ABSTRACT
The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline.
Subject(s)
Carcinoma, Hepatocellular/therapy , Decision Support Techniques , Liver Neoplasms/therapy , Medical Oncology/standards , Neoplasm Staging/standards , Algorithms , Argentina , Biopsy/standards , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/mortality , Carcinoma, Hepatocellular/pathology , Clinical Decision-Making , Consensus , Evidence-Based Medicine/standards , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/mortality , Liver Neoplasms/pathology , Predictive Value of Tests , Risk Assessment , Risk Factors , Treatment Outcome , Ultrasonography/standardsABSTRACT
The ECHO model was developed to expand access to medical care for populations with HCV infection in underserved areas. We aimed to compare HCV treatment outcomes in community-based clinics with the Austral University Hospital (AUH) and to assess improvement in physician knowledge and skills. In October 2015, we established an HCV ECHO clinic at the AUH in Buenos Aires. To evaluate the impact of this programme, we conducted a prospective cohort study comparing treatment for HCV infection at the AUH with healthcare providers from different Argentinean provinces. A survey evaluating skills and competence in HCV care was administered, and results were compared. The primary endpoint was sustained virologic response (SVR) and under direct-acting antivirals. Since the implementation of ECHO clinics, a total of 25 physicians participated in at least one session (median 10.0; IQR 3.0-18.0). SVR rates (n = 437 patients) were 94.2% (95% CI 90.4-96.8) in patients treated at AUH clinic (n = 227/242) and 96.4% (95% CI 92.7-98.5) in those treated at ECHO sites (n = 188/195), with a nonsignificant difference between sites, 2.2% SVR difference (95% CI -0.24-0.06; P = 0.4). We also found a significant improvement in all the evaluated skills and abilities. Replicating the ECHO model helped to improve participants' skills in the management of HCV achieving similar SVR rates. ECHO model was demonstrated to be an effective intervention able to multiply and expand HCV treatment, a critical barrier to access to care that needs to be solved if we are committed with WHO goals to eliminate HCV by 2030.
Subject(s)
Clinical Competence , Hepatitis C/epidemiology , Patient Care , Practice Patterns, Physicians' , Telemedicine , Adult , Aged , Antiviral Agents/therapeutic use , Argentina/epidemiology , Drug Therapy, Combination , Female , Geography , Hepatitis C/diagnosis , Hepatitis C/therapy , Hepatitis C/virology , Humans , Male , Middle Aged , Models, Theoretical , Sustained Virologic Response , Telemedicine/methodsABSTRACT
The Hepatitis C Virus Genotype 2 subtype 2c (HCV-2c) is detected as a low prevalence subtype in many countries, except in Southern Europe and Western Africa. The current epidemiology of HCV in Argentina, a low-prevalence country, shows the expected low prevalence for this subtype. However, this subtype is the most prevalent in the central province of Córdoba. Cruz del Eje (CdE), a small rural city of this province, shows a prevalence for HCV infections of 5%, being 90% of the samples classified as HCV-2c. In other locations of Córdoba Province (OLC) with lower prevalence for HCV, HCV-2c was recorded in about 50% of the samples. The phylogenetic analysis of samples from Córdoba Province consistently conformed a monophyletic group with HCV-2c sequences from all the countries where HCV-2c has been sequenced. The phylogeographic analysis showed an overall association between geographical traits and phylogeny, being these associations significant (αâ=â0.05) for Italy, France, Argentina (places other than Córdoba), Martinique, CdE and OLC. The coalescence analysis for samples from CdE, OLC and France yielded a Time for the Most Common Recent Ancestor of about 140 years, whereas its demographic reconstruction showed a "lag" phase in the viral population until 1880 and then an exponential growth until 1940. These results were also obtained when each geographical area was analyzed separately, suggesting that HCV-2c came into Córdoba province during the migration process, mainly from Europe, which is compatible with the history of Argentina of the early 20th century. This also suggests that the spread of HCV-2c occurred in Europe and South America almost simultaneously, possibly as a result of the advances in medicine technology of the first half of the 20th century.
Subject(s)
Hepacivirus/classification , Hepacivirus/genetics , Phylogeny , Aged , Amino Acid Substitution/genetics , Argentina , Base Sequence , Bayes Theorem , Demography , Humans , Likelihood Functions , Middle Aged , Molecular Sequence Data , Phylogeography , Viral Nonstructural Proteins/geneticsABSTRACT
BACKGROUND/AIMS: The possibility of the non-parenteral Hepatitis C Virus (HCV) transmission is supported by the demonstration that the actual virus is present in several body fluids. In this study, we investigated the relationship between the detection of HCV RNA in body fluids (saliva, cervical smears, seminal fluid and peripheral blood mononuclear cells) from chronically HCV-infected patients and several viral and host factors. METHODOLOGY: This study comprised 16 HIV/ HCV coinfected and 21 HCV monoinfected patients with a median age of 38 and 45 years, respectively. HCV-RNA was detected in serum and fluids samples by reverse transcription-nested polymerase chain reaction. Genotypes were determined by using RFLP and direct nucleotide sequencing of the PCR products and plasma viral loads by using NASBA HCV-QT. RESULTS: When compared on the basis of the results of the detection of HCV-RNA in fluids, patients did not differ significantly in relation to viral load, genotype, HCV/HIV coinfection, and epidemiological host factors. CONCLUSIONS: Our data suggest that HCV can be detected in body fluids of chronically HCV-infected patients independent of these cofactors, including circulating HCV load and HCV/HIV coinfection. Studies on HCV dynamics are needed to gain insights into nonparenteral transmission of HCV.
Subject(s)
Body Fluids/virology , HIV Infections/complications , Hepacivirus/isolation & purification , Hepatitis C/complications , Leukocytes, Mononuclear/virology , Adult , Cervix Uteri/virology , Chi-Square Distribution , Female , Genotype , Hepatitis C/virology , Humans , Male , Middle Aged , Prospective Studies , RNA, Viral/analysis , Reverse Transcriptase Polymerase Chain Reaction , Risk Factors , Saliva/virology , Semen/virology , Vaginal SmearsABSTRACT
La presencia de RNA-HCV y la distribución de genotipos se detectaron mediante técnicas moleculares (RT-nested PCR y RFLP) en 310 muestras de individuos de la región centro de Argentina. Se halló 11,8% de coinfección HCV/HIV, con mayor prevalencia de genotipo 1 (73%). La distribución de los genotipos 1 y 2 entre individuos monoinfectados fue de 49,4% y 43,9%, respectivamente. El análisis de regresión logística multivariado mostró que la edad y el uso de drogas endovenosas (UDEV) condicionó la distribución de genotipos. El genotipo 2 se halló frecuentemente entre adultos mayores y su diseminación no se pudo asociar a ninguna vía de transmisión. El genotipo 1 se lo halló principalmente en adultos jóvenes y asociados al UDEV. El notable incremento de genotipo 1, homogéneamente distribuido en todas las edades posee importantes implicancias en las decisiones terapéuticas, considerando que posee baja respuesta a laterapia antiviral.
Subject(s)
Molecular Epidemiology , Hepatitis C , Hepatitis VirusesABSTRACT
La presencia de RNA-HCV y la distribución de genotipos se detectaron mediante técnicas moleculares (RT-nested PCR y RFLP) en 310 muestras de individuos de la región centro de Argentina. Se halló 11,8% de coinfección HCV/HIV, con mayor prevalencia de genotipo 1 (73%). La distribución de los genotipos 1 y 2 entre individuos monoinfectados fue de 49,4% y 43,9%, respectivamente. El análisis de regresión logística multivariado mostró que la edad y el uso de drogas endovenosas (UDEV) condicionó la distribución de genotipos. El genotipo 2 se halló frecuentemente entre adultos mayores y su diseminación no se pudo asociar a ninguna vía de transmisión. El genotipo 1 se lo halló principalmente en adultos jóvenes y asociados al UDEV. El notable incremento de genotipo 1, homogéneamente distribuido en todas las edades posee importantes implicancias en las decisiones terapéuticas, considerando que posee baja respuesta a laterapia antiviral.(AU)
