Peace Coalition Politics: The Liberal Experiment, 1954-1965

This study offers an overview of the peace movement in the United States during the decade preceding the Vietnam War. This movement, unlike its forerunners, was led by liberals who attempted to reform the system from within. A coalition of established and new groups was forged, with the major constituencies drawn from world federalists and pacifists. This seemingly unlikely combination is analyzed through historical investigation with some aid from the political science mathematically-based theory of coalition formation. The creation of this coalition was facilitated by their championing of a nuclear test-ban in a period when the health hazards of atmospheric nuclear explosions were becoming known to the public. It was this issue that carried the movement until its final demise upon the signing of the limited test ban treaty in August of 1963. Given the generally negative assessment of the achievement of this peace coalition, the study attempts to analyze what the true goals of the various factions of this movement were and the shortcomings built into these objectives. Furthermore, alternative strategies and tactics are suggested for current and future activists looking to history for direction and precedent. Several pitfalls of the liberal peace experiment should be noticed throughout the study. The gradual co-opting of the peace movement into the government camp was possible because of the coalition liberal\u27s desire to maintain legitimacy, especially through its anti-communist vigilance. Secondly, liberals held a preponderance of power in the coalition, not the radicals, who were in the position of outsider so necessary to lead a reform movement to success

Peace Coalition Politics: The Liberal Experiment, 1954-1965

This study offers an overview of the peace movement in the United States during the decade preceding the Vietnam War. This movement, unlike its forerunners, was led by liberals who attempted to reform the system from within. A coalition of established and new groups was forged, with the major constituencies drawn from world federalists and pacifists. This seemingly unlikely combination is analyzed through historical investigation with some aid from the political science mathematically-based theory of coalition formation. The creation of this coalition was facilitated by their championing of a nuclear test-ban in a period when the health hazards of atmospheric nuclear explosions were becoming known to the public. It was this issue that carried the movement until its final demise upon the signing of the limited test ban treaty in August of 1963. Given the generally negative assessment of the achievement of this peace coalition, the study attempts to analyze what the true goals of the various factions of this movement were and the shortcomings built into these objectives. Furthermore, alternative strategies and tactics are suggested for current and future activists looking to history for direction and precedent. Several pitfalls of the liberal peace experiment should be noticed throughout the study. The gradual co-opting of the peace movement into the government camp was possible because of the coalition liberal\u27s desire to maintain legitimacy, especially through its anti-communist vigilance. Secondly, liberals held a preponderance of power in the coalition, not the radicals, who were in the position of outsider so necessary to lead a reform movement to success

Antiviral therapy of HCV in the cirrhotic and transplant candidate

Despite the improved efficacy of peginterferons, the rate of sustained virologic response is suboptimal in cirrhotic patients, relative to non-cirrhotic patients. However, the treatment of patients with compensated cirrhosis has recently been encouraged by expert panels. Interferon-based therapy may provide additional benefit by reducing the risk of hepatocellular carcinoma in cirrhotic patients as suggested in preliminary studies. Results of two ongoing prospective studies are awaited to answer the important question of the effectiveness of suppressive interferon therapy, even in the absence of sustained virologic response. Given the importance of recurrent HCV following liver transplantation, attention has been directed toward the antiviral treatment of patients with advanced liver disease. This approach needs to be pursued with caution given the potential morbidity of the therapy. Recently, a low accelerating dosage regimen has provided excellent results and is the subject of additional inquiry

Pegylated interferon 2a and 2b in combination with ribavirin for the treatment of chronic hepatitis C in HIV infected patients

Coinfection with hepatitis C virus (HCV) and HIV is an increasingly recognized clinical dilemma, particularly since the advent of highly active antiretroviral therapy. Several studies of this population have demonstrated both more rapid progression of liver disease and poorer overall prognosis compared to HCV monoinfected patients. Consensus guidelines, based primarily on the results of 4 major randomized trials, recommend treatment with peginterferon and ribavirin for 48 weeks in coinfected patients. However, this current standard of care is associated with lower response rates to therapy than those seen in monoinfected patients. Important predictors of response include HCV genotype, pretreatment HCV RNA level, and presence of rapid virologic response (RVR) and early virologic response (EVR). Use of weight-based ribavirin dosing appears to be safe and enhances the likelihood of sustained virologic response (SVR). Adverse effects most commonly encountered are anemia and weight loss. Mitochondrial toxicity can occur in the setting of concomitant nucleoside reverse transcriptase inhibitor use, especially didanosine, abacavir, and zidovudine, and these should be discontinued before initiation of ribavirin therapy. Discontinuation of therapy should be considered in patients failing to demonstrate EVR, though ongoing trials are investigating a potential role for maintenance therapy in these patients. Peginterferon combined with weight-based ribavirin is appropriate and safe for treatment of HCV in HIV – HCV coinfected patients. This review summarizes the data supporting these recommendations

The devil is in the third year: a longitudinal study of erosion of empathy in medical school.

PURPOSE: This longitudinal study was designed to examine changes in medical students\u27 empathy during medical school and to determine when the most significant changes occur. METHOD: Four hundred fifty-six students who entered Jefferson Medical College in 2002 (n = 227) and 2004 (n = 229) completed the Jefferson Scale of Physician Empathy at five different times: at entry into medical school on orientation day and subsequently at the end of each academic year. Statistical analyses were performed for the entire cohort, as well as for the matched cohort (participants who identified themselves at all five test administrations) and the unmatched cohort (participants who did not identify themselves in all five test administrations). RESULTS: Statistical analyses showed that empathy scores did not change significantly during the first two years of medical school. However, a significant decline in empathy scores was observed at the end of the third year which persisted until graduation. Findings were similar for the matched cohort (n = 121) and for the rest of the sample (unmatched cohort, n = 335). Patterns of decline in empathy scores were similar for men and women and across specialties. CONCLUSIONS: It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential. Implications for retaining and enhancing empathy are discussed

Obstetricians\u27 and gynecologists\u27 knowledge, education, and practices regarding chronic hepatitis B in pregnancy.

Background: In pregnant women with high viral loads, third-trimester initiation of antiviral agents can reduce the risk of vertical transmission. We aimed to assess obstetricians\u27 and gynecologists\u27 (OB-GYN) knowledge and clinical practice when treating pregnant women with chronic hepatitis B virus (HBV). Methods: All program directors (PDs) from 250 US OB-GYN residency programs were invited to anonymously complete an 18-item questionnaire. Descriptive statistics were calculated and analyzed. Results: A total of 323 participants responded, including both PDs (n=51, response rate 21%) and residents (n=272, response rate 11%). Responding PDs (62% university-based vs. 32% community-based) came from various practice types. All PDs and 95.2% of residents reported screening for chronic HBV in pregnant patients on the first prenatal visit. A majority of PDs (85.5%) and residents (85%) correctly interpreted HBV serologies. Referral patterns showed that 66.7% of PDs and 65.5% of residents refer to a specialist regardless of viral load. A minority of respondents (19.6% PDs and 12.6% residents) knew that third-trimester antiviral therapy is recommended for women with high viral loads (\u3e200,000 IU/mL). Few respondents had prescribed HBV antivirals (9.8% PDs and 6.0% residents), with residents more commonly prescribing tenofovir and less frequently lamivudine. Half the PDs believed trainees from their programs were comfortable managing HBV in pregnancy, but only 41.8% of residents reported being comfortable managing pregnant patients with HBV. Conclusion: OB-GYNs report screening almost all pregnant patients for chronic HBV, though significant gaps still exist in practitioner comfort and training regarding the management of HBV during pregnancy

Dilated cisternae chyli. A sign of uncompensated cirrhosis at MR imaging

Background: To retrospectively determine the frequency of dilated cisterna chyli (CC) on MR images in patients with cirrhosis, and to assess its value as a simple diagnostic imaging sign of uncompensated cirrhosis. Methods: Study population included 257 patients (149 with pathologically proved cirrhosis and 108 control subjects without history of chronic liver diseases) who had 1.5T MR imaging. Cirrhosis patients were divided into compensated and uncompensated groups. Three independent observers qualitatively evaluated visibility of CC 2mm or greater in transverse diameter, identified as a tubular structure with fluid signal intensity (SI). CC diameters greater than 6 mm were defined as dilated. Statistical analysis was performed by Student t test and interobserver agreement via intraclass correlation coefficient (ICC). Results: CCs with diameter 2 mm or more were recorded in 113 of 149 (76%) cirrhotic patients and 15 of 108 (14%) control subjects (P\u3c 0.001). Dilated CCs were significantly more frequent in uncompensated than compensated cirrhotic patients (54% vs 5%, P\u3c0.001). The sensitivity, specificity, accuracy, and positive predictive value of dilated CC for uncompensated cirrhosis were 54%, 98%, 80%, and 96%, respectively. Conclusion: Dilated CC can be used as a simple and specific sign complimentary to other findings of uncompensated cirrhosis

Employment and patient satisfaction after liver transplantation

Background and Aims: This study serves to revisit the effects of liver transplantation (LT) on employment in an era of improving survival outcomes post-transplant, and to identify areas of improvement in the transplant process to better op-timize post-LT employment and patient satisfaction. Methods: Prospectively, patients who had undergone LT at a single tertiary LT center were surveyed in person and by e-mail. Primary outcomes included employment rate pre-and post-LT, annual salary, weekly hours worked, barriers to re-employment, and patient satisfaction. Results: Responses were collected and analyzed from 121 patients who underwent LT. Pre-LT, 68 (56.1%) reported full-time employ-ment, 13 (10.7%) part-time employment, and 40 (33.1%) unemployment. Post-LT, 26 (21.4%) reported continued full-time employment, 18 (14.9%) part-time employment, and 77 (63.6%) unemployment. Average weekly work hours decreased post-LT (16.1 h/week vs. 39.9 h/week). Mean annual salaries decreased post-LT (17 earning salary $$40,000 vs. 56 earning salary$$40,000). These outcomes differed from patient pre-LT expectations, with 81.0% of previously employed patients believing they would return to employ-ment, resulting in decreased patient satisfaction. Patients working physically demanding jobs pre-LT were less likely to return to work. Reasons cited for lack of return to full employment included early fatigue and difficulty regaining physical strength. Conclusions: Re-employment rates remain low post-LT, which is particularly true for patients working physically active jobs. Fatigue is a significant barrier to re-employ-ment and increased physical rehabilitation post-LT may prove to be beneficial. Patients should be given realistic expectations about return to employment prior to their LT

The Time Is Now for Mandatory Liver-Focused Clinical Experiences in Medical School.

The national burden of chronic liver disease is steadily increasing and is only expected to worsen with the ongoing obesity and opioid epidemics fueling growth in the prevalence of nonalcoholic fatty liver disease and a resurgence of new hepatitis C infections. Our letter highlights the disparity between the rising prevalence of chronic liver disease and the proportion of medical students who receive exposure to patients with liver disease as part of their medical education. A more comprehensive survey of clerkship directors is needed to further corroborate this data, which may lead to reforms in medical school curricula to better address the expanding burden of chronic liver disease

Timely diagnosis and staging of non-alcoholic fatty liver disease using transient elastography and clinical parameters.

Background and Aim: There is no standardized guideline to screen, image, or refer patients with non-alcoholic fatty liver disease (NAFLD) to a specialist. In this study, we used transient elastography (TE) to examine the fibrosis stages at which patients are first diagnosed with NAFLD. Subsequently, we analyzed metabolic markers to establish cut-offs beyond which noninvasive imaging should be considered to confirm NAFLD/non-alcoholic steatohepatitis fibrosis in patients. Methods: Charts spanning July 2015-April 2018 for 116 NAFLD patients who had TE performed were reviewed. Univariate and multivariate analysis of metabolic markers was conducted. Results: At the first hepatology visit, TE showed 73% F0-F2 and 27% F3-F4. Univariate analysis showed that high-density lipoproteins (HDL), hemoglobin A1c (A1c), aspartate transaminase (AST), and alanine transaminase (ALT) were significantly different between the F0-F2 and F3-F4 groups. Multivariate analysis showed that AST (P = 0.01) and A1c (P = 0.05) were significantly different. Optimal cut-offs for these markers to detect liver fibrosis on TE were AST \u3e43 U/L and A1c \u3e6.6%. The logistic regression function combining these two variables to reflect the probability (P) of the patient having advanced fibrosis (F3-F4) on TE yielded the formula: P = e R /(1 + e R ), where R = -8.56 + 0.052 * AST + 0.89 * A1c. Conclusions: Our study suggested that \u3e25% of patients presenting to a specialist for NAFLD may have advanced fibrosis (F3-F4). Diabetes (A1c \u3e6.6%) and AST \u3e43 U/L were the most predictive in identifying NAFLD patients with advanced fibrosis on imaging. We proposed a formula that may be used to prioritize NAFLD patients at higher risk of having advanced fibrosis for specialist referral and imaging follow-up