Hepatitis B reactivation risk and physician awareness in rheumatological patients receiving anti-tumor necrosis factor-α treatment

OBJECTIVE: We aimed to evaluate the risk of hepatitis B virus reactivation in rheumatic patients using anti-tumor necrosis factor-alpha drugs and the awareness of physicians about hepatitis B virus reactivation. METHODS: Demographic characteristics, pre- and post-treatment hepatitis markers, and laboratory parameters of patients receiving anti-tumor necrosis factor-alpha therapy in our rheumatology clinic were retrospectively examined. RESULTS: A total of 448 patients, 240 (53.6%) female and 208 (46.4%) male, were evaluated. Their mean age was 48.02 +/- 14.64 years. While HBsAg was examined in 443 (98.9%) patients before treatment, 7 (1.6%) patients were found to be HBsAg positive. While anti-HBc IgG was examined in 405 (90.4%) patients, it was positive in 69 (17%) patients. HBs Ag (total 446-99.6%) test was performed in three patients who were not tested for HBsAg before the treatment, and anti-HBc total (431-96.2% total) test was performed in 26 patients who were not tested for anti-HBc total. All HBsAg positive patients and 17 (24.6%) of those with previous hepatitis B received antiviral treatment. While the median follow-up period of the patients was 24 (6-60) months, no patient developed hepatitis B virus reactivation. CONCLUSION: The screening rates and awareness of physicians providing anti-tumor necrosis factor-alpha therapy for hepatitis B virus infection were found to be higher compared to similar studies. Hepatitis B virus reactivation did not develop in any patient. Since the risk of hepatitis B virus reactivation is low, especially in patients with previous hepatitis B, it would be more appropriate to follow up the patients without giving antiviral prophylaxis

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Investigation of the hepatitis b virus in solid tumors and their detection policy

Giriş: Hepatit B virüsü (HBV) enfeksiyonu önemli morbidite ve mortalite ile ilişkili dünya çapında bir hastalıktır ve akut enfeksiyon sonrası HBV enfeksiyonuna bağışıklık kazanan kişilerin % 1-2'sinde HBV klirensine rağmen okkült olarak karaciğer dokusunda virüs replikasyona devam edebilir. Kemoterapi ile indüklenen immünsüpresyon ile HBV yeniden aktive olabilir ve karaciğer yetmezliğinden fulminan hepatite kadar ilerleyerek hastanın ölümüne neden olabilir. Kemoterapi gibi immünsupresif tedaviler sırasında ve sonrasında HBV enfeksiyonunun reaktivasyonu, kronik ya da geçirilmiş hepatit B aktivasyonunda görülebilen hayatı tehdit eden bir komplikasyondur.Bu nedenle özellikle son dekatta immünsüpresif tedavi seçeneklerin giderek artması neticesinde bu tip tedaviler öncesinde hepatit B virüs enfeksiyonunun taranması giderek önem kazanmıştır. Dünya'da bu konu ile ilgili çeşitli ülkelerde ve farklı disiplinlerde farkındalık düzeyleri ile ilgili yapılan çalışmalar mevcuttur. Ülkemizde ise immünsüpresif tedavi alan solid tümörlü hastalarda tedavi öncesi yapılması gereken hepatit B virüs enfeksiyonun taranma oranları ve bununla ilgili farkındalık düzeyi ile ilgili bir çalışma tespit edilmemiştir. Amaç: Araştırmamız ile immünsüpresif tedavi alan solid tümörü olan kanser hastalarında hepatit B virüsü ile temas ve tespit politikası değerlendirilecektir. Metod: 2010-2017 yılları arasında Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi İç Hastalıkları Anabilim Dalı'nda tanı, tedavi, takibi yapılan solid tümörlü hastaların kanser tipi, yaş, cinsiyet, ALT, AST, HBsAg, anti-HBs, anti-HBc IgM, anti-HBc Ig G, HBeAg, anti-HBe, HBV DNA düzeyleri tespit edilecektir. Yıllar arasında Hepatit B serolojisinin bakılması açısından farklılık olup olmadığı araştırılacaktır. Bulgular: 593 hasta ile yapılan çalışmada son 3 yıldır oranı artmakla beraber hastaların 126'sına (%21,2) anti HBc Ig G bakıldığı bulundu. Hastaların %23,6'sının tedavi öncesi HBsAg düzeylerinin izlenmediği, tedavi sürecinde KCFT düzeyi yükselen 82 hastanın 12'sine (%14,6) anti-HBc Ig G izlemi yapıldığı bulundu. Tartışma ve Sonuç: Yaptığımız çalışma sonucunda hastanemizde immünsupresif tedavi alacak solid tümörlü hastalarda tedavi öncesi hepatit B virüs enfeksiyonu taramasının yıllar içinde artan oranlarda yapıldığı gözlenmiştir. Tarama oranlarındaki bu artışa rağmen elde ettiğimiz oran dünyadaki birçok klinik ile benzer şekilde arzu edilen düzeyin altındadır. Bu konu ile ilgili bilimsel toplantıların artırılması, kılavuzların uygulanmasının içselleştirilmesi, immünsüpresif tedavi alacak hastaların tedavisi düzenlendiğinde otomasyon sistemlerinin klinisyeni uyarması gibi ek tedbirlerin alınması ve konunun tıbbi eğitim programlarında güncel olarak işlenmesinin tarama oranlarının istenilen düzeye gelmesinde katkı sağlayacağı kanaatine varılmıştır. Anahtar Kelimeler: Hepatit B, Kemoterapi, Okkült Hepatit B Hepatitis B virus (HBV) infection is a worldwide disease associated with significant morbidity and mortality, and 1-2% of individuals immunized against HBV infection after acute infection may continue to virus replication in the liver as occult in spite of HBV clearance. With chemotherapy-induced immunosuppression, HBV may reactivate and lead to fulminant hepatitis from liver failure, leading to death of the patient. Reactivation of HBV infection during and after immunosuppressive treatments such as chemotherapy is a life-threatening complication that can be seen in chronic or past hepatitis B activation. Therefore, the screening of hepatitis B virus infection has become increasingly important, especially in the last decade, when immunosuppressive treatment options are increasing. There are studies about the level of awareness in different countries and different disciplines related to this subject in the world. In our country, no study has been conducted on the screening rates of hepatitis B virus infection and its level of awareness in immunocompromised patients with solid tumors before treatment. Purpose: In our study, the contact and detection policy of hepatitis B virus will be evaluated in cancer patients receiving immunosuppressive therapy. Methodology: Cancer type, age, gender, ALT, AST, HBsAg, anti-HBs, anti-HBc IgM, anti-HBc Ig G, HBeAg, anti-HBe and HBV DNA levels of patients with solid tumors diagnosed, treated and followed up at Recep Tayyip Erdogan University Medical Faculty Department of Internal Medicine between 2010-2017 levels will be detected. Whether or not hepatitis B serology differs between years will be investigated. Findings: In the study with 593 patients, anti-HBc Ig G was found in 126 of the patients (21,2%) while the rate increased for the last 3 years.It was seen that 23.6% of the patients did not follow HBsAg levels before treatment.Anti-HBc Ig G was detected in 12 (14.6%) of the 82 patients with elevated KCFT levels during chemotherapy treatment. Discussion: It is observed that in our solid tumor patients who will receive immunosuppressive treatment in our hospital as a result of our work, the pre-treatment hepatitis B virus infection screening is done at increasing rates over the years. Despite this increase in screening rates, the rate we achieve is similar to that of many clinics around the world. It has been concluded that increasing the number of scientific meetings on this issue, internalizing the implementation of guidelines, taking additional measures such as the warning of the clinicians of automation systems when the patients receiving immunosuppressive treatment are arranged, and updating the current medical education programs in this way will contribute to the desired level of screening rates. Keywords:Hepatitis B, Chemotherapy, Occult Hepatitis