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\"The True Performing Of It places the two writers side by side and examines the resultant analogies in their work that spring from this positioning. After a teasing prologue, the book begins by reflecting on the significance of Dylan's remarks on Shakespeare when accepting the Nobel Prize for Literature, before examining their shared Bardic qualities, and their position of being feted for their undoubted literary qualities despite both being primarily artists of live performances of drama and music ... \"--Provided by publisher.

Hepatitis C virus (HCV) treatment took a major step forward at the end of 2013 with the approvals of the second-generation protease inhibitor simeprevir (Olysio) and the nucleotide polymerase inhibitor sofosbuvir (Sovaldi). The interferon-free regimen of sofosbuvir and ribavirin is now available for genotype 2 and 3 patients. This regimen for 12 weeks is highly effective for genotype 2, whereas genotype 3 has proven to be more challenging and requires 24 weeks of therapy. Genotype 1 patients have reduced exposure to peginterferon-α with a 12-week regimen with sofosbuvir and a 24-week regimen with simeprevir. Genotype 4, 5, and 6 patients also respond well to the regimen of sofosbuvir, peginterferon-α, and ribavirin. In another landmark event, the initial approval of sofosbuvir included HCV/HIV-1 coinfected patients. Simeprevir and sofosbuvir also provide a window to the future with sustained virologic response (SVR) rates of >90% for genotype 1 when these agents are combined. Interferon-free regimens for genotype 1 patients have anticipated approvals in late 2014 or early 2015. Clinicians and patients will have the opportunity to discuss and select from current treatment options or await upcoming regimens. These potent new agents provide the tools to cure HCV for many patients.

Background and AimsThe coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid expansion of telehealth services in hepatology. However, known racial and socioeconomic disparities in internet access potentially translate into barriers for the use of telehealth, particularly video technology. The specific aim of this study was to determine if disparities in race or socioeconomic status exist among patients utilizing telehealth visits during COVID-19.MethodsWe performed a retrospective cohort study of all adult patients evaluated in hepatology clinics at Duke University Health System. Visit attempts from a pre-COVID baseline period (January 1, 2020 through February 29, 2020; n = 3328) were compared to COVID period (April 1, 2020 through May 30, 2020; n = 3771).ResultsOn multinomial regression modeling, increasing age was associated with higher odds of a phone or incomplete visit (canceled, no-show, or rescheduled after May 30,2020), and non-Hispanic Black race was associated with nearly twice the odds of completing a phone visit instead of video visit, compared to non-Hispanic White patients. Compared to private insurance, Medicaid and Medicare were associated with increased odds of completing a telephone visit, and Medicaid was associated with increased odds of incomplete visits. Being single or previously married (separated, divorced, widowed) was associated with increased odds of completing a phone compared to video visit compared to being married.ConclusionsThough liver telehealth has expanded during the COVID-19 pandemic, disparities in overall use and suboptimal use (phone versus video) remain for vulnerable populations including those that are older, non-Hispanic Black, or have Medicare/Medicaid health insurance.

In this phase 3 study involving patients with HCV genotype 1, 2, 3, 4, or 6 and decompensated cirrhosis, sofosbuvir–velpatasvir with or without ribavirin for 12 weeks or sofosbuvir–velpatasvir for 24 weeks resulted in high rates of sustained virologic response. The number of patients with decompensated cirrhosis caused by chronic infection with the hepatitis C virus (HCV) is projected to rise in the coming decade. 1 For many years, the only treatment option for such patients was liver transplantation. Recently, however, clinical trials of newly approved direct-acting antiviral agents have shown that it is possible to treat HCV infection safely and effectively in patients with decompensated cirrhosis and that successful treatment is associated with early improvement in liver function. 2 – 11 The possible long-term benefits of treatment on existing liver disease remain unknown. The only regimen that is currently approved for the . . .

Cirrhosis and its related complications remain a prominent global health concern despite advances in understanding and treating the disorder. Early diagnosis and intervention strategies may reduce the impact of cirrhosis; however, it can be difficult for initial point-of-care health care providers to identify and refer patients with cirrhosis due to lack of knowledge and resources. This review examines current diagnostic strategies for cirrhosis and cirrhosis-related complications and the potential benefits of multidisciplinary care for patients with the disorder. A PubMed search of the medical literature was conducted to identify current diagnostic methods and standards and ascertain the impact of multidisciplinary care on patients with cirrhosis. Screening of patients at risk for cirrhosis has been recommended by several professional and governmental organizations. Unfortunately, identification of early-stage cirrhosis remains challenging despite development of novel calculations for risk (eg, aspartate transaminase-to-platelet count ratio) that use values from common, noninvasive laboratory tests to determine the extent of liver disease. Abnormal liver function test results and alterations in serum liver enzyme markers (eg, alanine and aspartate transaminases) may suggest cirrhosis in patients with chronic liver disease; however, they are not definitive. Liver biopsy is the gold standard for diagnosis and staging of cirrhosis, but its cost, invasiveness, and risk of complications have prompted the development of noninvasive tests (eg, elastography). Primary care physicians should be aware of the signs and symptoms of cirrhosis-related complications, particularly portal hypertension, and refer patients to specialists for further evaluation when warranted. Patients at risk for cirrhosis should be screened and the underlying etiologic factor(s) of the liver disease treated or appropriately managed when possible. Primary care physicians should be aware of the signs and symptoms of cirrhosis and its related complications and adopt a low threshold for referral to a specialist when the condition is suspected. An integrated, multidisciplinary approach to care between specialists and primary care physicians may improve early detection of cirrhosis and its related complications and strengthen management strategies.

ObjectiveIn retrospective studies, liver stiffness (LS) by vibration-controlled transient elastography (VCTE) is associated with the risk of liver decompensation in patients with non-alcoholic steatohepatitis (NASH), but prospective data in biopsy-confirmed cohorts with advanced fibrosis are limited. We aimed to establish thresholds for LS by VCTE that predict progression to cirrhosis among patients with bridging fibrosis and hepatic decompensation among patients with cirrhosis due to NASH.DesignWe used data from four randomised placebo-controlled trials of selonsertib and simtuzumab in participants with advanced fibrosis (F3–F4). The trials were discontinued due to lack of efficacy. Liver fibrosis was staged centrally at baseline and week 48 (selonsertib study) or week 96 (simtuzumab study). Associations between LS by VCTE with disease progression were determined using Cox proportional hazards regression analysis.ResultsProgression to cirrhosis occurred in 16% (103/664) of participants with bridging fibrosis and adjudicated liver-related events occurred in 4% (27/734) of participants with baseline cirrhosis. The optimal baseline LS thresholds were ≥16.6 kPa for predicting progression to cirrhosis, and ≥30.7 kPa for predicting liver-related events. Baseline LS ≥16.6 kPa (adjusted HR 3.99; 95% CI 2.66 to 5.98, p<0.0001) and a ≥5 kPa (and ≥20%) increase (adjusted HR 1.98; 95% CI 1.20 to 3.26, p=0.008) were independent predictors of progression to cirrhosis in participants with bridging fibrosis, while baseline LS ≥30.7 kPa (adjusted HR 10.13, 95% CI 4.38 to 23.41, p<0.0001) predicted liver-related events in participants with cirrhosis.ConclusionThe LS thresholds identified in this study may be useful for risk stratification of NASH patients with advanced fibrosis.

Barrier removal is a recognized solution for reversing river fragmentation, but restoring connectivity can have consequences for both desirable and undesirable species, resulting in a connectivity conundrum. Selectively passing desirable taxa while restricting the dispersal of undesirable taxa (selective connectivity) would solve many aspects of the connectivity conundrum. Selective connectivity is a technical challenge of sorting an assortment of things. Multiattribute sorting systems exist in other fields, although none have yet been devised for freely moving organisms within a river. We describe an approach to selective fish passage that integrates ecology and biology with engineering designs modeled after material recycling processes that mirror the stages of fish passage: approach, entry, passage, and fate. A key feature of this concept is the integration of multiple sorting processes each targeting a specific attribute. Leveraging concepts from other sectors to improve river ecosystem function may yield fast, reliable solutions to the connectivity conundrum.

Aquatic ecosystems support size structured food webs, wherein predator-prey body sizes span orders of magnitude. As such, these food webs are replete with extremely generalized feeding strategies, especially among the larger bodied, higher trophic position taxa. The movement scale of aquatic organisms also generally increases with body size and trophic position. Together, these body size, mobility, and foraging relationships suggest that organisms lower in the food web generate relatively distinct energetic pathways by feeding over smaller spatial areas. Concurrently, the potential capacity for generalist foraging and spatial coupling of these pathways often increases, on average, moving up the food web toward higher trophic levels. We argue that these attributes make for a food web architecture that is inherently 'adaptive' in its response to environmental conditions. This is because variation in lower trophic level dynamics is dampened by the capacity of predators to flexibly alter their foraging behavior. We argue that empirical, theoretical, and applied research needs to embrace this inherently adaptive architecture if we are to understand the relationship between structure and function in the face of ongoing environmental change. Toward this goal, we discuss empirical patterns in the structure of lake food webs to suggest that ecosystems change consistently, from individual traits to the structure of whole food webs, under changing environmental conditions. We then explore an empirical example to reveal that explicitly unfolding the mechanisms that drive these adaptive responses offers insight into how human-driven impacts, such as climate change, invasive species, and fisheries harvest, ought to influence ecosystem structure and function (e.g., stability, secondary productivity, maintenance of major energy pathways). We end by arguing that such a directed food web research program promises a powerful across-scale framework for more effective ecosystem monitoring and management.

BackgroundMalnutrition in cirrhosis is associated with poor outcomes, leading to guidelines for a high protein, low sodium diet; however, there is no guidance regarding the implementation of diet education in clinical practice.MethodsA mixed methods study enrolled 21 patients with cirrhosis and their caregivers. Semi-structured interviews on barriers and facilitators of dietary education and adherence were conducted. Demographic and clinical data were obtained, along with quantitative measures of dietary adherence, including 24-h food recall and spot urine sodium. Combined deductive and inductive coding was used to identify qualitative themes, along with a quantitative assessment of interviews. Quantitative data was reported using descriptive statistics with frequencies, mean and confidence intervals.ResultsParticipants were mostly male (16/21) with a mean age 57.8 years (SE 2.8) and MELD-Na 9 (SE 1.2). 4 themes emerged: 1. More than 50% of participants and caregivers endorsed no or inadequate diet education 2. They reported mostly negative experiences with dietary adherence with largest impact on social life 3. Facilitators of adherence included the presence of household support and fear of complications of cirrhosis 4. Overwhelmingly desired non-generic handouts and information. Dietary adherence was poor with only one participant meeting protein and sodium requirements based on food recall. Four participants who adhered to < 2000 mg sodium had inadequate daily caloric intake.ConclusionsDietary education is inadequate, and adherence to dietary recommendations is poor in patients with cirrhosis. Future studies should use these barriers and facilitators for intervention development.