Re-treatment of previous non-responders and relapsers to interferon plus ribavirin with peginterferon alfa-2a (40KD), ribavirin +/- amantadine in patients with chronic hepatitis C: randomized multicentre clinical trial

Introduction. A large number of patients with chronic hepatitis C have not been cured with interferon-based therapy. Therefore, we evaluated the efficacy of amantadine combined with the standard of care (pegylated interferon plus ribavirin) in patients who had not responded to or had relapsed after 24 weeks of treatment with conventional interferon plus ribavirin. Material and methods. Patients stratified by previous response (i.e., non-response or relapse) were randomized to 48 weeks of open-label treatment with peginterferon alfa-2a (401(D) 180 pg/week plus ribavirin 1,000/1,200 mg/day plus amantadine 200 mg/day (triple therapy), or the standard of care (peginterferon alfa-2a [40KD] plus ribavirin). Results. The primary outcome was sustained virological response (SVR), defined as undetectable hepatitis C virus RNA in serum (< 50 IU/mL) at end of follow-up (week 72). Among patients with a previous non-response, 12/53 (22.6%; 95% confidence interval [CI] 12.3-36.2%) randomized to triple therapy achieved an SVR compared with 16/52 (30.8%; 95% CI 18.7-45.1%) randomized to the standard of care. Among patients with a previous relapse 22/39 (56.4%; 95% CI 39.6-72.2%) randomized to triple therapy achieved an SVR compared with 23/38 (60.5%; 95% CI 43.4-76.0%) randomized to the standard of care. Undetectable HCV RNA (< 50 IU/mL) at week 12 had a high positive predictive value for SVR. A substantial proportion of non-responders and relapsers to conventional interferon plus ribavirin achieve an SVR when re-treated with peginterferon alfa-2a (40KD) plus ribavirin. Conclusion. Amantadine does not enhance SVR rates in previously treated patients with chronic hepatitis C and cannot be recommended in this setting.

Occluded Tunneled Venous Catheter in Hemodialysis Patients: Risk Factors and Efficacy of Alteplase

Thrombosis of tunneled central venous catheters (CVC) in hemodialysis (HD) patients is common and it can lead to the elimination of vascular sites. This study aimed to evaluate the incidence of thrombotic obstruction of tunneled CVC in HD patients and the efficacy of occlusion treatment with alteplase use, and identify factors associated with thrombotic occlusion. It was a prospective cohort study performed in two centers which evaluated the diagnosis and treatment of thrombotic occlusion of CVC in HD patients for 24 consecutive months. The catheter occlusion was defined as the difficulty infusing or withdrawing fluid from their paths. Alteplase dose was infused to fill the lumen of the occluded catheter and remained for 50 min. As there was no obstruction of the catheter, the procedure was repeated. Three hundred and thirty-nine CVC in 247 patients were evaluated and followed, totalling 67 244 CVC-days. One hundred fifty-seven patients had only one CVC, 88 patients had two CVC during the study, and two patients had three CVC. The median age was 58 (47–66) years, patients were predominantly men (54%), with diabetic nephropathy as the main cause of chronic kidney disease (44%), the internal jugular vein as the main site of implantation (82%), and duration of dialysis before CVC implantation of 119 (41.5 to 585.5) days. Eight hundred and fifteen occlusion episodes were diagnosed (12 episodes/1000 CVC-days), with primary success with alteplase in 596 episodes (77%) and secondary in 81 cases (10%). In 99 episodes (13%), success was not achieved after the second dose of alteplase. Two hundred and thirty CVC were removed during the study and the removal causes were arteriovenous fistula use in 88 patients (38.3%), infectious and mechanical complications in 89 (38.7%) and 21 (9.1%), respectively, and others (transplantation, transfer, or death) in 32 patients (13.9%). Adverse effects were also not observed. In the multivariate analysis, we identified the greatest number of days with CVC (OR = 1.02, CI = 1.01–1.04, P = 0.004), the presence of diabetes (OR = 1.560, CI = 1.351–1.894, P = 0.015), and exit site infection (ESI) (OR = 1.567 CI = 1347–1926, P = 0.023) as factors associated with obstruction. Thrombotic occlusion showed frequent mechanical complication in CVC of HD patients. We observed 12 episodes of obstruction per 1000 CVC-days, with a high success rate after alteplase use (87%). In the multivariate analysis, the time with CVC, the presence of diabetes, and ESI were identified as variables associated with thrombotic obstruction.

Sorafenib after arterial chemoembolization in child-pugh A and B cirrhotic patients with intermediate hepatocellular carcinoma: a retrospective analysis

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Visual outcomes and pacient satisfaction follwing implantation of a supplementary multifocal IOL in patients undergoing cataract surgery

Purpose: To assess visual outcomes and patient satisfaction following implantation of the Sulcoflex® multifocal intraocular lens (IOL; Rayner Intraocular Lenses Ltd., Hove, UK) in a procedure combining capsular bag lens implantation with sulcus placement of the Sulcoflex® IOL. Setting: Instituto de Oftalmologia de Assis, Assis, SP, Brazil. Methods: Cataract patients > 45 years, with hyperopia ≥ 1.50 D and potential acuity measurement ≥ 20/30 undergoing Sulcoflex® multifocal IOL implantation were included. Monocular and binocular uncorrected near and distance visual acuity (VA) were evaluated at five days, one month, and three months postoperatively. Contrast sensitivity and refraction were measured in a subset of patients three months postoperatively. Patient satisfaction was assessed one month postoperative. Results: This non-consecutive case series comprised 25 eyes of 13 patients. Eleven eyes (52%) had pre-existing retinal pathologies. Monocular distance VA improved significantly at all follow-up visits. At final follow-up, 88% of eyes had monocular uncorrected distance VA (UDVA) of at least 20/25 and 24% had monocular UDVA of 20/20. All eyes had binocular UDVA of at least 20/25, and 58% had binocular UDVA of 20/20. Monocular uncorrected near vision (UNVA) was J1 in 68% of eyes and all patients had binocular UNVA of J1. Of all eyes studied, 92% and 58% achieved a spherical equivalent within 1 D and −0.5 D, respectively. The majority of patients reported satisfaction with visual outcomes. Complications included a postoperative intraocular pressure spike in four eyes. Conclusion: The Sulcoflex® multifocal IOL improves near and distance VA in cataract patients with retinal abnormalities and good VA potential.