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IMPORTANCE For patients awaiting heart transplant, hepatitis C-positive donors offer an opportunity to expand the donor pool, shorten wait times, and decrease wait-list mortality. While early reported outcomes among few heart transplant recipients have been promising, knowledge of 1-year outcomes in larger cohorts of patients is critical to shared decision-making with patients about this option.OBJECTIVE To better define the association of hepatitis C-positive donors with heart transplant volumes, wait-list duration, the transmission and cure of donor-derived hepatitis C, and morbidity and mortality at 1 year. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, single-center observational study of 80 adult (age 18 years or older) patients who underwent heart transplant using hearts from hepatitis C-positive donors between September 2016 and April 2019 at a large academic medical center. Among donors, who were considered hepatitis C-positive if results from hepatitis C antibody and/or nucleic acid testing were positive, 70 had viremia and 10 were seropositive but did not have viremia. Follow-up was available through May 15, 2019. Comparisons were drawn with patients who underwent transplant with hearts from hepatitis C-negative donors during the same period.EXPOSURES In addition to standard posttransplant management, transplant recipients who developed donor-derived hepatitis C infection were treated with direct-acting antivirals. MAIN OUTCOMES AND MEASURESThe main outcomes included wait-list duration and 1-year survival in all patients, and for those who developed donor-derived hepatitis C, the response to direct-acting antiviral treatment. RESULTSOf 80 patients, 57 (71.3%) were men, 55 (68.7%) were white, and 17 (26.3%) were black; the median age at transplant was 54.5 years (interquartile range, 46-62 years). Following consent to accept hearts from hepatitis C-exposed donors, the median days to heart transplant was 4 (interquartile range, 1-18). No recipients of donors with negative nucleic acid testing results (10 [12.5%]) developed donor-derived hepatitis C. Of 70 patients who were recipients of donors with positive nucleic acid testing results, 67 (95.7%) developed donor-derived hepatitis C over a median follow-up of 301 days (interquartile range, 142-617). Treatment with direct-acting antivirals was well tolerated and yielded sustained virologic responses in all treated patients. Within the cohort with infection, 1-year patient survival was 90.4%, which was not significantly different compared with the cohort without infection or with patients who received transplants from hepatitis C-negative donors during the same period. CONCLUSIONS AND RELEVANCEIn the era of direct-acting antivirals, hepatitis C-positive donors are a viable option to expand the donor pool, potentially reducing wait-list duration and mortality. In heart transplant recipients with donor-derived hepatitis C, infection is well-tolerated and curable, and 1-year survival is equivalent to that in recipients of hepatitis C-negative donors.

No outside funding supported this study. The authors have nothing to disclose. Study concept and design were principally contributed by Bagwell and Newman, along with the other authors. Lee took the lead in data collection, along with Carver, Bagwell, Kelley, and Newman. Data interpretation was performed by Carver, Kelley, Lee, and Bagwell, with assistance from Newman. The manuscript was written by Bagwell, Carver, Kelley, and Lee and revised primarily by Bagwell, along with the other authors.

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Adherence and persistence to specialty medications are necessary to achieve successful outcomes of costly therapies. The increasing use of specialty medications has exposed several unique barriers to certain specialty treatments’ continuation. Integrated specialty pharmacy teams facilitate transitions in sites of care, between different provider types, among prescribed specialty medications, and during financial coverage changes. We review obstacles encountered within these types of transitions and the role of the specialty pharmacist in overcoming these obstacles. Case examples for each type of specialty transition provide insight into the unique complexities faced by patients, and shed light on pharmacists’ vital role in patient care. This insightful and real-world experience is needed to facilitate best practices in specialty care, particularly in the growing number of health-system specialty pharmacies.

Purpose of reviewAn increasing number of specialists and non-specialists are developing clinical programs to treat and cure hepatitis C virus (HCV). The goal of this paper is to evaluate and describe optimal strategies to improve outcomes related to HCV care delivery.Recent findingsScreening and diagnosis of HCV should be guided by established recommendations. Given the recognized disparity in HCV diagnosis and linkage to care, a multi-modal approach involving care coordination and technology resources should be used to improve patient engagement. Access to HCV treatment may be optimized through systematic documentation, prior authorization, and appeal processes. Treatment monitoring should emphasize medication adherence, side effect and drug interaction management, as well as elimination of practical barriers. Finally, post-treatment engagement to promote liver health and reduce the risk of complications or reinfection maximizes the benefit of HCV treatment.SummaryThe landscape of HCV treatment has evolved from a specialist-driven model with few patients qualifying for treatment to an opportunity for non-specialists and other providers to provide curative therapies in most patients. Innovative practice models that employ a multidisciplinary approach will likely improve screening, diagnosis, engagement, and treatment outcomes.

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Aims Acute leukaemia presenting with hyperleukocytosis (white cell count (WCC) >50×10 9 /L) is associated with organ dysfunction due to hyperviscosity. However, there is little evidence to guide which children are at highest risk and who might benefit from aggressive leukoreduction, including leukapheresis. We explored whether it is possible to risk stratify children based on initial WCC and evaluated the role of leukapheresis in preventing complications of hyperleukocytosis. Methods A retrospective analysis of all children with ALL or AML who were admitted to our tertiary paediatric oncology and critical care centre with an initial WCC >50×10 9 /L, 2007-2017. Results 37 patients were identified (ALL: 28; AML: 9). Median age 6 years, 54% were male. All patients were treated with immediate hyperhydration and chemotherapy within 48 hours. 5 patients were treated with leukapheresis. 11 children (30%) developed complications (21% of ALL; 55% of AML): 27% respiratory, 14% neurological and 8% renal.Children who presented with hyperleukocytic complications tended to have a higher initial WCC than those without complications at presentation (Median: 332 vs. 175 × 10 9 /L). The initial WCC of children who developed complications later in their admission did not differ from the WCC of those without complications (Median: 161 vs. 175 × 10 9 /L), suggesting that later complications cannot be related to WCC at presentation.Severe events (stroke or early mortality) occurred in 4 children (11%). All 4 had complications at presentation and 3 were treated with leukapheresis. Conclusions Several findings may be useful for risk stratification:. Complications are more likely in AML than in ALL . Complications did not occur with WCC <100 x10 9 /L . Severe events occurred only in children with complications at presentationthose who present without complications appear to be low risk for the most dangerous events regardless of their initial WCC.4 children with complications on admission were treated with leukapheresis yet all 4 developed further complications including 3 severe events. Therefore, leukapheresis did not help to avoid further complications. Early chemotherapy thus remains the most important aspect of clinical management and further research into the prevention of severe events is required.