Mohamed, Essa A.

Abstract Background: In Minnesota, the 2012 Cancer Report by the Department of Health reported both the incidence of liver cancer and mortality rates due to liver cancer among Blacks were significantly higher than Caucasians. African immigration to Minnesota is the third highest by percentage of state population in the US. Given that viral hepatitis disproportionately affects sub-Saharan Africans and that these individuals are emigrating from countries where childhood HBV vaccination has only recently been implemented on a national scale, we speculate that this unique immigrant community may be a major contributor to the increased burden of viral hepatitis and liver cancer complications in the state. Limited research exists on the burden of viral hepatitis and hepatocellular carcinoma among African immigrants. Thus, we conducted a prospective community-wide screening to assess the rates of chronic HBV and HCV infections among Somali, Liberian and Kenyan immigrants in Minnesota. Methods: Several African community health centers and organizations in Minnesota were selected for the study. Individuals of Somali, Liberian or Kenyan descent were enrolled in a prospective screening study for chronic HBV and HCV infection. Blood samples were collected and tested for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), hepatitis B surface antibody (HBsAb), and anti-hepatitis C virus antibody (anti-HCV). Follow-up testing, health education, counseling, and referral were provided to participants. Results: 853 participants provided blood specimens. 13.5% of participants had chronic HBV infection while 32.4% had prior HBV exposure with spontaneous viral clearance. 7% of participants had chronic HCV infection. Follow up and linkage to care were provided to participants with chronic hepatitis while preventive advice was provided to those who were negative for both infections. In particular, participants susceptible to HBV were informed about the availability of HBV vaccine in order to protect against future HBV infection. Conclusions: Chronic HBV and HCV are major health problems among recent African immigrants in Minnesota. Community-based screening is an effective way to identify and provide health education and linkage to care for individuals with or at risk for viral hepatitis. Citation Format: Essa A. Mohamed, Nasra H. Giama, Hassan M. Shaleh, Abdul M. Oseini, Hager Ahmed Mohammed, Jessica Cvinar, Ibrahim A. Waaeys, Hamdi A. Ali, Loretta K. Allotey, Lewis R. Roberts. Community-wide outreach and screening to reduce hepatitis B, hepatitis C and liver cancer disparities among African immigrants in Minnesota. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C76.

One of the most controversial health decisions facing women is deciding upon the use of hormonal treatments for symptoms of menopause. This brief review focuses on the historical context of use of menopausal hormone treatments (MHT), summarizes results of major observational, primary and secondary prevention studies of MHT and cardiovascular (CV) outcomes, provides evidence for how sex steroids modulate CV function and identifies challenges for future research. As medicine enters an era of personalization of treatment options, additional research into sex differences in the aetiology of CV diseases will lead to better risk identification for CV disease in women and identify whether a woman might receive CV benefit from specific formulations and doses of MHT.

Abstract Background: African immigrants in the US have substantially higher prevalences of viral hepatitis and hepatocellular carcinoma than the general population. In Minnesota, which has the third largest state population of African immigrants in the US, the incidence and mortality for hepatocellular carcinoma among Blacks is 3 times higher than Caucasians (The 2012 Minnesota Department of Health Cancer Report). Most African immigrants are unaware of their risk for hepatocellular carcinoma which contributes to substantial liver health disparities. Limited research exists on the burden of viral hepatitis and hepatocellular carcinoma among African immigrants. Thus, we conducted a pilot study to evaluate the knowledge, attitudes, and behaviors (KAB) of African immigrants related to liver disease. Methods: The study used a community-engaged research framework. The research team consisted of stakeholders from an academic medical center and Ethiopian, Liberian, and Kenyan community-based organizations and faith-based centers. A semi-structured focus group guide was developed using a KAB approach with open-ended questions. Content analysis was used to thematically code the transcribed data. Qualitative analysis software (ATLAS.TI) was used to organize codes and highlight major themes contributing to liver health disparities. Results: We enrolled 63 participants and conducted 9 focus groups (1 in Amharic, 2 in Oromo, and 6 in English) in Rochester and Minneapolis, Minnesota. The mean age was 47±19; 32 participants (51%) were male; the median years lived in the US was 12 years. General knowledge of the modes of transmission of viral hepatitis and of the prevention and development of liver cancer was minimal. Themes related to barriers to viral hepatitis screening and vaccination included perceived cultural stigma and use of traditional remedies. Common sources of general health information included internet, pamphlets, friends, family, spiritual leaders and healthcare professionals. Healthcare professionals are the source for information on screening, prevention, transmission and treatment of viral hepatitis and liver cancer. Most participants sought healthcare at reputable medical institutions. Media sources and community-based events at faith-centers were preferred modes of information dissemination on viral hepatitis and liver cancer screening and prevention. Conclusions: Participants identified several factors contributing to the increased burden of hepatocellular carcinoma in Minnesota including lack of knowledge of disease transmission and progression, cultural stigma/taboos, and lack of preventive care. Culturally and linguistically appropriate interventions are needed to increase awareness, prevention, early detection, and treatment of viral hepatitis and liver cancer among African immigrants in Minnesota. Citation Format: Essa A. Mohamed, Nasra H. Giama, Hassan M. Shaleh, Linda M. Kerandi, Abdul M. Oseini, Hager F. Ahmed Mohammed, Henry M. Kerandi, Dekermue Togbah, Abdiwahab O. Ali, Ibrahim A. Waaeys, Hamdi A. Ali, Safra A. Mohamed, Hawa M. Ali, Joyce E. Balls-Berry, Lewis R. Roberts. Evaluating knowledge, attitudes, and behaviors about viral hepatitis and hepatocellular carcinoma among recent African immigrants in Minnesota: A community-engaged qualitative study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C01.

Abstract Background: Hepatocellular Carcinoma (HCC) is the 6th most common cancer and the 2nd leading cause of cancer-related mortality in the world. Sub-Saharan Africa and Eastern Asia are regions endemic for viral hepatitis, accounting for 80% of all HCC cases worldwide. A recent hospital-based study assessing the frequency of hepatitis B (HBV), hepatitis C (HCV), and HCC among Somali immigrants seen at Mayo Clinic determined the adjusted frequency for HBsAg positivity was 10-fold higher and anti-HCV positivity was 3-fold higher as compared to non-Somali residents of Olmsted County, Minnesota. Furthermore, HCV infection was identified as the leading contributor to HCC development among Somalis. The overall goal of this study is to determine the risk factors, surveillance, treatment options, and outcomes of Somalis with HCC seen at Mayo Clinic. Methods: The Mayo Clinic Unified Data Platform Advanced Cohort Explorer (ACE) query tool was used to identify Somali patients seen at Mayo Clinic from March 1, 1998 to March 31, 2015. Clinical notes were searched in ACE using conjunction and disjunction combinations: the terms Somali, Somalia or Somalian were linked with the terms HCC, Hepatocellular Carcinoma or Liver Cancer. Diagnosis was validated using histopathology and/or imaging reports from the electronic medical record (EMR). To confirm the ethnicity of identified patients, names were screened by author HMA who is of Somali heritage. Variables abstracted from the EMR include demographics, etiology of HCC, diagnosis date, date of death or last contact, Child-Turcotte-Pugh class, Barcelona Clinic Liver Cancer (BCLC) stage, comorbid conditions, initial and subsequent treatments, HCC surveillance, cirrhosis and other malignancies. Results: 54 Somali patients diagnosed with HCC were seen at Mayo Clinic from March 1, 1998 to March 31, 2015. The mean age was 63±16.3 and 36 (67%) individuals were male. Thirty-eight (70%) of the 54 HCC patients had HCV, 14 (26%) had HBV, 1 (2%) had non-alcoholic steatohepatitis (NASH), and 1 (2%) had unknown etiology for HCC. Of those with known HCV genotypes, the most common were genotype 4 (45%) and 3 (35%). At the time of HCC diagnosis, 16 (32%) presented with BCLC stage A, 5 (10%) with stage B, 17 (34%) with stage C, and 12 (24%) with stage D. Of the 54 patients, 43 (80%) had cirrhosis, 15 (28%) had vascular invasion, and 10 (19%) had metastatic HCC. Regarding treatment, 12 (22%) patients received curative treatment while 42 (78%) received palliative treatment. Orthotopic liver transplantation (OLT) was received by 3 (6%) of Somali patients compared to 19% of non-Somali HCC patients seen at Mayo Clinic between 2007 and 2009. HCC was detected during surveillance in 11 (20%) Somali HCC patients; of the 11, 2 (4%) received semiannual surveillance. Conclusions: These findings provide a starting point to address liver cancer disparities among Somalis. HCV genotype 4 was most commonly associated with HCC development among the study population. Due to low surveillance rates, more Somalis presented with end-stage liver disease. Furthermore, advanced stage HCC was disproportionately found among Somalis compared to the general North American population. A recent study demonstrated that 11% of North American HCC patients seen at 4 major medical centers presented with stage D. By contrast, our study found 25% of Somalis had Stage D HCC. As a result, Somalis are more likely to receive palliative rather than curative treatments. Improving the identification of individuals with chronic HBV or HCV who are at increased risk for HCC and implementing more comprehensive HCC surveillance is likely to reduce the burden of HCC among this population. Citation Format: Hawa M. Ali, Nasra H. Giama, Hager Ahmed Mohammed, Essa A. Mohamed, Ju Dong Yang, Abdirashid M. Shire, Lewis R. Roberts. Hepatocellular carcinoma characteristics and outcomes among Somali immigrants. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B64.

Abstract Background: The rising incidence of hepatocellular carcinoma in the US is partly due to increased immigration from sub-Saharan Africa. Viral hepatitis is prevalent in sub-Saharan Africa, resulting in ~20% of all hepatocellular carcinoma cases worldwide. Community-based education and screening efforts aimed at identifying viral hepatitis cases among African immigrants will likely reduce the burden of hepatocellular carcinoma. Aim: To determine the knowledge, attitudes and behaviors (KAB) of Liberian and Kenyan immigrants residing in Minnesota about hepatitis B virus and hepatitis C virus screening, vaccination, acquisition, and disease management. Methods: A community-engaged research framework was used for the development of this cross-sectional study. The team created a survey using validated items designed to assess the KAB of viral hepatitis measured on a 1 to 20 scale with 1 being low and 20 being high. Using community-engaged methodology, participants who were ≥18 years of age and self-identified either as Liberian and Kenyan were recruited from churches, community centers, and community events. The survey was administered between June 2014 and February 2015. Spearman's rho correlation was used to identify associations among scores while the Mann-Whitney U-test was used for comparisons between Liberians and Kenyans. Results: Of 80 distributed surveys, 73 were returned, achieving a response rate of 91%. Respondents were 50 (64%) Liberians and 23 (29%) Kenyans; 42 (54%) were female; the mean age was 42 years (range 18-90); most were college educated (57%) and had health insurance (83%). 55% reported previous screening for hepatitis B, 51% had completed hepatitis B vaccination and 38% reported being screened for hepatitis C. Mean scores ± SD were 4.6±2.8 for knowledge, 4.7±1.0 for attitude, and 4.2±1.9 for behavior, resulting in poor knowledge and adequate attitude and behavioral levels. Significant and positive linear correlation was observed between attitude and behavior (r=.385, p<.001), while there were no significant correlations between knowledge and attitude (r=-.115, p=.33) or knowledge and behavior (r=-.11, p=.36). When Liberians and Kenyans were compared, knowledge was higher in Liberians (6.2±1.9 vs1.5±1.0; p<.001); there were no significant differences observed in attitude or behavior scores (p>.05 for both). Conclusions: There is lack of awareness among African immigrants of the health risks associated with viral hepatitis which contributes to disparities in healthcare seeking behaviors. It is important to implement comprehensive education and screening programs on viral hepatitis in these communities in order to reduce the burden of viral hepatitis and hepatocellular carcinoma development. Citation Format: Hassan M. Shaleh, Nasra H. Giama, Essa A. Mohamed, Hager F. Ahmed Mohammed, Linda M. Kerandi, Abdul M. Oseini, Abdiwahab O. Ali, Ibrahim A. Waaeys, Jonggi Choi, Henry M. Kerandi, Safra A. Mohamed, Hamdi A. Ali, Hawa M. Ali, Joyce E. Balls-Berry, Lewis R. Roberts. A cross-sectional assessment of knowledge, attitudes, and behaviors about viral hepatitis and hepatocellular carcinoma among Kenyan and Liberian immigrants living in Minnesota. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A46.

Chronic hepatitis B viral (HBV) infection remains a significant global health problem. Evidence‐based guidelines are needed to help providers determine when treatment should be initiated, which medication is most appropriate, and when treatment can safely be stopped. The American Association for the Study of Liver Diseases HBV guideline methodology and writing committees developed a protocol a priori for this systematic review. We searched multiple databases for randomized controlled trials and controlled observational studies that enrolled adults ≥18 years old diagnosed with chronic HBV infection who received antiviral therapy. Data extraction was done by pairs of independent reviewers. We included 73 studies, of which 59 (15 randomized controlled trials and 44 observational studies) reported clinical outcomes. Moderate‐quality evidence supported the effectiveness of antiviral therapy in patients with immune active chronic HBV infection in reducing the risk of cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In immune tolerant patients, moderate‐quality evidence supports improved intermediate outcomes with antiviral therapy. Only very low‐quality evidence informed the questions about discontinuing versus continuing antiviral therapy in hepatitis B e antigen‐positive patients who seroconverted from hepatitis B e antigen to hepatitis B e antibody and about the safety of entecavir versus tenofovir. Noncomparative and indirect evidence was available for questions about stopping versus continuing antiviral therapy in hepatitis B e antigen‐negative patients, monotherapy versus adding a second agent in patients with persistent viremia during treatment, and the effectiveness of antivirals in compensated cirrhosis with low‐level viremia. Conclusion: Most of the current literature focuses on the immune active phases of chronic HBV infection; decision‐making in other commonly encountered and challenging clinical settings depends on indirect evidence. (H epatology 2016;63:284–306)

Growing evidence suggests that pretransplant alpha‐fetoprotein (AFP) predicts outcomes of hepatocellular carcinoma (HCC) patients treated with liver transplantation. We aimed to determine whether pretransplant AFP, Lens culinaris agglutinin‐reactive alpha‐fetoprotein (AFP‐L3), and des‐gamma‐carboxyprothrombin (DCP) predicted HCC recurrence after transplantation. A retrospective cohort study of 313 HCC patients undergoing transplantation between 2000 and 2008 was conducted, and 48 (15.3%) developed recurrence during a median follow‐up of 90.8 months. The 127 patients with available serum drawn before transplantation were included; they included 86 without recurrence and 41 with recurrence. Serum was tested for AFP, AFP‐L3%, and DCP in a blinded fashion with the μTASWako i30 immunoanalyzer. All biomarkers were significantly associated with HCC recurrence. The hazard ratios (HRs) were 3.5 [95% confidence interval (CI), 1.9‐6.7; P < 0.0001] for DCP ≥ 7.5 ng/mL and 2.8 (95% CI, 1.4‐5.4; P = 0.002) for AFP ≥ 250 ng/mL. The HR increased to 5.2 (95% CI, 2.3‐12.0; P < 0.0001) when AFP ≥ 250 ng/mL and DCP ≥7.5 ng/mL were considered together. When they were combined with the Milan criteria, the HR increased from 2.6 (95% CI, 1.4‐4.7; P = 0.003) for outside the Milan criteria to 8.6 (95% CI, 3.0‐24.6; P < 0.0001) for outside the Milan criteria and AFP ≥ 250 ng/mL and to 7.2 (95% CI, 2.8‐18.1; P < 0.0001) for outside the Milan criteria and DCP ≥7.5 ng/mL. Our findings suggest that biomarkers are useful for predicting the risk of HCC recurrence after transplantation. Using both biomarkers and the Milan criteria may be better than using the Milan criteria alone in optimizing the decision of liver transplantation eligibility. Liver Transpl 21:599–606, 2015. © 2015 AASLD.