Long term nucleotide and nucleoside analogs treatment in chronic hepatitis B HBeAg negative genotype D patients and risk for hepatocellular carcinoma

Background and rationale of the study. Effect of Long-term nucleoside/nucleotide (NUC) on hepatocellular carcinoma (HCC) incidence in a population of HBeAg-negative genotype D patients has not been adequately studied in real-life cohorts. Our aim was to evaluate the impact of liver fibrosis and other variables on HCC incidence in this population of patients. Of 745 patients with chronic hepatitis B (CHB), 306 HBeAg-negative genotype D were selected and included in this study. All patients received treatment with NUC for at least 18 months. Patients with CHB or compensated cirrhosis were included. Patients with HCC diagnosed before or during the first 18 months of NUC therapy were excluded. Results. HCC was diagnosed in 2 CHB patients (1.0%) and 23 cirrhosis patients (20%) (OR = 24.41, 95% CI 5.40 < OR < 153.2; p < 0.0001). Multivariate analysis revealed that HCC risk was independently associated with age ≥ 60 years (OR = 6.45, 95% CI 1.22 to 34.0; p = 0.02) and liver cirrhosis (OR = 12.1, 95% CI 1.39 to 106.2; p = 0.02), but not with virological response (VR), and previous resistance to NUC, or rescue therapy. Multivariate analysis in cirrhosis patients revealed that only age ≥ 60 years was an independent risk factor associated with HCC (p = 0.003). Conclusions. Liver cirrhosis and age ≥ 60 years are the stronger risk factors for HCC in genotype D HBeAgnegative patients. Previous resistance to NUC in patients that achieved a VR after rescue therapy was not a predictive factor regarding HCC. VR does not appear to significantly reduce the overall incidence of HCC when a patient has already progressed to liver cirrhosis

Nonurgent patients in the emergency department? A French formula to prevent misuse

<p>Abstract</p> <p>Background</p> <p>Overcrowding in emergency department (EDs) is partly due to the use of EDs by nonurgent patients. In France, the authorities responded to the problem by creating primary care units (PCUs): alternative structures located near hospitals. The aims of the study were to assess the willingness of nonurgent patients to be reoriented to a PCU and to collect the reasons that prompted them to accept or refuse.</p> <p>Methods</p> <p>We carried out a cross sectional survey on patients' use of EDs. The study was conducted in a French hospital ED. Patients were interviewed about their use of health services, ED visits, referrals, activities of daily living, and insurance coverage status. Patients' medical data were also collected.</p> <p>Results</p> <p>85 patients considered nonurgent by a triage nurse were asked to respond to a questionnaire. Sex ratio was 1.4; mean age was 36.3 +/- 11.7 years.</p> <p>Most patients went to the ED autonomously (76%); one third (31.8%) had consulted a physician. The main reasons for using the ED were difficulty to get an appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the availability of medical services in the ED, like imaging, laboratory tests, and drug prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for going to the ED (43.5%).</p> <p>More than two-thirds of responders (68%) were willing to be reoriented towards PCUs. In the multivariate analysis, only employment and the level of urgency perceived by the patient were associated with the willingness to accept reorientation. Employed persons were 4.5 times more likely to accept reorientation (OR = 4.5 CI (1.6-12.9)). Inversely, persons who perceived a high level of urgency were the least likely to accept reorientation (OR = 0.9 CI (0.8-0.9).</p> <p>Conclusions</p> <p>Our study provides information on the willingness of ED patients to accept reorientation and shows the limits of its feasibility. Alternative structures such as PCUs near the ED seem to respond appropriately to the growing demands of nonurgent patients. Reorientation, however, will be successful only if the new structures adapt their opening hours to the needs of nonurgent patients and if their physicians can perform specific technical skills.</p

Attitudes et comportements des médecins des établissements de santé vis à vis des recommandations professionnelles

PARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF

Evaluation préliminaire des besoins de formation en gastroentérologie des médecins urgentistes au sein d’un centre hospitalo-universitaire

But : Depuis plusieurs années en France, s’est développée une offre de formation médicale continue destinée au perfectionnement des médecins libéraux. En revanche, au sein des Centres hospitalo-universitaires, il n’existe pas souvent de dispositif formel de formation spécifiquement destiné aux médecins généralistes urgentistes. Le but de notre travail était d’évaluer les besoins de formation en hépato-gastro-entérologie des médecins urgentistes de notre centre. Méthodes : Notre démarche d’évaluation des besoins s’est appuyée sur des entrevues individuelles et un questionnaire ouvert complété par une grille d’analyse quantitative et qualitative (grille Fréquence, Gravité, Problème). L’avis des gastroentérologues a également été recueilli grâce aux mêmes questionnaires. Résultats : Les réponses de 22 médecins urgentistes et des six gastroentérologues ont pu être recueillis. Les entrevues individuelles ont permis de mettre en évidence des besoins de formation ressentis par l’ensemble des médecins urgentistes. La réunion préalable à la remise des questionnaires a permis d’individualiser trois sujets (hémorragie digestive, pancréatite aiguë, angiocholite aiguë). Pour l’ensemble des sujets considérés, les médecins urgentistes exprimaient des besoins en termes de savoir et de savoir-faire mais pas de besoin dans le registre du savoir-être. En revanche, les gastroentérologues exprimaient, pour les médecins urgentistes, des besoins concernant les trois dimensions pour chaque problème. Conclusion : Notre travail a permis de mettre en évidence des besoins ressentis et exprimés de formation de la part des médecins urgentistes. L’utilisation ultérieure d’outils complémentaires d’analyse des besoins devrait nous permettre de préciser encore mieux ces besoins afin de développer une formation adéquate

HCV genotype 1a shows a better virological response to antiviral therapy than HCV genotype 1b

Background: The impact of viral subtype on the rate of sustained virological response (SVR) to antiviral therapy in patients chronically infected with hepatitis C genotype 1 subtype 1a and 1b has not been extensively investigated. The aim of this study is to determine whether the HCV genotype 1 subtypes 1a and 1b respond differently to treatment with PEGylated interferon (PEG-IFN) plus ribavirin. Methods: For 48 weeks, 388 "naive" genotype 1 patients were treated weekly with PEG-IFN a-2a or PEG-INF a-2b combined with daily ribavirin (1000-1200 mg/day). The numbers of patients in whom HCV-RNA was undetectable were compared after 4 (rapid virological response, RVR), 12 (early virological response, EVR), and 48 (end treatment virological response, ETR) weeks of treatment as well as 24 weeks after the last treatment (sustained virological response, SVR). Results: The rate of SVR was higher in subtype 1a patients than subtype 1b patients (55% vs. 43%; p < 0.02). Multiple logistic regression analysis showed that infection with genotype 1a (odds ratio(OR) : 1.8; 95% confidence interval (CI): 1.4 to 4.1), age < 50 years (OR: 7.0; 95% CI 1.1 to 21.2), alanine aminotransferase level (ALT)<100 IU/ml (OR:2.1; 95% CI: 1.3 to3.5), HCV-RNA < 5.6 log(10) IU/ml (OR: 3.2; 95% CI: 2.7 to 6.9) and fibrosis score < S3 (OR: 3.8; 95% CI: 3.2 to 7.4), were all independent predictors of SVR. Conclusion: Dual antiviral therapy is more effective against HCV subtype 1a than against subtype 1b and this difference is independent of other factors that may favour viral clearance