, with changes in incident NAFLD cases based on long-term trends for changes in the prevalence of obesity. Published estimates and surveillance data were applied to build and validate the model projections, including surveillance data for the incidence of liver cancer.

Results: Prevalent NAFLD cases were projected to increase 25% from the current burden (5 551 000 [4 748 000-6 306 000] cases in 2019) to 7 024 000 [5 838 000-7 886 000] cases in 2030. The projected increase in the number of NASH cases (40%) was greater than that of NAFLD cases. Incident cases of advanced liver disease are projected to increase up to 85% by 2030, and incident NAFLD liver deaths are estimated to increase 85% from 1900 (1100-3300) deaths in 2019 to 3500 (2100-6100) deaths in 2030.

Conclusions: Restraining growth of the obese and diabetic populations, along with potential therapeutic options, will be essential for mitigating disease burden.
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http://dx.doi.org/10.1111/jgh.15009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540570PMC
September 2020

Global prevalence of hepatitis C virus in children in 2018: a modelling study.

Lancet Gastroenterol Hepatol 2020 04 16;5(4):374-392. Epub 2020 Jan 16.

Department of Pediatrics and Clinical Research Centre, Ain Shams University, Cairo, Egypt.

Background: Hepatitis C virus (HCV) prevalence estimates for adults and high-risk groups have been widely published, but the disease burden in children is poorly understood. Direct-acting antiviral drugs, which are considered to be highly effective curative therapies for HCV, are now approved for paediatric patients as young as 3 years. Reliable prevalence estimates for this population are needed to inform scale-up of treatment and national strategies. This analysis combines past modelling and epidemiological work in 104 countries and territories to estimate global HCV prevalence in children in 2018.

Methods: In this modelling study, a comprehensive literature review for articles published between Jan 1, 2000, and March 31, 2019, was used to determine historical HCV prevalence estimates in children in all 249 countries and territories of the world. We identified published HCV prevalence estimates for children aged 0-18 years who are not at high risk of HCV infection in 39 countries and territories and inputted them into dynamic Markov disease-burden models to estimate viraemic HCV prevalence in 2018. For 25 of them, which had complete data, available information on HCV prevalence in children was used to build regression models to predict paediatric prevalence in an additional 65 countries and territories that had country-specific or territory-specific data about predictors only. Regression models were created for each 5-year paediatric age cohort from 0 to 19 years, considering several predictor variables. The data and forecasts from the 104 countries and territories for which data were available were used to calculate HCV prevalence by Global Burden of Disease region, which was then applied to the remaining 145 countries and territories to generate a global estimate.

Findings: The global estimate for viraemic prevalence in the paediatric population aged 0-18 years was 0·13% (95% uncertainty interval 0·08-0·16), corresponding to 3·26 million (2·07-3·90) children with HCV in 2018. HCV prevalence increased with age in all countries and territories. HCV prevalence in women of childbearing age was the strongest predictor of HCV prevalence in children aged 0-4 years (p<0·0001). Prevalence of HCV in adults was significantly associated with HCV prevalence in children aged 5-19 years (p<0·0001), and the proportion of HCV infections in people who inject drugs was significantly associated with HCV prevalence in children aged 15-19 years (p=0·036).

Interpretation: Most studies on HCV prevalence in children focus on high-risk groups and highly endemic geographic areas. Our analysis provides global prevalence estimates of HCV in the paediatric population. Treatment in paediatric patients requires different clinical and population health management optimisation than in adults. Because of this heterogeneity, country-specific or territory-specific and age-specific HCV prevalence estimates can help countries and territories to improve national HCV elimination strategies.

Funding: Gilead Sciences, John C Martin Foundation, and private donors.
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http://dx.doi.org/10.1016/S2468-1253(19)30385-1DOI Listing
April 2020

Nonalcoholic fatty liver disease burden - Switzerland 2018-2030.

Swiss Med Wkly 2019 Dec 17;149:w20152. Epub 2019 Dec 17.

Center for Disease Analysis, Lafayette, Colorado, USA 0017208903817 | 0017204423453.

As a result of epidemic levels of obesity and diabetes mellitus, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) will contribute to increases in the liver-related disease burden in Switzerland. A Markov model was built to quantify fibrosis progression among the NAFLD and NASH populations, and predict disease burden up to 2030. Long-term trending of NAFLD prevalence was based on changes in the prevalence of adult obesity. Published estimates and surveillance data were applied to build and validate the model projections. The prevalence of NAFLD increased up to 2030 in tandem with projected increases in adult obesity. By 2030, there were an estimated 2,234,000 (1,918,000–2,553,000) NAFLD cases, or 24.3% (20.9–27.8%) of the total Swiss population (all ages). Increases in NASH cases were relatively greater than NAFLD cases. Incident cases of advanced liver disease are projected to increase by approximately 40% by 2030, and incident NAFLD liver deaths to increase from 580 deaths in 2018 to 820 deaths in 2030. Continued growth in obesity, in combination with an aging population, will result in increasing number of cases of advanced liver disease and mortality related to NAFLD and NASH. Slowing the growth in obesity and metabolic syndrome, along with future potential therapies, are required to reduce liver disease burden.  .
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http://dx.doi.org/10.4414/smw.2019.20152DOI Listing
December 2019

Australia on track to achieve WHO HCV elimination targets following rapid initial DAA treatment uptake: A modelling study.

J Viral Hepat 2019 01 14;26(1):83-92. Epub 2018 Nov 14.

Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Subsidized direct-acting antiviral (DAA) treatment recently became available to all adults living with chronic hepatitis C virus (HCV) in Australia. Based on rapid uptake (32 600 people initiated DAA in 2016), we estimated the impact on HCV epidemiology and mortality in Australia and determined if Australia can meet the WHO HCV elimination targets by 2030. Using a mathematical model, we simulated pessimistic, intermediate and optimistic DAA treatment scenarios in Australia over 2016-2030. We assumed treatment and testing rates were initially higher for advanced fibrosis and the same across HCV transmission risk level sub-populations. We also assumed constant testing rates after 2016. We compared the results to the 2015 level and a counterfactual (IFN-based) scenario. During 2016-2030, we estimated an intermediate DAA treatment scenario (2016, 32 600 treated; 2017, 21 370 treated; 2018 17 100 treated; 2019 and beyond, 13 680 treated each year) would avert 40 420 new HCV infections, 13 260 liver-related deaths (15 320 in viraemic; -2060 in cured) and 10 730 HCC cases, equating to a 53%, 63% and 75% reduction, respectively, compared to the IFN-based scenario. The model also estimated that Australia will meet the WHO targets of incidence and treatment by 2028. Time to a 65% reduction in liver-related mortality varied considerably between HCV viraemic only cases (2026) and all cases (2047). Based on a feasible DAA treatment scenario incorporating declining uptake, Australia should meet key WHO HCV elimination targets in 10 to15 years. The pre-DAA escalation in those with advanced liver disease makes the achievement of the liver-related mortality target difficult.
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http://dx.doi.org/10.1111/jvh.13013DOI Listing
January 2019

Nonalcoholic fatty liver disease burden - Saudi Arabia and United Arab Emirates, 2017-2030.

Saudi J Gastroenterol 2018 Jul-Aug;24(4):211-219

Center for Disease Analysis, Lafayette, Colorado, USA.

Background/aim: Due to epidemic levels of obesity and type 2 diabetes mellitus (DM), nonalcoholic fatty liver disease (NAFLD) and resulting nonalcoholic steatohepatitis (NASH) will be driving factors in liver disease burden in the coming years in Saudi Arabia and United Arab Emirates (UAE).

Materials And Methods: Models were used to estimate NAFLD and NASH disease progression, primarily based on changes in adult prevalence rates of adult obesity and DM. The published estimates and expert interviews were used to build and validate the model projections.

Results: In both countries, the prevalence of NAFLD increased through 2030 parallel to projected increases in the prevalence of obesity and DM. By 2030, there were an estimated 12,534,000 NAFLD cases in Saudi Arabia and 372,000 cases in UAE. Increases in NASH cases were relatively greater than the NAFLD cases due to aging of the population and disease progression. Likewise, prevalent cases of compensated cirrhosis and advanced liver disease are projected to at least double by 2030, while annual incident liver deaths increase in both countries to 4800 deaths in Saudi Arabia and 140 deaths in UAE.

Conclusions: Continued high rates of adult obesity and DM, in combination with aging populations, suggest that advanced liver disease and mortality attributable to NAFLD/NASH will increase across both countries. Reducing the growth of the NAFLD population, along with potential therapeutic options, will be needed to reduce liver disease burden.
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http://dx.doi.org/10.4103/sjg.SJG_122_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080149PMC
November 2018

Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016-2030.

J Hepatol 2018 Oct 8;69(4):896-904. Epub 2018 Jun 8.

JW Goethe University Hospital, Frankfurt, Germany.

Background & Aims: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly a cause of cirrhosis and hepatocellular carcinoma globally. This burden is expected to increase as epidemics of obesity, diabetes and metabolic syndrome continue to grow. The goal of this analysis was to use a Markov model to forecast NAFLD disease burden using currently available data.

Methods: A model was used to estimate NAFLD and NASH disease progression in eight countries based on data for adult prevalence of obesity and type 2 diabetes mellitus (DM). Published estimates and expert consensus were used to build and validate the model projections.

Results: If obesity and DM level off in the future, we project a modest growth in total NAFLD cases (0-30%), between 2016-2030, with the highest growth in China as a result of urbanization and the lowest growth in Japan as a result of a shrinking population. However, at the same time, NASH prevalence will increase 15-56%, while liver mortality and advanced liver disease will more than double as a result of an aging/increasing population.

Conclusions: NAFLD and NASH represent a large and growing public health problem and efforts to understand this epidemic and to mitigate the disease burden are needed. If obesity and DM continue to increase at current and historical rates, both NAFLD and NASH prevalence are expected to increase. Since both are reversible, public health campaigns to increase awareness and diagnosis, and to promote diet and exercise can help manage the growth in future disease burden.

Lay Summary: Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis can lead to advanced liver disease. Both conditions are becoming increasingly prevalent as the epidemics of obesity and diabetes continue to increase. A mathematical model was built to understand how the disease burden associated with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis will change over time. Results suggest increasing cases of advanced liver disease and liver-related mortality in the coming years.
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http://dx.doi.org/10.1016/j.jhep.2018.05.036DOI Listing
October 2018

Chlorhexidine Antiseptic Irrigation Eradicates Staphylococcus epidermidis From Biofilm: An In Vitro Study.

Clin Orthop Relat Res 2018 03;476(3):648-653

K. Schmidt OrthoArizona, Phoenix, AZ, USA C. Estes Portland Adventist Medical Center, Portland, OR, USA A. McLaren University of Arizona, College of Medicine, Phoenix Department of Orthopaedic Surgery, Phoenix, AZ, USA M. J. Spangehl Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA.

Background: Antiseptic and antibacterial solutions used for intraoperative irrigation are intended to kill bacteria and thereby decrease the incidence of surgical site infections. It is unknown if the concentrations and exposure times of irrigation solutions commonly used for prophylaxis in clean cases (povidone-iodine 0.35% for 3 minutes) are effective against bacteria in biofilm that are present in implant infections. Currently, povidone-iodine (0.35%), chlorhexidine (0.05%), sodium hypochlorite (0.125%), and triple antibacterial solution are all being used off-label for wound irrigation after surgical débridement for orthopaedic infections.

Questions/purposes: Do commonly used antibacterials and antiseptics kill bacteria in established biofilm at clinically relevant concentrations and exposure times?

Methods: Staphylococcus epidermidis (ATCC#35984) biofilms were exposed to chlorhexidine (0.025%, 0.05%, and 0.1%), povidone-iodine (0.35%, 1.0%, 3.5%, and 10%), sodium hypochlorite (0.125%, 0.25%, and 0.5%,), and triple antibacterial solution (bacitracin 50,000 U/L, gentamicin 80 mg/L, and polymyxin 500,000 U/L) for 1, 5, and 10 minutes in triplicate. Surviving bacteria were detected by 21-day subculture. Failure to eradicate all bacteria in any of the three replicates was considered to be "not effective" for that respective solution, concentration, and exposure time.

Results: Chlorhexidine 0.05% and 0.1% at all three exposure times, povidone-iodine 10% at all three exposure times, and povidone-iodine 3.5% at 10 minutes only were effective at eradicating S epidermidis from biofilm. All concentrations and all exposure times of sodium hypochlorite and triple antibacterial solution were not effective.

Conclusions: Chlorhexidine is capable of eradicating S epidermidis from biofilm in vitro in clinically relevant concentrations and exposure times. Povidone-iodine at commonly used concentrations and exposure times, sodium hypochlorite, and triple antibacterial solutions are not.

Clinical Relevance: This in vitro study suggests that chlorhexidine may be a more effective irrigation solution for S epidermidis in biofilm than other commonly used solutions, such as povidone-iodine, Dakin's solution, and triple antibiotic solution. Clinical outcomes should be studied to determine the most effective antiseptic agent, concentration, and exposure time when intraoperative irrigation is used in the presence of biofilm.
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http://dx.doi.org/10.1007/s11999.0000000000000052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260035PMC
March 2018

Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease.

Hepatology 2018 01 1;67(1):123-133. Epub 2017 Dec 1.

Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, VA.

Nonalcoholic fatty liver disease (NAFLD) and resulting nonalcoholic steatohepatitis (NASH) are highly prevalent in the United States, where they are a growing cause of cirrhosis and hepatocellular carcinoma (HCC) and increasingly an indicator for liver transplantation. A Markov model was used to forecast NAFLD disease progression. Incidence of NAFLD was based on historical and projected changes in adult prevalence of obesity and type 2 diabetes mellitus (DM). Assumptions were derived from published literature where available and validated using national surveillance data for incidence of NAFLD-related HCC. Projected changes in NAFLD-related cirrhosis, advanced liver disease, and liver-related mortality were quantified through 2030. Prevalent NAFLD cases are forecasted to increase 21%, from 83.1 million (2015) to 100.9 million (2030), while prevalent NASH cases will increase 63% from 16.52 million to 27.00 million cases. Overall NAFLD prevalence among the adult population (aged ≥15 years) is projected at 33.5% in 2030, and the median age of the NAFLD population will increase from 50 to 55 years during 2015-2030. In 2015, approximately 20% of NAFLD cases were classified as NASH, increasing to 27% by 2030, a reflection of both disease progression and an aging population. Incidence of decompensated cirrhosis will increase 168% to 105,430 cases by 2030, while incidence of HCC will increase by 137% to 12,240 cases. Liver deaths will increase 178% to an estimated 78,300 deaths in 2030. During 2015-2030, there are projected to be nearly 800,000 excess liver deaths.

Conclusion: With continued high rates of adult obesity and DM along with an aging population, NAFLD-related liver disease and mortality will increase in the United States. Strategies to slow the growth of NAFLD cases and therapeutic options are necessary to mitigate disease burden. (Hepatology 2018;67:123-133).
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http://dx.doi.org/10.1002/hep.29466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767767PMC
January 2018

Historical Trends in the Hepatitis C Virus Epidemics in North America and Australia.

J Infect Dis 2016 Nov 28;214(9):1383-1389. Epub 2016 Aug 28.

School of Medical Sciences, Faculty of Medicine.

Background:  Bayesian evolutionary analysis (coalescent analysis) based on genetic sequences has been used to describe the origins and spread of rapidly mutating RNA viruses, such as influenza, Ebola, human immunodeficiency virus (HIV), and hepatitis C virus (HCV).

Methods:  Full-length subtype 1a and 3a sequences from early HCV infections from the International Collaborative of Incident HIV and Hepatitis C in Injecting Cohorts (InC3), as well as from public databases from a time window of 1977-2012, were used in a coalescent analysis with BEAST software to estimate the origin and progression of the HCV epidemics in Australia and North America. Convergent temporal trends were sought via independent epidemiological modeling.

Results:  The epidemic of subtype 3a had more recent origins (around 1950) than subtype 1a (around 1920) in both continents. In both modeling approaches and in both continents, the epidemics underwent exponential growth between 1955 and 1975, which then stabilized in the late 20th century.

Conclusions:  Historical events that fuelled the emergence and spread of injecting drug use, such as the advent of intravenous medical therapies and devices, and growth in the heroin trade, as well as population mixing during armed conflicts, were likely drivers for the cross-continental spread of the HCV epidemics.
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http://dx.doi.org/10.1093/infdis/jiw389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5079374PMC
November 2016

Hepatitis C virus infection in Argentina: Burden of chronic disease.

World J Hepatol 2016 May;8(15):649-58

Ezequiel Ridruejo, Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, Ciudad Autónoma de Buenos Aires C1425ASG, Argentina.

Aim: To estimate the progression of the hepatitis C virus (HCV) epidemic and measure the burden of HCV-related morbidity and mortality.

Methods: Age- and gender-defined cohorts were used to follow the viremic population in Argentina and estimate HCV incidence, prevalence, hepatic complications, and mortality. The relative impact of two scenarios on HCV-related outcomes was assessed: (1) increased sustained virologic response (SVR); and (2) increased SVR and treatment.

Results: Under scenario 1, SVR raised to 85%-95% in 2016. Compared to the base case scenario, there was a 0.3% reduction in prevalent cases and liver-related deaths by 2030. Given low treatment rates, cases of hepatocellular carcinoma and decompensated cirrhosis decreased < 1%, in contrast to the base case in 2030. Under scenario 2, the same increases in SVR were modeled, with gradual increases in the annual diagnosed and treated populations. This scenario decreased prevalent infections 45%, liver-related deaths 55%, liver cancer cases 60%, and decompensated cirrhosis 55%, as compared to the base case by 2030.

Conclusion: In Argentina, cases of end stage liver disease and liver-related deaths due to HCV are still growing, while its prevalence is decreasing. Increasing in SVR rates is not enough, and increasing in the number of patients diagnosed and candidates for treatment is needed to reduce the HCV disease burden. Based on this scenario, strategies to increase diagnosis and treatment uptake must be developed to reduce HCV burden in Argentina.
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http://dx.doi.org/10.4254/wjh.v8.i15.649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876291PMC
May 2016

Chronic hepatitis C burden and care cascade in Australia in the era of interferon-based treatment.

J Gastroenterol Hepatol 2017 Jan;32(1):229-236

The Kirby Institute, UNSW Australia, Sydney, New South Wales, Australia.

Background And Aim: Interferon-free direct-acting antiviral regimens for hepatitis C virus (HCV) infection have been recently available in Australia, beginning a new era in clinical and public health management of HCV infection. This study provided updated estimates of the HCV infection care cascade and burden in Australia as a reliable platform for assessing the future impact of interferon-free therapies.

Methods: A modeling approach was applied to estimate the number of individuals living with chronic HCV infection and with various liver disease stages. Data from national registries of HCV notification and liver transplantation, literature review, and expert consensus informed the model parameters. HCV notification and Pharmaceutical Benefits Scheme data were used to estimate the number of HCV diagnosed individuals and treatment uptake.

Results: In 2014, an estimated 230 470 individuals (range: 180 490-243 990) were living with HCV, among whom 75% were diagnosed (n = 172 720; range: 156 720-188 770), 20% had ever received treatment (n = 45 000; range: 39 280-50 720), and 11% had been cured (n = 24 750; range: 21 520-27 990). Among individuals with HCV infection, the proportion with hepatic fibrosis stage ≥F3 doubled during the last decade, increasing from 9% (n = 18 580) in 2004 to 19% (n = 44,730) in 2014. Individuals initiating HCV treatment increased from 1100 in 1997 to 3840 in 2007, plateaued until 2010 and decreased to 2790 in 2014.

Conclusions: The burden of HCV-related liver disease has increased markedly. Although the proportion diagnosed was high, treatment uptake remained low, with no increase over the last 7 years. Reducing the HCV burden in Australia requires scale-up of interferon-free HCV therapies.
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http://dx.doi.org/10.1111/jgh.13453DOI Listing
January 2017

Disease burden of chronic hepatitis C in Brazil.

Braz J Infect Dis 2015 Jul-Aug;19(4):363-8. Epub 2015 Jun 4.

Escola de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil.

Background: Hepatitis C virus infection is a major cause of cirrhosis; hepatocellular carcinoma; and liver transplantation. The aim of this study was to estimate hepatitis C virus disease progression and the burden of disease from a nationwide perspective.

Methods: Using a model developed to forecast hepatitis C virus disease progression and the number of cases at each stage of liver disease; hepatitis C virus-infected population and associated disease progression in Brazil were quantified. The impact of two different strategies was compared: higher sustained virological response and treatment eligibility rates (1) or higher diagnosis and treatment rates associated with increased sustained virological response rates (2).

Results: The number of infected individuals is estimated to decline by 35% by 2030 (1,255,000 individuals); while the number of cases of compensated (n=325,900) and decompensated (n=45,000) cirrhosis; hepatocellular carcinoma (n=19,100); and liver-related deaths (n=16,700) is supposed to peak between 2028 and 2032. In strategy 2; treated cases increased over tenfold in 2020 (118,800 treated) as compared to 2013 (11,740 treated); with sustained virological response increased to 90% and treatment eligibility to 95%. Under this strategy; the number of infected individuals decreased by 90% between 2013 and 2030. Compared to the base case; liver-related deaths decreased by 70% by 2030; while hepatitis C virus-related liver cancer and decompensated cirrhosis decreased by 75 and 80%; respectively.

Conclusions: While the incidence and prevalence of hepatitis C virus in Brazil are decreasing; cases of advanced liver disease continue to rise. Besides higher sustained virological response rates; new strategies focused on increasing the proportion of diagnosed patients and eligibility to treatment should be adopted in order to reduce the burden of hepatitis C virus infection in Brazil.
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http://dx.doi.org/10.1016/j.bjid.2015.04.004DOI Listing
March 2016

Impact of improved treatment on disease burden of chronic hepatitis C in New Zealand.

N Z Med J 2014 Dec 19;127(1407):61-74. Epub 2014 Dec 19.

New Zealand Liver Transplant Unit, 15th Floor Support Building, Auckland City Hospital, Grafton, Auckland, New Zealand.

Background: We describe the burden of HCV infection and estimate the effect of four different treatment strategies to reduce HCV-related morbidity and mortality.

Methods: Baseline model parameters were based upon literature review and expert consensus, focusing on New Zealand data. Four scenarios were modelled: Scenario 1 estimated the impact of increased treatment efficacy, while Scenario 2 estimated the effect of increased treatment efficacy and gradual increases in numbers treated. Scenarios 3 and 4 estimated the impact of deferred introduction of new DAAs for either 1 or 2 years.

Results: Prevalence of HCV infection peaked in 2010 (50,480 cases). Peak prevalence of cirrhosis and HCC will occur after 2030. Scenario 2 resulted in sizeable decreases in HCV-related morbidity and mortality. The impact of Scenario 1 was smaller. Deferring funding for new DAA treatments for a further 1 or 2 years resulted in an 18-36% increase in liver-related deaths in 2030.

Conclusions: While prevalence of chronic HCV infection may have peaked, disease burden continues to grow. Increased treatment uptake and efficacy combined with efforts to reduce disease transmission, will help prevent advanced liver disease and deaths.
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December 2014

Global epidemiology and genotype distribution of the hepatitis C virus infection.

J Hepatol 2014 Nov 30;61(1 Suppl):S45-57. Epub 2014 Jul 30.

Center for Disease Analysis, Louisville, CO, USA. Electronic address:

The treatment of chronic hepatitis C virus (HCV) infection has the potential to change significantly over the next few years as therapeutic regimens are rapidly evolving. However, the burden of chronic infection has not been quantified at the global level using the most recent data. Updated estimates of HCV prevalence, viremia and genotypes are critical for developing strategies to manage or eliminate HCV infection. To achieve this, a comprehensive literature search was conducted for anti-HCV prevalence, viraemic prevalence and genotypes for all countries. Studies were included based on how well they could be extrapolated to the general population, sample size and the age of the study. Available country estimates were used to develop regional and global estimates. Eighty-seven countries reported anti-HCV prevalence, while HCV viraemic rates were available for fifty-four countries. Total global viraemic HCV infections were estimated at 80 (64-103) million infections. Genotype distribution was available for ninety-eight countries. Globally, genotype 1 (G1) was the most common (46%), followed by G3 (22%), G2 (13%), and G4 (13%). In conclusion, the total number of HCV infections reported here are lower than previous estimates. The exclusion of data from earlier studies conducted at the peak of the HCV epidemic, along with adjustments for reduced prevalence among children, are likely contributors. The results highlight the need for more robust surveillance studies to quantify the HCV disease burden more accurately.
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http://dx.doi.org/10.1016/j.jhep.2014.07.027DOI Listing
November 2014

Enhanced antiviral treatment efficacy and uptake in preventing the rising burden of hepatitis C-related liver disease and costs in Australia.

J Gastroenterol Hepatol 2014 Aug;29 Suppl 1:1-9

Monash University and Monash Health, Melbourne, Victoria, Australia.

Background And Aim: Chronic hepatitis C virus (HCV) infection is an important cause of advanced liver disease and liver-related deaths in Australia. Our aim was to describe the burden of HCV infection and consider treatment strategies to reduce HCV-related morbidity and mortality.

Methods: Baseline model parameters were based upon literature review and expert consensus with a focus on Australian data. Three treatment scenarios based on anticipated introduction of improved direct-acting antiviral regimens were considered to reduce HCV disease burden. Scenario 1 evaluated the impact of increased treatment efficacy alone (to 80-90% by 2016). Scenario 2 evaluated increased efficacy and increased treatment uptake (2550 to 13,500 by 2018) without treatment restriction, while Scenario 3 considered the same increases with treatment limited to ≥ F3 during 2015-2017.

Results: In 2013, there were an estimated 233,490 people with chronic HCV infection: 13,850 with cirrhosis, 590 with hepatocellular carcinoma (HCC) and 530 liver-related deaths. If the current HCV treatment setting is unchanged, threefold increases in the number of people with cirrhosis, HCC, and liver disease deaths will be seen by 2030. Scenario 1 resulted in modest impacts on disease burden (4% decrease in HCC, decompensated cirrhosis, and liver deaths) and costs. Scenario 3 had the greatest impact on disease burden (approximately 50% decrease in HCC, decompensated cirrhosis, and liver deaths) and costs, while Scenario 2 had slightly lesser impact.

Conclusions: Considerable increases in the burden of HCV-related advanced liver disease and its complications will be seen in Australia under current treatment levels and outcomes. Introduction of improved direct-acting antiviral regimens with enhanced efficacy at current treatment levels will lead to limited impacts on this disease burden. A combination of increased treatment efficacy and greater uptake is required to achieve major reductions in advanced liver disease and related costs.
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http://dx.doi.org/10.1111/jgh.12677DOI Listing
August 2014

Burden of disease and cost of chronic hepatitis C infection in Canada.

Can J Gastroenterol Hepatol 2014 May;28(5):243-50

Background: Chronic infection with hepatitis C virus (HCV) is a major cause of cirrhosis, hepatocellular carcinoma and liver transplantation.

Objective: To estimate the burden of HCV-related disease and costs from a Canadian perspective.

Methods: Using a system dynamic framework, the authors quantified the HCV-infected population, disease progression and costs in Canada between 1950 and 2035. Specifically, 36 hypothetical, age- and sex-defined cohorts were tracked to define HCV prevalence, complications and direct medical costs (excluding the cost of antivirals). Model assumptions and costs were extracted from the literature with an emphasis on Canadian data. No incremental increase in antiviral treatment over current levels was assumed, despite the future availability of potent antivirals.

Results: The estimated prevalence of viremic hepatitis C cases peaked in 2003 at 260,000 individuals (uncertainty interval 192,460 to 319,880), reached 251,990 (uncertainty interval 177,890 to 314,800) by 2013 and is expected to decline to 188,190 (uncertainty interval 124,330 to 247,200) in 2035. However, the prevalence of advanced liver disease is increasing. The peak annual number of patients with compensated cirrhosis (n=36,210), decompensated cirrhosis (n=3380), hepatocellular carcinoma (n=2220) and liver-related deaths (n=1880) are expected to occur between 2031 and 2035. During this interval, an estimated 32,460 HCV-infected individuals will die of liver-related causes. Total health care costs associated with HCV (excluding treatment) are expected to increase by 60% from 2013 until the peak in 2032, with the majority attributable to cirrhosis and its complications (81% in 2032 versus 56% in 2013). The lifetime cost for an individual with HCV infection in 2013 was estimated to be $64,694.

Conclusions: Although the prevalence of HCV in Canada is decreasing, cases of advanced liver disease and health care costs continue to rise. These results will facilitate disease forecasting, resource planning and the development of rational management strategies for HCV in Canada.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049256PMC
http://dx.doi.org/10.1155/2014/317623DOI Listing
May 2014

Effect of body mass index on limb alignment after total knee arthroplasty.

J Arthroplasty 2013 Sep 25;28(8 Suppl):101-5. Epub 2013 Jul 25.

Banner Good Samaritan Orthopaedic Surgery Residency, Phoenix, Arizona.

Prior studies have reported increased failure rates in obese patients with postoperative limb mal-alignment. This study was undertaken to determine if a relationship exists between postoperative limb alignment and BMI in patients undergoing primary TKA performed with mechanical instruments. An IRB-approved retrospective review of 196 knees was undertaken. Limb alignment was determined on full-length, standing, hip-to-ankle x-rays, preoperatively and postoperatively. The effects of gender, side, preoperative mechanical alignment and BMI on postoperative alignment were analyzed via multivariate regression analysis. Both preoperative mechanical limb alignment (P<0.001) and BMI (P=0.009) had a significant effect on postoperative limb alignment following TKA performed with mechanical instruments.
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http://dx.doi.org/10.1016/j.arth.2013.02.038DOI Listing
September 2013

HCV infection prevalence in a population recruited at health centers in Jordan.

J Epidemiol Glob Health 2013 Jun 19;3(2):67-71. Epub 2013 Mar 19.

Al-Bashir Hospital, Jordan.

Background: Jordan lacks statistical data regarding prevalence of HCV.

Aim: To determine the prevalence of HCV in selected areas of Jordan (north, middle and south of Jordan).

Methods: A random sample of 700 patients attending health centers was used to determine HCV prevalence. ELISA testing was used to determine HCV-Ab positive cases, which were confirmed by PCR testing.

Results And Conclusion: The study concluded that the prevalence of HCV infection in the population recruited from different health centers in Jordan is relatively low and estimates a prevalence of 0.42% among all age groups and 0.56% among those aged >15 years old.
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http://dx.doi.org/10.1016/j.jegh.2013.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320397PMC
June 2013

Chronic hepatitis C virus (HCV) disease burden and cost in the United States.

Hepatology 2013 Jun 6;57(6):2164-70. Epub 2013 May 6.

Center for Disease Analysis, Louisville, CO, USA.

Unlabelled: Hepatitis C virus (HCV) infection is a leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation. A better understanding of HCV disease progression and the associated cost can help the medical community manage HCV and develop treatment strategies in light of the emergence of several potent anti-HCV therapies. A system dynamic model with 36 cohorts was used to provide maximum flexibility and improved forecasting. New infections incidence of 16,020 (95% confidence interval, 13,510-19,510) was estimated in 2010. HCV viremic prevalence peaked in 1994 at 3.3 (2.8-4.0) million, but it is expected to decline by two-thirds by 2030. The prevalence of more advanced liver disease, however, is expected to increase, as well as the total cost associated with chronic HCV infection. Today, the total cost is estimated at $6.5 ($4.3-$8.4) billion and it will peak in 2024 at $9.1 ($6.4-$13.3) billion. The lifetime cost of an individual infected with HCV in 2011 was estimated at $64,490. However, this cost is significantly higher among individuals with a longer life expectancy.

Conclusion: This analysis demonstrates that US HCV prevalence is in decline due to a lower incidence of infections. However, the prevalence of advanced liver disease will continue to increase as well as the corresponding healthcare costs. Lifetime healthcare costs for an HCV-infected person are significantly higher than for noninfected persons. In addition, it is possible to substantially reduce HCV infection through active management. (HEPATOLOGY 2013;57:2164-2170).
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http://dx.doi.org/10.1002/hep.26218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763475PMC
June 2013

Jeannette Wilkins Award: Can locally delivered gadolinium be visualized on MRI? A pilot study.

Clin Orthop Relat Res 2012 Oct;470(10):2654-62

Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA.

Background: Management of orthopaedic infections relies on débridement and local delivery of antimicrobials; however, the distribution and concentration of locally delivered antimicrobials in postdébridement surgical sites is unknown. Gadolinium-DTPA (Gd-DTPA) has been proposed as an imaging surrogate for antimicrobials because it is similar in size and diffusion coefficient to gentamicin.

Questions/purposes: Is in vivo distribution of locally delivered Gd-DTPA (1) visible on MRI; (2) reliably visualized by different observers; (3) affected by the anatomic delivery site; and (4) affected by the in vitro release rate from the delivery vehicle?

Methods: Twenty-four local delivery depots were imaged in nine rabbits using two anatomic sites (intramedullary canal, quadriceps) with Gd-DTPA in intermediate-porosity polymethylmethacrylate (PMMA) or high-porosity PMMA; six of the nine rabbits also had Gd-DTPA delivered in collagen at a third site (hamstring). A total of 45,000 fat-suppressed T1-weighted RARE scans were acquired using a 7-T Bruker Biospec MRI: nine rabbits, 2-mm slices over 10 cm, four TR values, 25 time periods (pre, every 15 minutes for 6 hours). T1 maps were constructed at every time period. Gd-DTPA distribution was observed qualitatively on the T1 maps. Interobserver reliability was determined.

Results: Locally delivered Gd-DTPA was visible. Interobserver agreement was excellent. Intramuscular delivery followed intermuscular planes; intramedullary delivery was contained within the canal by bone. Distribution from collagen decreased after 1 hour but from PMMA increased over 6 hours.

Conclusions: Locally delivered Gd-DTPA can be visualized on MRI; distribution is affected by anatomical location and delivery vehicle.

Clinical Relevance: Contrast-based imaging using locally delivered Gd-DTPA may be useful as an antibiotic surrogate to determine antibiotic distribution in surgical sites.
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http://dx.doi.org/10.1007/s11999-012-2315-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442007PMC
October 2012

Surveillance of traumatic firefighter fatalities: an assessment of four systems.

Public Health Rep 2011 Jul-Aug;126(4):540-51

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Safety Research, Surveillance and Field Investigations Branch, 1095 Willowdale Rd., MS-1808, Morgantown, WV 26505, USA.

Objectives: Firefighters regularly respond to hazardous situations that put them at risk for fatal occupational injuries. Traumatic occupational fatality surveillance is a foundation for understanding the problem and developing prevention strategies. We assessed four surveillance systems for their utility in characterizing firefighter fatalities and informing prevention measures.

Methods: We examined three population-based systems (the Bureau of Labor Statistics' Census of Fatal Occupational Injuries and systems maintained by the United States Fire Administration and the National Fire Protection Association) and one case-based system (data collected through the National Institute for Occupational Safety and Health Fire Fighter Fatality Investigation and Prevention Program). From each system, we selected traumatic fatalities among firefighters for 2003-2006. Then we compared case definitions, methods for case ascertainment, variables collected, and rate calculation methods.

Results: Overall magnitude of fatalities differed among systems. The population-based systems were effective in characterizing the circumstances of traumatic firefighter fatalities. The case-based surveillance system was effective in formulating detailed prevention recommendations, which could not be made based on the population-based data alone. Methods for estimating risk were disparate and limited fatality rate comparisons between firefighters and other workers.

Conclusions: The systems included in this study contribute toward a greater understanding of firefighter fatalities. Areas of improvement for these systems should continue to be identified as they are used to direct research and prevention efforts.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115213PMC
http://dx.doi.org/10.1177/003335491112600410DOI Listing
August 2011

A two-stage retention débridement protocol for acute periprosthetic joint infections.

Clin Orthop Relat Res 2010 Aug;468(8):2029-38

Banner Good Samaritan Orthopaedic Residency Program, Phoenix, AZ, USA.

Background: Due to the historically poor infection control rates with débridement and component retention for acute periprosthetic infections we developed a new approach for treating acute periprosthetic total joint infections: initial débridement with prosthesis retention and placement of antibiotic-impregnated cement beads followed by a second débridement within 7 days, at which time the beads are removed and new modular parts inserted. Intravenous antibiotics were used for 6 weeks followed by oral antibiotics. Depending on the clinical situation, antibiotics are discontinued or in selected patients continued indefinitely.

Questions/purposes: We determined the ability of this two-stage débridement to control infection.

Methods: We retrospectively reviewed the charts of 20 patients who underwent this technique; 2 had postoperative and 18 had hematogenous infections. The primary outcome measure was the infection control. The minimum followup was 1 year (mean, 3.5 years; range, 1.2-7.5 years).

Results: Two of the 20 patients had persistent infection. There were no failures in the acute postoperative group (0 of 2) and two of 18 in the acute hematogenous group. Of the 18 patients without evidence of persistent infection, 10 were no longer on antibiotics at the most recent followup and eight were treated with long-term antibiotics due to compromised host status.

Conclusions: The control of infection in 18 of 20 patients using this technique compares favorably with historical success rates, which range from 24% to 100%. Further research is required to analyze the individual contribution of débridement technique, the use of serial débridements, local depot antibiotics, and combination antibiotic therapy on short-term infection control rates and the long-term persistent control of periprosthetic infection.

Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
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http://dx.doi.org/10.1007/s11999-010-1293-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895840PMC
August 2010

The economic cost of environmental factors among North Carolina children living in substandard housing.

Am J Public Health 2009 Nov;99 Suppl 3:S666-74

Chenoweth & Associates Inc, New Bern, NC, USA.

Objectives: We quantified the economic cost of selected environmental factors among North Carolina children living in substandard housing.

Methods: We gathered data on direct medical care costs for specific childhood medical conditions associated with environmental factors commonly found in substandard housing. Medical claims data for 2006 and 2007 were obtained from BlueCross BlueShield of North Carolina and the North Carolina Department of Health and Human Services. Indirect costs were based in part on nonmedical data obtained from several previous studies.

Results: Total (direct and indirect) costs for the conditions assessed exceeded $92 million in 2006 and $108 million in 2007. Neurobehavioral conditions contributed to more than 52% of all costs, followed by lead poisoning (20%) and respiratory conditions (12%). Neurobehavioral conditions were the largest contributor to direct medical costs (44%), followed by respiratory conditions (38%) and accidental burns and falls (10%).

Conclusions: Direct and indirect costs associated with environmental factors appear to be increasing at about twice the rate of medical inflation. More aggressive policies and funding are needed to reduce the substantial financial impact of childhood illnesses associated with substandard housing in North Carolina.
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http://dx.doi.org/10.2105/AJPH.2008.141671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2774188PMC
November 2009