Trasplante hepático exitoso en un paciente portador del Virus de la Inmunodeficiencia Humana (VIH) / Liver transplantation in a patient with human immunodeficiency virus (HIV): case report

Abstrac: Before the advent of highly active antiretroviral therapy (HAART), patients infected with human immunodeficiency virus (HIV) were considered as having an absolute contraindication for liver transplantation (LT). Considering the increased life expectancy in HIV positive patients under HAART and the improvements in the management of graft recipients, these patients are now suitable for carrying out transplants in selected cases. We report a 26 years old HIV positive male who developed acute liver failure possibly caused by drug induced liver injury who underwent a successful liver transplantation.

Nuevas terapias orales de acción directa para tratamiento de virus de hepatitis C (VHC) / Direct antivirals for the treatment of chronic hepatitis C virus infection: experience in 106 patients

Background: The availability of direct-acting antivirals (DAA) for the treatment of chronic hepatitis C virus (HCV) infection is just starting to expand in Chile. Aim: To report the initial experience of patients treated with DAA and their evolution after treatment. Material and Methods: Prospective cohort study, from June 2013 to August 2016 of patients treated with DAA for HCV in three clinical centers. The presence of cirrhosis, clinical and laboratory features; adverse events (AE) and post-treatment changes in liver function were evaluated. Sustained viral response at 12 weeks post-treatment (SVR12) was determined. Results: One hundred six patients aged 58 ± 13 years, 54% males, were included. HCV genotype 1b was present in 88% and 47% had cirrhosis. Treatment regimens were asunaprevir + daclatasvir (DCV) in 17% of patients, paritaprevir / ritonavir / ombitasvir + dasabuvir in 33%, sofosbuvir (SOF) + DCV in 19%, and SOF + ledipasvir in 30%. Twenty five percent of patients used generic drugs. SVR12 was 92.1%, with no differences between generic and brand-name drugs. Serious AE were recorded in 22% of patients, being more common in those with cirrhosis (34% vs 11.5%, p < 0.01). At 12 weeks post-treatment follow-up, there was a decrease in aminotransferase values (p < 0.01), improvement in Child-Pugh score (5.9 vs. 5.5, p = 0.03) and decreased presence of ascites (p = 0.02). Conclusions: In our setting, DAA for HCV was highly effective and safe in non-cirrhotic patients. Hepatic function and inflammation improved at 12 weeks of follow-up. AE were common in patients with cirrhosis, suggesting that these patients should be treated by experienced teams. Generic drugs had similar effectiveness compared to originals.

Conversion to Mycophenolate Mofetil Monotherapy in Liver Recipients: Calcineurin Inhibitor Levels are Key

Abstract: The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to mycophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow- up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112.

Evaluación de docentes clínicos de Postgrado: desarrollo y propiedades psicométricas del instrumento MEDUC-PG14 / Development of MEDUC-PG14 survey to assess postgraduate teaching in medical specialties

Background: Feedback is one of the most important tools to improve teaching in medical education. Aim: To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties. Material and Methods: A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha). Results: Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947. Conclusions: MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

Incidencia y características del shock cardiogénico en el IAM: comparación de las eras pre y post trombolíticas / Incidence and features of cardiogenic shock in AMI: a comparison of the pre and post thrombolytic periods

El shock cardiogénico secundario al infarto del miocardio (IAM) ocurre en realción a infartos muy extensos y tiene alta mortalidad. Para evaluar el impacto del tratamiento actual del infarto, hemos comparado la incidencia y características del shock cardiogénico entre 252 pacientes admitidos por IAM entre 1983-1985 (Grupo 1), con 228 pacientes admitidos después de 1990 (Grupo 2). Mientras en el Grupo 1 sólo se trataron las complicaciones del infarto, en el Grupo 2 hubo 69 pacientes (31 por ciento ) que se sometieron a trombolisis o angioplastía en las primeras seis horas y todos recibieron heparina, antiagregantes plaquetarios y nitroglicerina i.v. La incidencia de shock cardiogénico fue la misma en Grupo 1 y Grupo 2 (13 por ciento y 12,8 por ciento ). Tampoco hubo diferencias en la incidencia de shock no relacionada a ruptura cardiaca (8,3 por ciento para el Grupo 1 y 7,9 por ciento para el grupo 2). Los grupos se diferenciaron, sin embargo, en el momento de aparición del shock. Mientras en el Grupo 1 el 53 por ciento de los casos lo desarrollaron después de 24 horas de iniciado el infarto, en el Grupo 2 la mayor parte lo presentó en las primeras 24 horas del infarto (88 por ciento ), período en el que se concentra la mayor mortalidad. En conclusión, el tratamiento actual del IAM ha disminuido la incidencia de shock cardiogénico por falla miocárdica tardía, pero no ha influido en la incidencia del shock que se presenta en las primeras horas del infarto