Time to Switch to Second-line Antiretroviral Therapy in Children With Human Immunodeficiency Virus in Europe and Thailand.

Background: Data on durability of first-line antiretroviral therapy (ART) in children with human immunodeficiency virus (HIV) are limited. We assessed time to switch to second-line therapy in 16 European countries and Thailand. Methods: Children aged <18 years initiating combination ART (≥2 nucleoside reverse transcriptase inhibitors [NRTIs] plus nonnucleoside reverse transcriptase inhibitor [NNRTI] or boosted protease inhibitor [PI]) were included. Switch to second-line was defined as (i) change across drug class (PI to NNRTI or vice versa) or within PI class plus change of ≥1 NRTI; (ii) change from single to dual PI; or (iii) addition of a new drug class. Cumulative incidence of switch was calculated with death and loss to follow-up as competing risks. Results: Of 3668 children included, median age at ART initiation was 6.1 (interquartile range (IQR), 1.7-10.5) years. Initial regimens were 32% PI based, 34% nevirapine (NVP) based, and 33% efavirenz based. Median duration of follow-up was 5.4 (IQR, 2.9-8.3) years. Cumulative incidence of switch at 5 years was 21% (95% confidence interval, 20%-23%), with significant regional variations. Median time to switch was 30 (IQR, 16-58) months; two-thirds of switches were related to treatment failure. In multivariable analysis, older age, severe immunosuppression and higher viral load (VL) at ART start, and NVP-based initial regimens were associated with increased risk of switch. Conclusions: One in 5 children switched to a second-line regimen by 5 years of ART, with two-thirds failure related. Advanced HIV, older age, and NVP-based regimens were associated with increased risk of switch

Usefulness of endoscopic ultrasonography in the clinical suspicion of biliary disease Utilidad de la ultrasonografía endoscópica en la sospecha clínica de patología biliar

Background and aims: endoscopic ultrasound (EUS) is a very sensitive and specific technique for the diagnosis of biliary diseases. This procedure has proven its usefulness in cases of high suspicion of biliary disease (history of gallstones and dilatation of the intrahepatic and/or extrahepatic bile ducts). We know less about its usefulness in cases of low suspicion of biliary pathology. The aim of this study was to assess the diagnostic accuracy of EUS in patients with low suspicion of biliary disease (patients with dilatation of the biliary tract were excluded). Methods: 33 patients with low suspicion of biliary disease were recruited in 12 months. All of them had no biliary findings in a previous abdominal ultrasound and computer tomography scan. All of them underwent EUS and were studied prospectively. The diagnosis was confirmed by surgery and/or by ERCP in patients with positive EUS or clinical follow-up in those with normal EUS. Time of follow-up was 9 months (range, 3-12 months). Results: seventeen patients (51.5%) presented with abnormal biliary findings on EUS (7 choledocholithiasis, 3 cholelithiasis, 2 choledocholithiasis + cholelithiasis and 5 microlithiasis). Conclusion: EUS is a useful and safe procedure for diagnosing patients with low suspicion of biliary disease.Antecedentes y objetivos: la ultrasonografía endoscópica (USE) es una técnica muy sensible y específica para el diagnóstico de enfermedades biliares. Este procedimiento ha demostrado su utilidad en casos de alta sospecha de enfermedad biliar (historia de colelitiasis y dilatación de la vía biliar intra- y/o extrahepática). Sabemos menos sobre su utilidad en casos de baja sospecha de patología biliar. El objetivo de este estudio fue evaluar la precisión diagnóstica de la USE en pacientes con baja sospecha de enfermedad biliar (los pacientes con dilatación de la vía biliar fueron excluidos). Métodos: 33 pacientes con baja sospecha de enfermedad biliar fueron reclutados en 12 meses. Todos ellos presentaban una ecografía abdominal previa y un TAC sin hallazgos relevantes. Todos se sometieron a una USE y se estudiaron de forma prospectiva. El diagnóstico fue confirmado con los hallazgos quirúrgicos y/o con la colangiopancreatografía retrógrada endoscópica (CPRE) en pacientes con USE positiva o con seguimiento clínico en pacientes con USE normal. El tiempo de seguimiento medio fue de 9 meses (3-12 meses). Resultados: diecisiete pacientes (51,5%) presentaron patología biliar en la USE (7 coledocolitiasis, 3 colelitiasis, 2 colelitiasis + coledocolitiasis y 5 microlitiasis). Conclusión: la USE es un procedimiento útil y seguro para el diagnóstico de pacientes con baja sospecha de enfermedad biliar

Portal hypertensive colopathy is associated with portal hypertension severity in cirrhotic patients

AIM: To assess the prevalence of portal hypertension (PH) related colorectal lesions in liver transplant candidates, and to evaluate its association with the severity of PH

Diagnostic incidence of the presence of positive HBsAg: epidemiologic, clinical, and virological characteristics Incidencia diagnóstica de AgHBs positivo: Características epidemiológicas, clínicas y virológicas

Objective: to analyze the epidemiological, clinical, and virological characteristics of patients newly diagnosed with active hepatitis B virus (HBV) infection based on the presence of positive hepatitis B surface antigen (HBsAg) in the digestive diseases department of a district hospital. Patients and methods: we performed a 3-year prospective study in patients newly diagnosed with HBV infection. We analyzed epidemiological, clinical, and virological characteristics, complete HBV markers, quantification of HBV DNA, and infection by hepatitis delta virus. We performed genotyping and resistance testing in patients with a high viral load. Results were obtained for patients who required liver biopsy. Results: we diagnosed 213 patients (18.8/10,000 inhabitants/year). Men accounted for 61%, and 59% were aged 20 to 40 years. Immigrants accounted for 53% of the population: 46% were from Rumania and 37% from Sub-Saharan African countries. At diagnosis, 2.3% had acute hepatitis (all with jaundice) and 3.3% had cirrhosis with portal hypertension. With the exception of cases of acute hepatitis, positive HBeAg was observed in 9%. Serum transaminase levels were normal in 62.2% of patients, HBV DNA was > 2,000 IU/mL in 33.8%, and delta virus was present in 3.3%. Genotyping and resistance testing were performed in 70 patients: the most common genotype was D, followed by A. Resistance was detected at baseline in only 2 cases: to adefovir in one case and to entecavir in another. Among the 36 biopsies performed, 32.4% showed inflammatory activity &ge; 2, and 23.5% had fibrosis &ge; 2 according to the METAVIR scoring system. According to clinical practice, specific treatment for HBV infection was necessary (any reason) in 17.4% of those diagnosed (3 patients per 100,000 inhabitants/year). Conclusions: despite prevention and vaccination, HBV infection is a health problem that most commonly affects the immigrant population and men. Serum transaminase levels are normal in 62.2% of patients. The most frequent genotype is D, followed by A, and baseline resistance is scarce.Objetivo: analizar las características epidemiológicas, clínicas y virológicas de los pacientes que han sido nuevos diagnósticos de infección activa por VHB, por la presencia de AgHBs positivo, en el servicio de Aparato Digestivo de un hospital de área. Pacientes y métodos: se trata de un estudio prospectivo realizado durante 3 años, en pacientes de nuevo diagnóstico de infección por VHB, donde se han analizado las características epidemiológicas, clínicas, marcadores completos de VHB, cuantificación de DNA-VHB e infección por virus Delta. En los pacientes con alta carga viral se han estudiado genotipos y resistencias. En los pacientes con indicación de biopsias hepáticas sus resultados. Resultados: se han diagnosticado 213 pacientes, 18,8/10.000 habitantes y año. El 61% son varones, el 59% con edad comprendida entre 20 y 40 años. El 53% corresponde a población inmigrante, 46% procedentes de Rumanía y 37% de países subsaharianos. En el momento del diagnóstico, el 2,3% tenían una hepatitis aguda, todos los casos con ictericia, y el 3,3% una cirrosis hepática con hipertensión portal. El AgHBe positivo, descontando los cuadros de hepatitis aguda, estaba presente en el 9%. Las transaminasas eran normales en el 62,2%, el DNA-VHB en el 33,8% es superior a 2.000 UI/ml y la asociación del virus Delta está presente en el 3,3%. En 70 pacientes se analiza el genotipo y resistencias, siendo el más frecuente el D, seguido del A; solo se han detectado dos resistencias basales, una a adefovir y otro a entecavir. En las 36 biopsias hepáticas realizadas, el 32,4% tenían una actividad inflamatoria mayor o igual a 2, y el 23,5% una fibrosis igual o superior a 2, valorada según la clasificación de METAVIR. El 17,4% de los diagnosticados ha precisado tratamiento específico para el VHB según práctica clínica por algún motivo, lo que ha supuesto iniciar tratamiento a unos 3 pacientes por cada 100.000 habitantes y año. Conclusión: a pesar de la prevención y vacunación, la infección por VHB es un problema de salud, afecta de forma más frecuente a población inmigrante, varones y cursa en el 62,2% con transaminasas normales. El genotipo más frecuente es el D seguido del A y las resistencias basales son escasas

Prevalence and Clinical Outcomes of Poor Immune Response Despite Virologically Suppressive Antiretroviral Therapy Among Children and Adolescents With Human Immunodeficiency Virus in Europe and Thailand: Cohort Study

International audienceIn human immunodeficiency virus (HIV)-positive adults, low CD4 cell counts despite fully suppressed HIV-1 RNA on antiretroviral therapy (ART) have been associated with increased risk of morbidity and mortality. We assessed the prevalence and outcomes of poor immune response (PIR) in children receiving suppressive ART

Prevalence and Clinical Outcomes of Poor Immune Response Despite Virologically Suppressive Antiretroviral Therapy Among Children and Adolescents With Human Immunodeficiency Virus in Europe and Thailand: Cohort Study

BACKGROUND: In human immunodeficiency virus (HIV)-positive adults, low CD4 cell counts despite fully suppressed HIV-1 RNA on antiretroviral therapy (ART) have been associated with increased risk of morbidity and mortality. We assessed the prevalence and outcomes of poor immune response (PIR) in children receiving suppressive ART. METHODS: Sixteen cohorts from the European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC) contributed data. Children &lt;18 years at ART initiation, with sustained viral suppression (VS) (≤400 copies/mL) for ≥1 year were included. The prevalence of PIR (defined as World Health Organization advanced/severe immunosuppression for age) at 1 year of VS was described. Factors associated with PIR were assessed using logistic regression. Rates of acquired immunodeficiency syndrome (AIDS) or death on suppressive ART were calculated by PIR status. RESULTS: Of 2318 children included, median age was 6.4 years and 68% had advanced/severe immunosuppression at ART initiation. At 1 year of VS, 12% had PIR. In multivariable analysis, PIR was associated with older age and worse immunological stage at ART start, hepatitis B coinfection, and residing in Thailand (all P ≤ .03). Rates of AIDS/death (95% confidence interval) per 100 000 person-years were 1052 (547, 2022) among PIR versus 261 (166, 409) among immune responders; rate ratio of 4.04 (1.83, 8.92; P &lt; .001). CONCLUSIONS: One in eight children in our cohort experienced PIR despite sustained VS. While the overall rate of AIDS/death was low, children with PIR had a 4-fold increase in risk of event as compared with immune responders