Hepatocellular carcinoma: A real-life experience in a specialized center in Bogotá, Colombia / Hepatocarcinoma: experiencia de la vida real en un centro especializado de Bogotá, Colombia

Abstract Introduction: Hepatocellular carcinoma (HCC) is the most frequent malignant primary liver tumor globally. In 2018, it ranked sixth and represented the fourth cause of death from cancer; the five-year overall survival is 18 %. Most cases of HCC develop in patients with cirrhosis of any etiology, especially because of hepatitis B and C viruses, alcohol, and recently nonalcoholic steatohepatitis (NASH). Aim: To analyze the clinical characteristics, diagnostic methods, treatments, prognostic variables, and survival. Materials and methods: This retrospective descriptive study was conducted on a cohort of patients diagnosed with cirrhosis and treated between January 2011 and December 2020 at a health care center in Bogotá. The diagnosis of HCC was confirmed radiologically or by biopsy. We analyzed the information descriptively with absolute frequency measures in the case of categorical variables. For continuous variables, the information was summarized with measures of central tendency (mean or median) and their relevant measures of dispersion. Results: We included 152 patients diagnosed with HCC, with a mean age of 69.4 years; 51.3 % were men. The leading cause of HCC was nonalcoholic fatty liver disease (NAFLD), which accounted for almost a third of cases (32 %); other causes were alcohol (15 %) and hepatitis C virus (14 %). The median manifestation of the tumor was two nodules with a size close to 4 cm. Besides, 35 % of patients had a BCLC (Barcelona Clinic Liver Cancer) stage with curative options, and 25 % received curative treatment options. The first-line systemic therapy used in this cohort was sorafenib®, used in 35 patients (33.7 %). Survival curves showed that women, Child-Pugh class A, and BCLC stage 0 had higher median survival. Multivariate analysis showed a higher risk of death for males (hazard ratio [HR]: 2.16; confidence interval [CI]: 1.24-3.76), Child-Pugh class B (HR: 2.14; CI 1.16-3.95), and Child-Pugh class C (HR: 7.52; CI 2.88-19.57). Conclusions: NAFLD is the leading cause of HCC in this cohort. A third of patients are diagnosed in early BCLC stages with a curative treatment option, and 25 % are treated with curative therapies. Sorafenib was the first-line therapy in advanced HCC. Overall survival after diagnosis of HCC remains low, being necessary to join forces in the follow-up of patients with cirrhosis to improve these outcomes.

Resumen Introducción: el hepatocarcinoma (HCC) es el tumor hepático primario maligno más frecuente en el mundo: en 2018 ocupó la sexta posición y representó la cuarta causa de muerte por cáncer; la supervivencia global a 5 años es del 18 %. La mayoría de los casos de HCC se desarrolla en pacientes con cirrosis de cualquier etiología, especialmente por virus de la hepatitis B y C, alcohol y, recientemente, por la esteatohepatitis no alcohólica (NASH). Objetivo: analizar las características clínicas, métodos de diagnóstico, tratamientos, variables pronósticas y supervivencia. Metodología: estudio descriptivo retrospectivo de una cohorte de pacientes con diagnóstico de cirrosis atendidos entre enero de 2011 y diciembre de 2020 en un centro de atención médica de Bogotá, con diagnóstico de HCC confirmado radiológicamente o por biopsia. La información se analizó de forma descriptiva con medidas de frecuencia absoluta en el caso de las variables categóricas; para las variables continuas se resumió la información con medidas de tendencia central (media o medianas) y su respectiva medida de dispersión. Resultados: se incluyeron 152 pacientes diagnosticados con HCC, con edad promedio de 69,4 años, 51,3 % eran hombres. La principal causa de HCC fue el hígado graso no alcohólico (NAFLD), que representó casi una tercera parte de los casos (32 %); otras causas fueron el alcohol (15 %) y el virus de la hepatitis C (14 %). La mediana de presentación del tumor fue de 2 nódulos con un tamaño cercano a 4 cm. El 35 % de los pacientes tenía un estadio BCLC (Barcelona Clinic Liver Cancer) con opciones curativas y el 25 % de los pacientes recibió opciones curativas de tratamiento. La terapia sistémica de primera línea utilizada en esta cohorte fue el sorafenib®, que se utilizó en 35 pacientes (33,7 %). Las curvas de supervivencia mostraron que las mujeres, el estadio Child-Pugh A y el estadio BCLC 0 presentaron mayores medianas de supervivencia. El análisis multivariado evidenció un mayor riesgo de muerte al ser hombre (Hazard ratio [HR]: 2,16; intervalo de confianza [IC]: 1,24 a 3,76), estar en los estadios Child-Pugh B (HR: 2,14; IC: 1,16 a 3,95) y Child-Pugh C (HR: 7,52; IC: 2,88 a 19,57). Conclusiones: el NAFLD es la principal causa de HCC en la presente cohorte, una tercera parte de los pacientes se diagnostica en estadios BCLC tempranos con opción curativa de tratamiento, y un 25 % se trata con terapias curativas. El sorafenib fue la terapia de primera línea en HCC avanzado. La supervivencia global luego del diagnóstico de HCC sigue siendo baja, y es necesario aunar esfuerzos en el seguimiento de los pacientes con cirrosis para mejorar estos resultados.

Rendimiento del ASAS Health Index en pacientes con Espondiloartritis de la vida real / Performance of ASAS Health Index in real life spondyloarthritis patients

Introducción: El cuestionario "Assessment of Spondyloarthritis International Society Health Index" (ASAS-HI) fue desarrollado para medir de manera global la funcionalidad y el estado de salud en pacientes con espondiloartritis (EspA). Se han propuesto puntos de corte para determinar diferentes estados de salud que fueron poco evaluados en pacientes de la vida real. Objetivos: Describir el estado de salud medido por ASAS-HI en pacientes argentinos con EspA axial (EspAax) y periférica (EspAp) en la práctica diaria y evaluar los factores asociados al pobre estado de salud. Materiales y métodos: Estudio de corte transversal, analítico y multicéntrico. Se incluyeron consecutivamente pacientes con EspAax y EspAp según criterios ASAS, de 15 centros argentinos. Análisis estadístico: Se realizó estadística descriptiva, análisis bivariado y multivariado (regresión logística múltiple) para evaluar los factores asociados al pobre estado de salud (ASAS-HI ≥12). Para analizar la validez de constructo de la herramienta se realizó correlación de Spearman entre el ASAS-HI y otros parámetros de evaluación de la enfermedad. Resultados: Se incluyeron 274 pacientes con EspA, con una edad media de 49 (±14) años y una duración mediana de la enfermedad de 62 meses (p25-75: 24-135), 155 (56,6%) de los pacientes eran de sexo masculino, 129 pacientes (47%) con EspAax y 145 (52,9%) EspAp. Según el ASAS-HI 119 pacientes (43,4%) presentaban buen estado de salud, 117 (42,7%) tenían estado de salud moderado y 38 (13.9%) pobre estado de salud. En los pacientes con EspAp el valor de ASAS-HI mediano fue de 7 (p25-75: 3-10). El ASAS-HI correlacionó positivamente con: DAS28: rho: 0.5 (p<0.001) y HAQ: rho: 0.54 (p<0.001). La variable asociada de manera independiente con pobre estado de salud fue el DAS28 (OR: 1.9, IC95% 1.1-3.4, p: 0.029). En los pacientes con EspAax el valor de ASAS-HI mediano fue de 6 (p25-75: 2.75-10). El ASAS-HI mostró correlación con: BASDAI: rho: 0.7 (p<0.001), ASDAS-ERS: rho: 0.7 (p<0,001), ASQoL: rho: 0.8 (p<0.001), BASFI rho: 0.75 (p<0.001). La variable que se asoció de manera independiente a pobre estado de salud fue el ASDAS-ERS (OR 6.6, IC95% 2-22, p 0.002). Conclusión: Un pobre estado de salud se asoció independientemente a mayor actividad de la enfermedad en pacientes con EspAax y EspAp. El ASAS-HI correlacionó con otros parámetros de la enfermedad, lo que refuerza la validez de constructo de esta nueva herramienta.

Introduction: The "Assessment of Spondyloarthritis International Society Health Index" (ASAS-HI) questionnaire was developed to globally measure function and health status in patients with spondyloarthritis (SpA). Cut-off points have been proposed to determine different health states that were poorly evaluated in real-life patients. Objectives: To describe the health status measured by ASAS-HI in Argentine patients with axial SpA (AxSpA) and peripheral SpA (SpAp) in daily practice and to evaluate the factors associated with poor health. Materials and methods: Cross-sectional, analytical and multicenter study. Patients with SpAax and SpAp were consecutively included according to ASAS criteria, from 15 Argentine centers. Statistical analysis: Descriptive statistics, bivariate and multivariate analysis (multiple logistic regression) were performed to evaluate the factors associated with poor health status (ASAS-HI ≥12). To analyze the construct validity of the tool, Spearman correlation was performed between the ASAS-HI and other disease evaluation parameters. Results: 274 patients with SpA were included, with a mean age of 49 (± 14) years and a median duration of the disease of 62 months (p25-75: 24-135), 155 (56.6%) were male, 129 patients (47%) with AxSpA and 145 (52.9%) SpAp. According to the ASAS-HI, 119 patients (43.4%) had good health, 117 (42.7%) had moderate health and 38 (13.9%) had poor health. In patients with SpAp, the mean ASAS-HI value was 7 (p25-75: 3-10). The ASAS-HI positively correlated with: DAS28: rho: 0.5 (p <0.001) and HAQ: rho: 0.54 (p <0.001). The variable independently associated with poor health status was DAS28 (OR: 1.9, 95% CI 1.1-3.4, p: 0.029). In patients with AxSpA, the mean ASAS-HI value was 6 (p25-75: 2.75-10). The ASAS-HI showed correlation with: BASDAI: rho: 0.7 (p <0.001), ASDAS-ERS: rho: 0.7 (p <0.001), ASQoL: rho: 0.8 (p <0.001), BASFI rho: 0.75 (p <0.001). The variable that was independently associated with poor health was the ASDAS-ERS (OR 6.6, 95% CI 2-22, p 0.002). Conclusion: Poor health status was independently associated with higher disease activity in patients with AxSpA and SpAp. The ASAS-HI correlated with other parameters of the disease, which reinforces the construct validity of this new tool.

Intravitreal treatment realities and experiences in diabetic macular edema / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To evaluate the real life anatomical and visual outcome after intravitreal anti-VEGF treatment in diabetic macular edema(DME)throughout 24mo.<p> METHODS: Treatment naive central-involved DME patients with intraretinal and/or subretinal fluid and baseline central macular thickness(CMT)over 300 μm in spectral domain optic coherence tomography scans who received intravitreal injections between June 2012 and December 2016 were included in the study. The changes in visual acuity(VA)and CMT, and total number of patient visits and intravitreal injections were assessed in the baseline of 3, 6, 12, 18 and 24mo.<p> RESULTS: Totally 54 eyes of 40 patients were included. VA at baseline improved from 0.67±0.47 LogMAR to 0.59±0.43 LogMAR at 3mo and maintained with 3.5±2.19 injections throughout 12mo. The average number of visits was 9±2.39 and 15.48±4.84 at 12mo and 24mo, respectively. The mean CMT at baseline was 450±153μm and decreased to 385±141μm and 305±111μm at 12 and 24mo, respectively(<i>P</i><0.001).<p> CONCLUSION: Pro re nata(PRN)approach in DME treatment may keep the VA stable and reduce macular edema, but probably similar or better treatment effectivity could be obtained with a lower visit burden in proactive regimens.

Speech Recognition in Real-Life Background Noise by Young and Middle-Aged Adults with Normal Hearing

BACKGROUND AND OBJECTIVES: People usually converse in real-life background noise. They experience more difficulty understanding speech in noise than in a quiet environment. The present study investigated how speech recognition in real-life background noise is affected by the type of noise, signal-to-noise ratio (SNR), and age. SUBJECTS AND METHODS: Eighteen young adults and fifteen middle-aged adults with normal hearing participated in the present study. Three types of noise [subway noise, vacuum noise, and multi-talker babble (MTB)] were presented via a loudspeaker at three SNRs of 5 dB, 0 dB, and -5 dB. Speech recognition was analyzed using the word recognition score. RESULTS: 1) Speech recognition in subway noise was the greatest in comparison to vacuum noise and MTB, 2) at the SNR of -5 dB, speech recognition was greater in subway noise than vacuum noise and in vacuum noise than MTB while at the SNRs of 0 and 5 dB, it was greater in subway noise than both vacuum noise and MTB and there was no difference between vacuum noise and MTB, 3) speech recognition decreased as the SNR decreased, and 4) young adults showed better speech recognition performance in all types of noises at all SNRs than middle-aged adults. CONCLUSIONS: Speech recognition in real-life background noise was affected by the type of noise, SNR, and age. The results suggest that the frequency distribution, amplitude fluctuation, informational masking, and cognition may be important underlying factors determining speech recognition performance in noise.

Tenofovir disoproxil fumarate monotherapy for nucleos(t)ide-naive chronic hepatitis B patients in Korea: data from the clinical practice setting in a single-center cohort

BACKGROUND/AIMS: This study assessed the antiviral efficacy and safety of tenofovir disoproxil fumarate (TDF) for up to 12 months in Korean treatment-naive chronic hepatitis B (CHB) patients. METHODS: A total of 411 treatment-naive CHB patients who had been treated with TDF for at least 3 months (median 5.6) were consecutively enrolled. Clinical, biochemical, virological parameters and treatment adherence were routinely assessed every 3 months. RESULTS: The median age was 51.3 years, 63.0% of the patients were male, 49.6% were HBeAg (+), and 210 patients had liver cirrhosis. The median baseline HBV DNA was 5.98 (SD 1.68) log10 IU/mL. Among the patients completing week 48, 83.3% had a complete virologic response (CVR, <12 IU/mL by HBV PCR assay), and 88.2% had normalized levels of alanine aminotransferase (ALT). The cumulative probabilities of CVR at 3, 6, 9 and 12 months were 22.8%, 53.1%, 69.3% and 85.0%. During the follow-up period, 9.8% patients achieved HBeAg loss and 7.8% patients achieved HBeAg seroconversion. There was no virological breakthrough after initiating TDF. The most common TDF-related adverse event was gastrointestinal upset, and three patients discontinued TDF therapy. However, no serious life-threatening side effect was noted. CONCLUSIONS: In a clinical practice setting, TDF was safe and highly effective when administered for 12 months to Korean treatment-naive CHB patients.

Estudio STAR*D: buscando estrategias ente la falta de respuesta a un ISRS / STAR* D study: searching strategies regarding lack of response to an ISRS

El STAR*D es la más grande investigación que se ha realizado sobre el tratamiento de la depresión mayor. El objetivo del estudio fue determinar qué tratamientos sucesivos resultaban más efectivos en caso de falta de respuesta o intolerancia a un inhibidor selectivo de la recaptación de serotonina. Sus hallazgos principales fueron: 1) La tasa de remisión en monoterapia es baja; 2) No hubo diferencias en cambiar a otro IRSS, a un dual o a otro mecanismo de acción; 3) Las potenciaciones funcionaron posiblemente un poco mejor, en pacientes que tenían respuesta parcial y buena tolerancia al citalopram. Leve ventaja del bupropión sobre la buspirona y mejor tolerabilidad y facilidad de manejo de la T3 sobre el litio; 4) No hubo diferencias entre agregar o cambiar a psicoterapia y medicación en pacientes que no responden al citalopram; la medicación fue más rápida como potenciación; 5) Todos los caminos que se tomaron dieron en general resultados similares; 6) La probabilidad de remitir va decreciendo a medida que se suceden tratamientos, especialmente a partir del tercero, mientras que las chances de recaer aumentan; 7) La remisión tiene menores posibilidades de recurrencia que la simple respuesta.

STAR*D, the biggest investigation ever conducted on the treatment of major depression, was aimed to determine prospectively which of several treatments is the most effective "next step" for patients who do not reach remission with an initial or subsequent treatment or who cannot tolerate the treatment. Its main findings show that: 1) Monotherapy remission rates are low; 2) There were no outcome differences in changing to another SSRI, to a dual reuptake inhibitor o to another mechanism of action. 3) Augmentation strategies worked perhaps better in patients with partial response and good citalopram tolerability. There was a slight advantage of bupropion over buspirone. T3 had better tolerability and was easier to use than lithium; 4) There was no difference between cognitive therapy as a switch or as augmentation strategy versus medication as a switch or augmentation strategy. Antidepressants were faster in augmentation. 5) There were no statistical differences in remission rates among any of the medications compared in this study; 6) Remission rates drop level after level, more substantially after two failed treatments. Conversely, recurrence rates rise progressively; 7) Patients who achieve remission are less likely to relapse than patients who have only responded.