Black Americans (blacks) have a high prevalence of chronic hepatitis C virus (HCV) infection and respond poorly to therapy with interferon alfa-based regimens, but they have been underrepresented in clinical trials. The aim of this study was to assess the rate of sustained virological response (SVR) to peginterferon alfa-2a (40 kd) in combination with ribavirin in black patients chronically infected with HCV genotype 1. In a prospective, multicenter, open-label trial, 78 black and 28 white American interferon-naïve patients were enrolled to receive once weekly subcutaneous injections of 180 g peginterferon alfa-2a plus oral ribavirin (1000 mg/d for patients weighing less than 75 kg and 1200 mg/d for patients weighing 75 kg or more) for 48 weeks. Pre-and post-treatment liver biopsies were evaluated for necroinflammation and fibrosis. SVR, defined as undetectable (<50 IU/mL) HCV RNA, was 26% in the black group and 39% in the white group. Although the SVR rate was lower in blacks than in whites, the SVR of 26% represents an improvement over previously reported SVR rates from smaller, retrospective studies of black patients. We also observed improvement in fibrosis in 25% of the black patients. No unexpected adverse events occurred. In conclusion, this prospective study evaluating responses of black patients with chronic hepatitis C to peginterferon alfa-2a/ribavirin has demonstrated that treatment can be safely offered to such individuals with reasonable antiviral and histological benefit. L arge racial disparities in the prevalence of hepatitis C virus (HCV) infection exist in the United States. Antibodies to HCV are 2 to 3 times more common among black Americans (blacks) than among white Americans (whites), 1 as is hepatocellular carcinoma, a serious complication of chronic HCV infection. 2,3 In addition, the distribution of HCV genotypes differs among racial groups, with genotype 1 virus responsible for approximately 90% of HCV infections in blacks, compared with only 67% in whites. 1 Meaningful assessment of the efficacy and safety of antiviral therapy in blacks has been hampered by the underrepresentation of these patients in prospective clinical trials. 4 Nevertheless, the limited data from retrospective analyses indicate that the response to interferon, alone and in combination with ribavirin, is lower among blacks than among whites. 5-7 Pegylated interferons plus ribavirin are now the standard of care for the treatment of patients with chronic hepatitis C. 8 Two recent large clinical studies of treatment with pegylated interferons plus ribavirin showed overall sustained virological response (SVR) rates of 54% and 56%. 9,10 For patients with HCV genotype 1, the SVR rates were 42% and 46% in the respective studies. 9,10 The primary objective of the present study was to investigate the efficacy and safety of peginterferon alfa-2a (40 kd) plus ribavirin in a population of non-Hispanic black patients with HCV genotype-1 infection. Patients and MethodsPatient Selection. Eligible patients included male and female ...

We assessed the relative importance healthcare consumers attach to various factors in choosing a primary care doctor (PCD) in a cross-sectional, in-person survey. Three survey locations were used: doctors' offices, a public shopping area, and meetings of a women's organization. A total of 636 community residents, varying across major demographic categories, participated. Participants completed a 23-item survey, designed to assess which factors consumers perceive as most relevant in choosing a PCD. Participants perceived professionally relevant factors (e.g. whether the doctor is board certified, office appearance) and management practices (e.g. time to get an appointment, evening and weekend hours) as more important than the doctor's personal characteristics (race, age, gender, etc.). Participants' own characteristics bore little relationship to the perceived importance of doctor characteristics. Factors patients perceive as most important to their choice of a PCD are also those that have the greatest effect on the quality of healthcare they will receive. However, they do not always have access to this information. A better understanding of the factors that influence people's choice of a PCD can contribute to efforts to provide them with the resources to make well-informed decisions in selecting among healthcare options.

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Drug prices in the United States remain the highest in the world. 1 New payment approaches are needed, a point illustratedbythenewtreatmentsforhepatitisCvirus(HCV) infection that are highly effective but also very expensive, at least from the view of many payers, physicians, and patients. Five years after the introduction of these drugs, and due in many cases to budgetary constraints of state Medicaid programs and prisons, only 15% of the estimated population of more than 3 million individuals with HCV in-fectionintheUnitedStateshavebeentreated. 2 Yettheoptimal way to treat HCV is at the population level, that is, by treating every patient possible, with as much speed as is possible. Doing so would reduce the health consequences for those infected, generate the most future savings from improved health, and help decrease future transmission of HCV from person to person.The Department of Health of the State of Louisiana, a statewithahighprevalenceofHCVinfectionandlowtreatment rates, recently published a Request for Information regarding an alternative payment approach, seeking to engage a drug corporation in a subscription-based arrangement to pay for HCV treatment for the state's residents. 3 Gilead Pharmaceuticals indicated the corporation's willingness to explore the idea. 4 The National Governors Association has released a white paper endorsing subscriptionbased models for treating HCV infection as well. 5 In a few media outlets, the idea has been referred to as "the Netflix model," a term used to describe subscription-based models in general. 6 Netflix is a videostreaming service that provides unlimited content for a flat fee; the analogy is a pharmaceutical corporation VIEWPOINT

Although investigative research of animal models in cocaine metabolism and associated liver cell injury has been fairly extensive during the past 10 yr, little evidence of hepatotoxicity has been documented in man. We report a case of fulminant hepatic failure and acute rhabdomyolysis resulting from cocaine use. Coagulative-type perivenular and midzonal necrosis and periportal microvesicular fatty change were the predominant morphological features throughout all lobules of the liver, in contrast to periportal necrosis described in the only previous case report with biopsy. Differences in zonal necrosis caused by the same drug are not typically seen in man experiencing direct or indirect intrinsic hepatotoxicity. However, experimental models have shown cocaine to have this ability, dependent on enzyme induction or inhibition, sex and dose. Therapeutic approaches for prevention of possible liver cell injury by cocaine toxicity are discussed.