1
|
Szpakowski JL, Tucker LY, Baer DM, Pauly MP. Hepatotoxicity during legacy cancer chemotherapy in patients infected with hepatitis C virus: A retrospective cohort study. Can Liver J 2022; 5:43-60. [PMID: 35990784 PMCID: PMC9231429 DOI: 10.3138/canlivj-2021-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/04/2023]
Abstract
BACKGROUND The rates and causes of significant hepatotoxicity with cancer chemotherapy (CCT) in patients infected with hepatitis C virus (HCV) are incompletely characterized. METHODS We compared rates of grade 3 or 4 hepatotoxicity, defined as elevated transaminases, during CCT in patients who are mono-infected with HCV compared with rates in controls matched on demographics, diagnosis, and rituximab use. We excluded patients with hepatobiliary cancers, hepatitis B virus or human immunodeficiency virus infection. Hepatotoxicity was attributed to a medical cause, cancer progression, or CCT, including HCV flare. RESULTS Patients with HCV (n = 196) had a higher rate of cirrhosis than the 1,130 matched controls (21.9% versus 4%; P <0.001). Their higher rate of overall hepatotoxicity (8.7% versus 4.5% of controls, P = 0.01) was due to higher rate of CCT-related hepatotoxicity (4.1% versus 1.2%, P = 0.01). On multivariable analysis, the largest risk factor for overall hepatotoxicity was cirrhosis, and the only risk factor for CCT-related hepatotoxicity was HCV infection. Among those with HCV, the only significant risk factor for hepatotoxicity was rituximab use. Hepatotoxicity caused by CCT delayed or altered treatment in only 3 HCV patients and 1 control (1.5% versus 0.1%, P = 0.01). CONCLUSIONS Most patients with HCV can safely be treated with cancer chemotherapy. Cirrhosis and HCV infection contributed to increased hepatotoxicity in subjects on CCT. Among HCV patients, rituximab use was the major risk factor for increased hepatotoxicity. Hepatotoxicity due to CCT itself rarely altered or delayed CCT. Nonetheless, HCV-positive patients should be monitored carefully during CCT.
Collapse
Affiliation(s)
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - David M Baer
- Kaiser Permanente Medical Center, Oakland, California, USA
| | - Mary Pat Pauly
- Kaiser Permanente Medical Center, Sacramento, California, USA
| |
Collapse
|
2
|
Chak E, Vu F, Dang J, Smith U, Stewart S, Tam K, Beste‐Fong A, Phelps B, Johnson I, Suarez M, Pat Pauly M, Chen MS. Enhancing Electronic Health Systems to End Transmission of Chronic Hepatitis B During COVID-19: A Collaborative Approach. Clin Liver Dis (Hoboken) 2021; 17:424-428. [PMID: 34386208 PMCID: PMC8340353 DOI: 10.1002/cld.1144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 04/07/2021] [Accepted: 05/25/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Eric Chak
- Division of Gastroenterology and HepatologyUC Davis School of MedicineSacramentoCA
| | - Fresnia Vu
- Sacramento Community ClinicsHealth and Life Organization, Inc.SacramentoCA
| | - Julie Dang
- Department of Public Health SciencesUC Davis School of MedicineSacramentoCA
| | - Ulissa Smith
- Office of Community Outreach and EngagementUC Davis Comprehensive Cancer CenterSacramentoCA
| | - Susan Stewart
- Division of BiostatisticsUC Davis Department of Public Health SciencesSacramentoCA
| | - Karman Tam
- Sacramento County Department of Health ServicesDivision of Public HealthSacramentoCA
| | - Amy Beste‐Fong
- Sacramento County Department of Health ServicesDivision of Public HealthSacramentoCA
| | | | - Ian Johnson
- Sacramento Community ClinicsHealth and Life Organization, Inc.SacramentoCA
| | - Miguel Suarez
- Sacramento Community ClinicsHealth and Life Organization, Inc.SacramentoCA
| | | | - Moon S. Chen
- Division of Hematology and OncologyUC Davis School of MedicineSacramentoCA
| |
Collapse
|
3
|
Marcus JL, Hurley LB, Chamberland S, Champsi JH, Gittleman LC, Korn DG, Lai JB, Lam JO, Pauly MP, Quesenberry CP, Ready J, Saxena V, Seo SI, Witt DJ, Silverberg MJ. Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population. Public Health Rep 2018; 133:452-460. [PMID: 29750893 PMCID: PMC6055302 DOI: 10.1177/0033354918772059] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation. METHODS We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation. RESULTS Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007). CONCLUSIONS Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.
Collapse
Affiliation(s)
- Julia L. Marcus
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Leo B. Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Scott Chamberland
- Regional Pharmacy, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jamila H. Champsi
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | - Laura C. Gittleman
- Medical Group Support Services, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Daniel G. Korn
- Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Jennifer B. Lai
- Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Jennifer O. Lam
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mary Pat Pauly
- Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA
| | | | - Joanna Ready
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Varun Saxena
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | - Suk I. Seo
- Kaiser Permanente Antioch Medical Center, Antioch, CA, USA
- Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - David J. Witt
- Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | | |
Collapse
|
4
|
Drees JC, Wi S, Ready JB, Dlott RS, Fetterman BJ, Seo SI, Pat Pauly M, Petrie MS, Lorey TS. Serum Fibrosis Marker Panels FIB-4 Index and Aspartate Aminotransferase (AST)-to-Platelet Ratio Index (APRI) Are Equivalent to AST Alone at Predicting Liver Fibrosis in a Cohort of 1731 Patients Infected with Hepatitis C Virus. J Appl Lab Med 2017; 2:76-85. [PMID: 33636957 DOI: 10.1373/jalm.2016.022509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/28/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Efficient tools are needed to stage liver disease before treatment of patients infected with hepatitis C virus (HCV). Compared to biopsy, several studies demonstrated favorable performance of noninvasive multianalyte serum fibrosis marker panels [fibrosis-4 (FIB-4) index] and aspartate aminotransferase (AST)-to-platelet ratio index (APRI), but suggested cutoffs vary widely. Our objective was to evaluate FIB-4 index and APRI and their component tests for staging fibrosis in our HCV-infected population and to determine practical cutoffs to help triage an influx of patients requiring treatment. METHODS Transient elastography (TE) results from 1731 HCV-infected patients were mapped to an F0-F4 equivalent scale. Each patient's APRI and FIB-4 index were calculated. Areas under the receiver operator curve (AUROCs) and false-positive and false-negative rates were calculated to retrospectively compare the performance of the indices and their component tests. RESULTS The highest AUROCs for distinguishing severe (F3-F4) from mild-to-moderate (F0-F2) fibrosis had overlapping 95% CIs: APRI (0.77; 0.74-0.79), FIB-4 index (0.76; 0.73-0.78), and AST (0.74; 0.72-0.77). Cutoffs had false-negative rates of 2.7%-2.8% and false-positive rates of 6.4%-7.4% for all 3 markers. CONCLUSIONS AST was as effective as FIB-4 index and APRI at predicting fibrosis. Published cutoffs for APRI and FIB-4 index would have been inappropriate in our population, with false-negative rates as high as 11%. For our purposes, no serum fibrosis marker was sufficiently sensitive to rule-out significant fibrosis, but cutoffs developed for AST, FIB-4 index, and APRI all had specificities of 79.2%-80.3% for ruling-in severe fibrosis and could be used to triage 1/3 of our population for treatment without waiting for TE or liver biopsy.
Collapse
Affiliation(s)
- Julia C Drees
- Kaiser Permanente, TPMG Regional Laboratory, Berkeley, CA
| | - Soora Wi
- Kaiser Permanente, TPMG Regional Laboratory, Berkeley, CA
| | - Joanna B Ready
- Kaiser Permanente, TPMG Gastroenterology and Hepatology, Santa Clara, CA
| | | | | | - Suk I Seo
- Kaiser Permanente, TPMG Gastroenterology and Hepatology, Walnut Creek, CA
| | - Mary Pat Pauly
- Kaiser Permanente, TPMG Gastroenterology and Hepatology, Sacramento, CA
| | | | - Thomas S Lorey
- Kaiser Permanente, TPMG Regional Laboratory, Berkeley, CA
| |
Collapse
|
5
|
Price JC, Murphy RC, Shvachko VA, Pauly MP, Manos MM. Effectiveness of telaprevir and boceprevir triple therapy for patients with hepatitis C virus infection in a large integrated care setting. Dig Dis Sci 2014; 59:3043-52. [PMID: 25102983 PMCID: PMC4237658 DOI: 10.1007/s10620-014-3294-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/13/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND In 2011, the FDA approved telaprevir (TVR) and boceprevir (BOC) for use with pegylated interferon and ribavirin to treat hepatitis C virus (HCV) genotype 1. We aimed to evaluate the real-world application, tolerability, and effectiveness of TVR- and BOC-based HCV treatment in a large integrated care setting. METHODS We utilized Northern California Kaiser Permanente Medical Care Program (KPNC) electronic databases and medical records to study the experience of all KPNC patients who initiated TVR or BOC from June 2011 to March 2012. RESULTS Compared with the pool of 5,194 treatment-eligible patients, the 352 treatment initiators were more likely to be cirrhotic (24 vs. 10%, p < 0.001) and treatment-experienced (44 vs. 22%, p < 0.001). Among the treatment initiators, 211 received TVR and 141 BOC. Overall, 31% discontinued treatment prematurely; 16% of patients stopped treatment early because of side effects. One patient with cirrhosis died of sepsis during treatment. Premature discontinuation was highest among TVR-treated cirrhotic patients (58%). Sustained virologic response (SVR) was achieved in 55% overall and was similar comparing the TVR (56%)- and BOC (53%)-treated groups. The only independent predictors of treatment failure were cirrhosis at baseline [odds ratio (OR) for SVR 0.44, p = 0.004] and prior partial or null response (OR for SVR 0.57, p = 0.02). CONCLUSIONS In the initial application of TVR and BOC, patients with cirrhosis and prior treatment failure were prioritized for treatment. In this real-world experience, most patients successfully completed a full treatment course. However, side effect-related premature discontinuations were common, and SVR rates were lower than reported in clinical trials.
Collapse
Affiliation(s)
- Jennifer C. Price
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, United States
| | - Rosemary C. Murphy
- Viral Hepatitis Registry, Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Valentina A. Shvachko
- Viral Hepatitis Registry, Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - Mary Pat Pauly
- Viral Hepatitis Registry, Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| | - M. Michele Manos
- Viral Hepatitis Registry, Division of Research, Kaiser Permanente Northern California, Oakland, California, United States
| |
Collapse
|
6
|
Abstract
9645 Background: Patients with chronic hepatitis B virus infection (HBV) are at risk for hepatotoxicity (HT) from viral reactivation during chemotherapy courses (TC). This can be minimized with antiviral prophylaxis (AV). Screening for HBV before TC remains controversial. Methods: A retrospective observational data only study was conducted at a Northern California integrated health care delivery system examining patients undergoing TC between 2000 and 2010. Patients were categorized as HBV positive (HBV+) if they had a positive HBsAg, HBeAg, or HBV DNA any time before and 1 year post TC. Grade 3 and 4 HT was determined using the National Cancer Institute Common Toxicity Criteria, with adaptation for those who had baseline abnormal liver function tests. We excluded patients with HIV, co-infection with both HBV and hepatitis C, and HBsAb of unclear provenance. Two control groups (CTRL1 and CTRL2) were established that had tested negative for HBV and HCV 1996 through 1 year after the last TC: CTRL1 tested negative for both before TC initiation (index TC); CTRL2 tested negative for one pre and the other post index TC or both at any time after index TC. AV prophylaxis (AVP+) was defined as anti-HBV medication given before HT; the remainder were AVP-, including those given AV after HT. Electronic medical record review was conducted on all HBV+ patients. Results: We identified 9,279 patients who received 15,960 TC; 57.8% were female with a mean age of 57.8 (±14.4) at TC initiation. 464 TC were given to 289 HBV+ patients; 22.8% had HT, with 7 deaths from HT, all AVP-. The rate of HT in the controls was 9.9% in CTRL1 (34/343), 12.6% in CTRL 2 (1907/15,153). Conclusions: These findings support the recommendation that all patients planning to receive TC should be screened for HBV. Those found positive should receive AV prophylaxis during therapy. [Table: see text]
Collapse
|
7
|
Jacobson IM, Brown RS, Freilich B, Afdhal N, Kwo PY, Santoro J, Becker S, Wakil AE, Pound D, Godofsky E, Strauss R, Bernstein D, Flamm S, Pauly MP, Mukhopadhyay P, Griffel LH, Brass CA. Peginterferon alfa-2b and weight-based or flat-dose ribavirin in chronic hepatitis C patients: a randomized trial. Hepatology 2007; 46:971-81. [PMID: 17894303 DOI: 10.1002/hep.21932] [Citation(s) in RCA: 231] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED This prospective, multicenter, community-based and academic-based, open-label, investigator-initiated, U.S. study evaluated efficacy and safety of pegylated interferon (PEG-IFN) alfa-2b plus a flat or weight-based dose of ribavirin (RBV) in adults with chronic hepatitis C. Patients (n = 5027) were randomly assigned to receive PEG-IFN alfa-2b 1.5 microg/kg/week plus flat-dose (800 mg/day) or weight-based (800-1400 mg/day) RBV for 48 weeks (patients with genotype 1, 4, 5, or 6) and for 24 or 48 weeks (genotype 2/3 patients). Primary end point was sustained virologic response (undetectable [<125 IU/mL] serum hepatitis C virus RNA at 24-week follow-up). Sustained virologic response, but not end-of-treatment, rates were significantly higher with weight-based than with flat-dose RBV (44.2% versus 40.5%; P = 0.008). Sustained virologic response rates by intention-to-treat analysis were 34.0% and 28.9%, respectively, in genotype 1 patients (P = 0.005) and 31.2% and 26.7%, respectively, in genotype 1 patients with high baseline viral load (P = 0.056). In genotype 2/3 patients, rates were not significantly different (61.8% and 59.5%, respectively) regardless of treatment duration. Besides greater hemoglobin reductions with weight-based RBV, safety profiles were similar across RBV dosing groups, including the 1400-mg/day group. CONCLUSION PEG-IFN alfa-2b plus weight-based RBV is more effective than flat-dose RBV, particularly in genotype 1 patients, providing equivalent efficacy across all weight groups. RBV 1400 mg/day is appropriate for patients 105 to 125 kg. For genotype 2/3 patients, 24 weeks of treatment with flat-dose RBV is adequate; no evidence of additional benefit of extending treatment to 48 weeks was demonstrated.
Collapse
Affiliation(s)
- Ira M Jacobson
- Weill Medical College of Cornell University, Center for the Study of Hepatitis C, New York Presbyterian Hospital, New York, NY 10021, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Allison JE, Sakoda LC, Levin TR, Tucker JP, Tekawa IS, Cuff T, Pauly MP, Shlager L, Palitz AM, Zhao WK, Schwartz JS, Ransohoff DF, Selby JV. Screening for Colorectal Neoplasms With New Fecal Occult Blood Tests: Update on Performance Characteristics. J Natl Cancer Inst 2007; 99:1462-70. [PMID: 17895475 DOI: 10.1093/jnci/djm150] [Citation(s) in RCA: 246] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND One type of fecal occult blood test (FOBT), the unrehydrated guaiac fecal occult blood test (GT), is recommended by the United States Preventive Services Task Force and the Institute of Medicine for use in screening programs, but it has relatively low sensitivity as a single test for detecting advanced colonic neoplasms (cancer and adenomatous polyps > or = 1 cm in diameter). Thus, improving the sensitivity of FOBT should make colon cancer screening programs that use these tests more effective. METHODS We assessed prospectively the performance characteristics of two newer FOBTs in 5841 subjects at average risk for colorectal cancer in a large group-model managed care organization. The tests evaluated included a sensitive GT, a fecal immunochemical test (FIT), and the combination of both tests. Patients with positive and negative test results were advised to have colonoscopy and sigmoidoscopy, respectively. Sensitivity and specificity for detecting advanced neoplasms in the left colon within 2 years after the FOBT screening were evaluated for the two tests administered separately and in combination. RESULTS A total of 139 patients were diagnosed with advanced colorectal neoplasms (n = 14 cancers, n = 128 adenomas) within the 2 years following their initial FOBT screening. Sensitivity for detecting cancer was 81.8% (95% confidence interval [CI] = 47.8% to 96.8%) for the FIT alone and 64.3% (95% CI = 35.6% to 86.0%) for the sensitive GT and the combination test. Sensitivity for detecting advanced colorectal adenomas was 41.3% (95% CI = 32.7% to 50.4%) for the sensitive GT, 29.5% (95% CI = 21.4% to 38.9%) for the FIT, and 22.8% (95% CI =16.1% to 31.3%) for the combination test. Specificity for detecting cancer and adenomas was 98.1% (95% CI = 97.7% to 98.4%) and 98.4% (95% CI = 98.0% to 98.7%), respectively, for the combination test; 96.9% (95% CI = 96.4% to 97.4%) and 97.3% (95% CI = 96.8% to 97.7%), respectively, for the FIT; and 90.1% (95% CI = 89.3% to 90.8%) and 90.6% (95% CI = 89.8% to 91.4%), respectively, for the sensitive GT. CONCLUSIONS The FIT has high sensitivity and specificity for detecting left-sided colorectal cancer, and it may be a useful replacement for the GT.
Collapse
Affiliation(s)
- James E Allison
- Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, Oakland, CA 94612-2304, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Abstract
Pseudomembranous colitis usually presents with diarrhea in a clinical setting of recent antibiotic use. It is uncommon to see it as a cause of obstipation and colonic pseudo-obstruction. We report an unusual case of an elderly woman with hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, and diabetes mellitus, who was admitted with fever, abdominal pain, and distension without diarrhea. She presented with decreased stool frequency and obstipation. She did not respond to conservative management. Colonoscopy revealed a picture of pseudomembranous colitis, and Clostridium difficile toxin was positive. She responded well to metronidazole therapy.
Collapse
Affiliation(s)
- R A Sheikh
- Division of Gastroenterology/Hepatology, San Joaquin General Hospital, Stockton, CA95201, USA
| | | | | | | |
Collapse
|
10
|
Abstract
Subcapsular hemorrhage and hepatic rupture are unusual catastrophic complications of the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. A high index of suspicion and prompt recognition are keys to proper diagnosis and management of affected patients. The optimal management of these patients is evolving. An aggressive multidisciplinary approach has considerably improved the morbidity and mortality associated with these complications. We present our experience with four cases of hepatic hemorrhage occurring in association with the HELLP syndrome and review the literature on this subject. All of our patients were multiparous, and three had a history of eclampsia/preeclampsia in a previous pregnancy. All four patients developed intrahepatic hemorrhage; two developed hepatic rupture requiring surgical intervention. Three patients developed disseminated intravascular coagulation and acute renal failure. Two patients developed pericardial effusion, pleural effusions, and ascites. One patient died of septic complications after multiple surgical interventions.
Collapse
Affiliation(s)
- R A Sheikh
- Division of Gastroenterology, University of California, Davis, USA
| | | | | | | |
Collapse
|
11
|
Sonnenberg A, Pauly MP, Levenson SD, Schwartz JS. Antibiotic therapy of Helicobacter pylori infection reduces healthcare expenditures related to duodenal ulcer. Am J Manag Care 1999; 5:53-9. [PMID: 10345967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To test whether eradication of Helicobacter pylori saves costs in the treatment of duodenal ulcer disease, compared with conventional antisecretory therapy. STUDY DESIGN A prospective, double-blind clinical trial was conducted at 132 sites in the United States. PATIENTS AND METHODS Adult patients with active duodenal ulcer and confirmed H pylori infection were randomized to receive treatment with clarithromycin plus omeprazole, omeprazole alone, or ranitidine alone. Utilization of ulcer-related healthcare resources was documented during 1 year following therapy. Costs were calculated by multiplying the number of health resources utilized by the cost of each resource. Resource costs were obtained from a database containing actual average costs spent by managed care organizations on outpatient and inpatient treatment. RESULTS Of the 819 patients enrolled, 727 completed the study: 243 received clarithromycin plus omeprazole, 248 omeprazole alone, and 236 ranitidine alone. Ulcer-related health resource utilization and total ulcer-related healthcare costs were decreased after treatment with clarithromycin plus omeprazole, compared to treatment with omeprazole or ranitidine alone. In multivariate linear regression analyses, type of treatment was found to be a significant predictor of total costs. Specific costs associated with endoscopic examinations, clinic visits, and medications were also significantly reduced by treatment with clarithromycin plus omeprazole as compared to other treatment forms. CONCLUSIONS In a managed care environment, therapy with clarithromycin and omeprazole to eradicate H pylori in patients with duodenal ulcer disease would result in significant cost savings secondary to a reduction in the utilization of healthcare resources.
Collapse
Affiliation(s)
- A Sonnenberg
- Department of Veterans Affairs Medical Center 111F, Albuquerque, NM 87108, USA
| | | | | | | |
Collapse
|
12
|
Pauly MP, Ruebner BH. Hepatic fibrosis and cirrhosis in tropical countries (including portal hypertension). Baillieres Clin Gastroenterol 1987; 1:273-96. [PMID: 3311230 DOI: 10.1016/0950-3528(87)90005-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The spectrum of diseases seen in patients from certain 'tropical areas' requires that a physician be aware of some of the syndromes discussed here. A high index of suspicion for less usual causes of cirrhosis is imperative when evaluating such patients presenting with hepatocellular disease. The differential must be expanded and the work-up complete. Liver biopsy should be performed as early in the course of disease as is feasible and will often provide valuable diagnostic information. It will not only facilitate treatment but allow for needed clinical trials and may help to increase our understanding of the various disease processes.
Collapse
|
13
|
|
14
|
|