Predictive value of serum markers of hepatic fibrosis in patients with chronic hepatitis C

INTRODUCTION: Serum markers have been used in the assessment of liver fibrosis in patients with chronic hepatitis C (CHC). AIMS: We evaluated the capacity of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio, gama-glutamyltransferase (GGT) levels, platelet count, the AST to platelet ratio index (APRI) and serum hyaluronic acid (HA) to predict the intensity of hepatic fibrosis in patients with CHC and the variation of these markers after therapy with interferon. PATIENTS AND METHODS: In 72 patients with hepatitis C, AST/ALT ratio, GGT levels, platelet count, the APRI index (calculated as the ratio of AST to platelets) and serum HA concentration were determined and compared to histological staging according to the scoring system of METAVIR. Sixty-five patients received interferon and ribavirin therapy. The individuals that completed the treatment (n = 33) underwent a new test for serum marker of fibrosis in order to compare it with pre-treatment levels. RESULTS: GGT levels, platelet count, the APRI index and serum HA were correlated with the stage of hepatic fibrosis (p < 0.01), except AST/ALT ratio. The analysis of the areas under the ROC curve (AUC) evidenced that APRI and HA levels were the markers with the best association with hepatic staging: AUC (APRI) = 0.85 and AUC (HA) = 0.86. After therapy with interferon, only GGT and the APRI showed reduction of their levels (p < 0.05). CONCLUSION: HA and the APRI index were the most accurate approaches to liver fibrosis staging and they may be used as alternative diagnostic methods in patients with CHC.INTRODUÇÃO: Os marcadores séricos têm sido empregados na avaliação da fibrose hepática em pacientes portadores de hepatite crônica C (HCC). OBJETIVOS: Avaliar a capacidade do índice aspartato aminotransferase (AST)/alanina aminotransferase (ALT), dos níveis séricos de gama-glutamiltransferase (GGT), contagem de plaquetas, do índice AST/plaquetas (APRI) e do ácido hialurônico (AH) em predizer a intensidade da fibrose hepática na HCC e a variação desses marcadores após tratamento com interferon. PACIENTES E MÉTODOS: Em 72 pacientes portadores de hepatite C determinamos no soro o índice AST/ALT, GGT, plaquetas, índice APRI (obtido pelo quociente AST/plaquetas) e o AH, que foram comparados ao estadiamento histológico, segundo os critérios de METAVIR. Receberam tratamento com interferon e ribavirina 65 pacientes. Os indivíduos que concluíram o tratamento (n = 33) realizaram nova dosagem dos marcadores séricos de fibrose para comparar com os níveis pré-tratamento. RESULTADOS: Observamos que a GGT, a contagem de plaquetas, o índice APRI e o AH se correlacionaram com estádio de doença hepática (p < 0,01), exceto o índice AST/ALT. A análise das áreas sob as curvas ROC (AUC) evidenciaram que a melhor associação com estadiamento hepático foi para o índice APRI e a dosagem sérica do AH: AUC (APRI) = 0,85 e AUC (AH) = 0,86. Na avaliação pós-terapia com interferon, apenas a GGT e o índice APRI apresentaram redução de seus níveis (p < 0,05). CONCLUSÃO: O AH e o índice APRI apresentaram maior acurácia no estadiamento da fibrose, podendo ser aplicados como métodos diagnósticos alternativos na HCC.Universidade Federal de São Paulo (UNIFESP)Universidade Federal de Alagoas Hospital UniversitárioUNIFESPFundação Universitária de Ciências da Saúde de Alagoas Governador Lamenha FilhoUFAL HUUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Avaliação da Fibrose Hepática por Elastografia nos pacientes portadores de Esquistossomose Mansônica

Introduction: Schistosomiasis persists as an important public health problem. Its main pathogenic event is hepatic fibrosis, associated with disease progression and its prognosis. The applicability of hepatic elastography in the evaluation of schistosomal fibrosis remains undefined. Objectives: To correlate the degree of fibrosis obtained by transient liver elastography (TE) with sonographic graduation and clinical forms of patients with schistosomiasis mansoni (SM). Methods: A cross sectional study with prospective inclusion of patients with SM, in all its forms, coming from the hepatology outpatient clinic of the University Hospital of the Federal University of Alagoas and from active search in Alagoas municipalities with high endemicity. Clinical and laboratory characteristics (clinical form, AST dosage, ALT, gammaGT, alkaline phosphatase and platelet count) were evaluated. The patients were classified according to the degree of hepatic fibrosis of the Niamey sonographic protocol, adopted by the World Health Organization, gold standard in this study. The TE, performed with FIBROSCAN ECHOSENS 502 device, was correlated with sonographic findings and its performance was calculated as area under the ROC curve (AUC). Results: A total of 117 patients with schistosomiasis mansoni, 55.6% female and 44.4% male, with mean age of 47 + 15 years were studied, 37 patients with intestinal forms, 12 with hepatointestinal form and 68 with compensated hepatosplenic form. Applying the Niamey sonographic protocol, the patients were regrouped for a better statistical analysis in absent fibrosis (A) 34.2%, mild to moderate fibrosis (MM) 27.4% and intense fibrosis (I) 38.5% of the sample. The median value of TE in the entire study population was 8.0 kPa; in the hepatointestinal form 4.4 kPa, in the hepatointestinal form 5.8 kPa and in the hepatosplenic form 10.6 kPa, with statistical differentiation between the clinical forms (p=0.77) and moderate and direct with the levels of AST and GGT (0.45=0,77) e moderada e direta com os níveis de AST e GGT (0,45<=r<=0,56). O ponto de corte da EHT para definir a presença fibrose segundo a classificação sonográfica que apresentou a melhor relação de sensibilidade e especificidade foi 6,1 kPa (AUC 0,92) e para fibrose avançada 8,9 kPa (AUC 0,791). Conclusões: A EHT teve correlação direta com a classificação sonográfica de Niamey e foi capaz de diferenciar as formas clínicas da EM. Baseado no valor da AUC, a EHT provou ser eficaz em detectar a presença da fibrose esquistossomótica e pode auxiliar na identificação de formas avançadas da doença hepática causada pelo Schistosoma mansoni.Dados abertos - Sucupira - Teses e dissertações (2019

Direct antiviral therapy for treatment of hepatitis C: A real-world study from Brazil

Introduction and objectives: Direct antiviral agents (DAAs) including sofosbuvir (SOF), daclatasvir (DCV), simeprevir (SIM) and ombitasvir, paritaprevir and dasabuvir were introduced 2015 in Brazil for treatment of hepatitis C virus (HCV) infection. The aims of this study were to assess effectiveness and safety of HCV treatment with DAA in real-life world in a highly admixed population from Brazil. Materials and methods: All Brazilian reference centers for HCV treatment were invited to take part in a web-based registry, prospectively conducted by the Brazilian Society of Hepatology, to assess outcomes of HCV treatment in Brazil with DAAs. Data to be collected included demographics, disease severity and comorbidities, genotype (GT), viral load, DAA regimens, treatment side effects and sustained virological response (SVR). Results: 3939 patients (60% males, mean age 58 ± 10 years) throughout the country were evaluated. Most had advanced fibrosis or cirrhosis, GT1 and were treated with SOF/DCV or SOF/SIM. Overall SVR rates were higher than 95%. Subjects with decompensated cirrhosis, GT2 and GT3 have lower SVR rates of 85%, 90% and 91%, respectively. Cirrhosis and decompensated cirrhosis in GT1 and male sex and decompensated cirrhosis in GT3 were significantly associated with no SVR. Adverse events (AD) and serious AD occurred in 18% and 5% of those subjects, respectively, but less than 1% of patients required treatment discontinuation. Conclusion: SOF-based DAA regimens are effective and safe in the heterogeneous highly admixed Brazilian population and could remain an option for HCV treatment at least in low-income countries

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research