Effect of hepatitis B virus on steatosis in hepatitis C virus co-infected subjects: A multi-centre study and systematic review

It remains unclear whether hepatitis B virus (HBV) infection may modify the severity of viral steatosis in patients coinfected with chronic hepatitis C virus (HCV). We examined the influence of coinfection with HBV on prevalence of steatosis in chronic hepatitis C in a multi-centre cohort of HBV-HCV subjects, and by performing a systematic review and meta-analysis of the literature. We centrally and blindly assessed steatosis prevalence and severity in a cohort of HBV-HCV coinfected subjects compared to HCV and HBV monoinfected controls and we performed a systematic review of studies addressing the prevalence of steatosis in HBV-HCV subjects compared to HCV controls. In the clinical cohort, we included 85 HBV-HCV, 69 HBV and 112 HCV subjects from 16 international centres. There was no significant difference in steatosis prevalence between the HBV-HCV and the HCV groups (33% vs 45%, P = .11). In subgroup analysis, lean HBV-HCV subjects with detectable HBV DNA had less steatosis than lean HCV subjects matched for HCV viremia (15% vs 45%, P = .02). Our literature search identified 5 additional studies included in a systematic review. Overall, prevalence of steatosis > 5% was similar in HBV-HCV infection compared to HCV (pooled odds ratio [OR] 0.91, 95% CI 0.53-1.6) although there was significant heterogeneity (I² 69%, P = .007). In conclusion, although the prevalence of steatosis is similar in HBV-HCV compared to HCV subjects, our analysis suggests that there may be an inhibitory effect of HCV-induced steatogenesis by HBV in certain subgroups of patients.

Sublingual tacrolimus administration provides similar drug exposure to per-oral route employing lower doses in liver transplantation: a pilot study

BACKGROUND

Per-oral tacrolimus administration is not always practicable. Sublingual administration is a potential alternative, but its feasibility and effectiveness compared with oral route has not been established.

AIM

To compare tacrolimus drug exposure after sublingual and oral administration in liver transplant recipients.

METHODS

Experimental, open-label, non-randomised, cross-over study. Tacrolimus exposure was evaluated in 32 liver transplant recipients receiving oral administration. 12 h tacrolimus area-under-the-curve (AUC_{0-12 h} ) was calculated using tacrolimus blood concentrations at 0-0.5-1-2-4-6-8-12 hrs post-dose. Recipients were switched to sublingual administration, and dose was adjusted to reach similar trough levels, new AUC_{0-12 h} was calculated. Correlation between AUC_{0-12 h} and trough levels was determined for both oral and sublingual phases.

RESULTS

Similar trough levels were accomplished with oral and sublingual administration (6.68 ± 2 ng/mL vs. 6.62 ± 1.9 ng/mL (P = 0.8)). Although concentration 2 h post dose was higher in oral phase (15.36 ± 7.14 vs. 13.18 ± 5.64, P = 0.015), AUC_{0-12 h} was similar in both phases (116.6 ± 34.6 vs. 111.5 ± 36.93 ng/mL_* h, P = 0.19). Daily dose of tacrolimus required in sublingual phase was 37% lower than that used in oral phase (P < 0.0001), suggesting significantly increased bioavailability of tacrolimus when employing sublingual route. Good correlation between AUC_{0-12 h} and trough levels was observed in sublingual phase (r² = 0.74). Twenty-two recipients were maintained on sublingual administration after the end of study (mean follow-up: 18.7 ± 5.8 months). No difference in liver function tests or rejection rates was found during follow-up period.

CONCLUSIONS

Sublingual administration of tacrolimus is feasible and provides similar drug exposure compared with oral administration. In our study, at long-term follow-up, sublingual administration was not associated with liver transplant rejection.

An analysis of timeout and response cost in a programmed environment

A group of mildly retarded adolescents with high rates of antisocial behavior was exposed to two parameters of timeout and response cost within the context of a programmed environment. For five of the six subjects, the two higher values (30 tokens response cost or 30 min timeout) were significantly more suppressive than the lower values (five tokens or 5 min). For the one remaining subject, there was a strong relationship in the opposite direction. Also, the timeout and response cost of higher value became increasingly more suppressive over time, whereas those of lower value did not. There were few appreciable differences between the timeout and response cost of similar magnitude. A discussion of these results is presented in support of the notion that the functional aversiveness of timeouts (and response costs) appears to be critically dependent upon interactions with the environmental conditions in which they are implemented and the reinforcement histories of the subjects.

[Necrobiotic xanthogranuloma: efficacy of surgery in 2 patients]

Necrobiotic xanthogranuloma is a rare disease characterized by indurated nodules and yellowish-red plaques in the dermis or subdermal tissues particularly in the periorbital region; the lesions are often ulcerated. This disease is frequently associated with hematological disorders such as monoclonal gammopathy and lymphoproliferative disorders. Its pathogenesis is unknown and the small number of cases makes long-term studies difficult. We present 2 cases of periorbital lesions in which the biopsies established a diagnosis of necrobiotic xanthogranuloma. Both patients were treated with corticosteroids and cyclophosphamide, with no improvement. The lesions were excised and the periorbital regions were reconstructed with skin grafts. After 1 year of follow-up there are no signs of recurrence.

[Cost-effectiveness analysis of 2 strategies of Helicobacter pylori eradication: results of a prospective and randomized study in primary care]

BACKGROUND

To analyze cost-effectiveness of two different strategies to treat H. pylori infection in peptic ulcer in the primary care setting.

PATIENTS AND METHODS

Consecutive patients with endoscopic diagnosis of peptic ulcer were randomized to one of two strategies: a) treatment during 7 days with omeprazole, tetracycline, metronidazole and bismuth subcitrate ("quadruple" therapy) and if failure second-line treatment with omeprazole, amoxycillin and clarithromycin during 7 days (OCA7), and b) initial treatment with OCA7 and if failure treatment with "quadruple therapy". End point was eradication 8 weeks after last treatment dose. Direct and indirect costs were estimated (euros, 1997) and a cost-effectiveness analysis using a decision-tree model was undertaken after real clinical data. 95% confidence intervals are given.

RESULTS

After screening 255 patients, 97 were finally included. 48 patients were given strategy a and 49 strategy b. Eradication was obtained (intention-to-treat) in 72.9% (CI 95%: 58.2-84.7) in group a versus 91.8% (CI 95%: 80.4-97.7) (p < 0.05) in group b. Mean cost per case treated was lower in group a (237 versus 268 euros) but cost per case eradicated was lower in group b (320 versus 296 euros). The cost was primarily determined by efficacy.

CONCLUSIONS

Treatment with OCA7 followed by rescue with "quadruple" therapy if failure is more efficient in our area that the inverse strategy. Efficiency is mostly determined by efficacy.

Is 1-week treatment for peptic ulcer healing sufficient and safe?

OBJECTIVE

To confirm whether 1-week anti-Helicobacter therapy to achieve ulcer healing is sufficient and safe.

METHODS

We retrospectively analyzed patients with peptic ulcer who were infected with Helicobacter pylori and treated with 3 different 7-day regimens, according to predefined protocols in 3 different centers in the same geographical area (Aragón, Spain). Three combinations commonly described in the literature were used: a) omeprazole (40 mg/24 h), tetracycline hydrochloride (2 g/24 h), colloidal bismuth subcitrate (480 mg/24 h) and metronidazole (750 mg/24 h) (OBTM, n = 105); b) omeprazole (40 mg/24 h), clarithromycin (1.5 g/24 h) and amoxicillin (3 g/24 h) (O40C1.5A3, n = 13); and c) omeprazole (40 mg/24 h), clarithromycin (1 g/24 h) and amoxicillin (2 g/24 h) (O40C1A2, n = 4). In all patients the diagnosis of peptic ulcer disease was confirmed endoscopically, and H. pylori infection was verified with urease testing and histological analysis. After treatment ended, no other antacids were allowed until after endoscopic examination to check eradication and ulcer healing.

RESULTS

122 patients were included (107 with duodenal ulcer, 12 with gastric ulcer and 3 with both). Compliance was good and side effects infrequent and mild. Eradication rates were 88.5% (93/105) in the OBTM group, 100% (13/13) with O40C1.5A3, and 75% (3/4) with O40C1A2. Healing was achieved in 98.16% (107/109) of the patients in whom the bacterial infection was eradicated, and in 23.07% (3/13) of those in whom it was not (p < 0.0001). No patient had any complications during the period without treatment.

CONCLUSIONS

1-week eradication therapy with previously described combinations commonly used in clinical practice achieves high ulcer healing rates with no complications in the period without antacid treatment. We consider that it is not necessary, at least in most patients, to prolong antacid therapy.

[Total gastrectomy in newborn infant]

Total gastrectomy is rarely indicated in childhood and when necessary it involves multiple ulterior therapeutic problems, mainly nutritional, which need a meticulous physiological approach to avoid further complications, as illustrated by the following patient who, at age 15 months, was submitted to total gastric resection, Y en Roux esophagojejunal anastomosis and splenectomy, because of peritonitis secondary to dehiscence of a recent esophagogastric anastomosis for partial gastric resection due to gastric volvulus and necrosis, which in turn were associated to diaphragmatic relaxation. The patient was admitted to our hospital one month later with signs of acute calorie-protein malnutrition (W/A 60% and W/H 68%, NCHS standards) requiring combined parenteral and enteral nutritional support (via central venous catheter and jejunostomy tube for 15 and 35 days respectively) together with intramuscular vitamin B 12, oral iron and oral vitamin supplements before it became possible to fed him only by mouth. Prophylaxis against Streptococcus pneumonia infections with monthly benzatin penicillin was also instituted. Mean daily weight increases of 16 g, W/A 68% and W/H 74% were thus achieved before hospital discharge, without evidence of dumping syndrome nor alkaline reflux.

[Modular diet and parenteral support in persistent diarrhea]

Eleven infants with protracted diarrhea were treated with modular diet and short-term parenteral nutrition. Mean age at admission was 3.7 months with males predominating. Enteropathogenic E. coli, classic serotypes, were isolated from 7 patients and rotavirus from one. A child with combined, severe immunodeficiency died. Milk protein intolerance was diagnosed in another patient. Balance studies and peroral biopsies were performed. Malnutrition was more frequent and hospital stay was longer in those infants who developed nosocomial infections. Even though this treatment shortened the duration of the hospitalization, the negative nutritional impact persisted: Weight/Age (NCHS) decreased from 84% to 61%, with rapid recovery after discharge. Fecal lactic acid excretion was increased on admission to 1,296 mg x day and disaccharidase activity was decreased. The modular diet decreased both fecal volume and lactic acid excretion.

[Rotavirus in the feces of children with acute diarrhea in Cochabamba, Bolivia]

Eighty patients with acute diarrheal disease from Cochabamba, Bolivia, were investigated for rotavirus infection by rotapheresis. Rotavirus ARN was detected in 18 (22.5%) of the cases, thus suggesting that this agent is also a frequent cause of acute diarrhea in the studied population as reported from other places of the world.

Role of reflexes following myocardial necrobiosis

Intracoronary administration of hexachlorotetrafluorobutane (Hexa) into non-thoracotomized dogs produced a statistically significant decrease in left ventricular systolic pressure (LVSP), mean femoral arterial blood pressure (MFAP), first derivative of left ventricular pressure pulse (dP/d t), total peripheral resistance (TPR), and cardiac output (C.O.) lasting up to 1 hr after injection. Femoral vascular resistance decreased during the first 3 min after production of necrobiosis. Fifty percent of the dogs died of ventricular fibrillation (VF) after Hexa infarction. Prereserpinized dogs did not show significant changes in the parameters which were significantly changed in normal dogs after Hexa necrobiosis except in the case of VF which was almost absent in this group. Bilateral vagotomy prior to Hexa administration prevented most hemodynamic changes after necrobiosis whereas atropine did not. Bilateral vagotomy and atropine 1 hr after necrobiosis increased MFAP, dP/d t, LVSP, C.O., and TPR. Apparently excitatory efferent sympathetic activity on heart and femoral arterial vessels is reflexly inhibited by the effects of intracoronary injection of Hexa. The afferent pathway is via the vagus nerve.