Fast-track recovery after major liver and pancreatic resection from the nursing point of view.

Postoperative fast-track recovery protocols combine various methods to support immediate care of patients who undergo major surgery. These protocols include control of postoperative pain and early beginning of oral diet and mobilization. The combination of these approaches may reduce the rate of postoperative complications and facilitate hospital discharge. The aim of this study was to evaluate progress and parameters of fast-track recovery after major liver and pancreatic resection. A descriptive bibliographical review from 2001 to 2012 via electronic databases such as MEDLINE, PubMed, and Google Scholar was undertaken. Articles that focused on a fast-track protocol were studied. Reports focusing on the implementation of a fast-track protocol in the postoperative recovery of patients after major hepatectomy or pancreatectomy were selected. Fast-track protocols may be applicable to patients recovering after major liver or pancreatic resection. Future research should be focused on particular parameters of the fast-track protocol separately.

Liver function tests in viremic and nonviremic chronic hepatitis B virus-infected pregnant women: importance of alanine aminotransferase/sodium ratio.

The major risk factor of perinatal transmission of Hepatitis B virus (HBV) infection is the level of maternal HBV-deoxyribonucleic acid (DNA) during the third trimester of pregnancy. The primary aim of this study was to evaluate the hematological and biochemical status in Hepatitis B e-antigen (HBeAg)-negative chronic HBV-infected pregnant women and to correlate the findings with the presence or absence of viremia. Ninety-five consecutive chronic HBV-infected pregnant women were evaluated between the 28th and 32nd week of gestation. Viral load was determined by using the COBAS TaqMan HBV test. Sixty-nine women were evaluated and 14 of them exhibited HBV-DNA levels higher than 2000 IU·ml. In this study, viremic women exhibited significantly higher alanine aminotransferase (ALT), creatinine, and uric acid values as well as significantly lower white blood cell count compared with nonviremic women. There was also a significant statistical difference concerning ALT/sodium ratio between viremic and nonviremic women (0.20 ± 0.22 vs. 0.10 ± 0.09, respectively, p= .024). The optimal cutoff points discriminating those women with a high probability to have detectable serum HBV-DNA were 0.092 for ALT/sodium ratio (sensitivity = 73.0%, specificity = 61.5%, area under the receiver operating characteristic curve [AUC] = 71.05%) and 12.8 IU/L for ALT (sensitivity = 73.0%, specificity = 63.0%, AUC = 72.2%). Chronic HBV-infected pregnant women with ALT/sodium ratio ≥ 0.11 had the higher probability of having serum HBV-DNA levels higher than 2000 IU/ml (sensitivity = 76.92%, specificity = 58%, AUC = 62.38%). Presence of HBV-DNA in maternal blood during the third trimester of pregnancy is significantly associated with maternal serum ALT levels in HBeAg-negative chronic HBV-infected pregnant women. Women with an ALT/sodium ratio greater than 0.092 have the higher probability of HBV-DNA presence in maternal blood whereas an ALT/sodium ratio greater than 0.11 could discriminate those women with HBV-DNA levels higher than 2000 IU/ml.

Epidemiological factors affecting "hepatitis C".

Hepatitis C is an infectious disease affecting the liver, caused by the hepatitis C virus (HCV). The infection is often asymptomatic, but once established, chronic infection can progress to scarring of the liver (fibrosis), and advanced scarring (cirrhosis) which is generally apparent after many years. The main goal of this work is the investigation of the important factors that affect hepatitis C. Epidemiological and Statistical analysis using non-parametric tests (Kruskal-Willis, Mann-Whitney) are considered to present the amount of significant differences between important factors. Proposed model are analyzed when logistic regression is applied.

Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection.

BACKGROUND/AIM: The spontaneous preterm birth (SPB) rates in a group of HBeAg-negative chronic HBV infected pregnant women without several known risk factors for preterm delivery as well as the mother to infant HBV transmission rates was evaluated. Moreover the role of maternal data during perinatal period as well as the role of HBsAg and/or HBV-DNA presence in cord blood in respect to preterm labour and vertical transmission of the infection was examined. METHODS: 138 consecutive chronic HBV infected pregnant women were haematologically, serologically and virologically evaluated during the perinatal period. 102 women were finally evaluated and fifteen of them (14.7%) exhibited SPB. Overall, 44 infants who had completed the proposed vaccination schedule were evaluated at month 12 of their life. RESULTS: A significant association between SPB and HBV-DNA presence in cord blood was observed (p=0.007). HBV-DNA positivity in cord blood was significantly associated with maternal HBV-DNA levels (p=0.002). The relative risk of HBV-DNA presence in cord blood was 6.43 times higher among women with serum HBV-DNA ≥ 10.000 copies/ml and lymphocyte count<1500 compared to those with all the other combinations of both parameters (p=0.001). All infants evaluated at month 12 were HBsAg-negative and exhibited undetectable HBV-DNA levels. CONCLUSION: The presence of HBV-DNA in cord blood is significantly associated with SPB in chronic HBV infected pregnant women. Maternal or cord blood viremia does not pose an additional risk factor for vertical transmission of HBV infection, in passive-active immunoprotected infants from HBeAg-negative chronic HBV infected mothers.

Presence of HBV-DNA in cord blood is associated with spontaneous preterm birth in pregnant women with HBeAg-negative chronic hepatitis B virus infection.

Spontaneous preterm birth is the leading cause of perinatal morbidity and mortality. In this study the spontaneous preterm birth rates in a group of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B virus (HBV)-infected pregnant women without known risk factors for preterm delivery as well as the role of maternal laboratory data and hepatitis B surface antigen/HBV deoxyribonucleic acid (HBV-DNA) in cord blood in respect to preterm labour were evaluated. 138 consecutive HBeAg-negative chronic HBV-infected pregnant women were evaluated during the perinatal period. Serum HBV-DNA was determined by using the Cobas Amplicor HBV Test in both maternal and cord blood samples. 102 women were finally evaluated (36 were excluded) and 15 of them (14.7%) had spontaneous preterm birth. A significant association between spontaneous preterm birth and HBV-DNA in cord blood was observed (p = 0.007). HBV-DNA positivity in cord blood was significantly associated with maternal HBV-DNA levels (p = 0.002). The relative risk of HBV-DNA in cord blood was 6.43 times higher among women with serum HBV-DNA ≥10,000 copies/ml and lymphocyte count <1,500 compared to those with all the other combinations of both parameters (p = 0.001). In conclusion, the presence of HBV-DNA in cord blood is significantly associated with spontaneous preterm birth in chronic HBV-infected pregnant women. Women with HBV-DNA ≥10,000 copies/ml and lymphocyte count <1,500 during the perinatal period have a higher probability of HBV-DNA in their cord blood.

Hepatitis B markers and vaccination-induced protection rate among Albanian pregnant women in Greece.

Hepatitis B has long been a serious public health problem both in Greece and in Albania. In the February 2009 issue of World Journal of Gastroenterology, Resuli et al presented the interesting epidemiological data concerning hepatitis B virus infection in Albania. The results of this study were discussed and several data from our similar research were provided.

Impact of hepatitis B exposure on sustained virological response rates of highly viremic chronic hepatitis C patients.

AIM: To evaluate the impact of hepatitis B core antibody (anti-HBc) seropositivity in sustained virological response (SVR) rates in treatment-naïve, chronic hepatitis C (CHC) patients with high pretreatment viral load (>800000 IU/mL). METHODS: 185 consecutive CHC patients (14.4% cirrhotics, 70.2% prior intravenous drug users) treated with pegylated interferon-a2b plus ribavirin, for 24 or 48 weeks based on viral genotype, were retrospectively analyzed. SVR was confirmed by undetectable serum HCV-RNA six months after the end of treatment schedule. RESULTS: Thirty percent of CHC/HBsAg-negative patients were anti-HBc-positive. Anti-HBc positivity was more prevalent in cirrhotic, compared to noncirrhotic patients (76.9% versus 19.5%, P < .05). Serum HBV-DNA was detected in the minority of anti-HBc-positive patients (1.97%). Overall, 62.1% of patients exhibited SVR, while 28.6% did not; 71.4% of non-SVRs were infected with genotype 1. In the univariate analysis, the anti-HBc positivity was negatively associated with treatment outcome (P = .065). In the multivariate model, only the advanced stage of liver disease (P = .015) and genotype-1 HCV infection (P = .003), but not anti-HBc-status (P = .726), proved to be independent predictors of non-SVR. CONCLUSION: Serum anti-HBc positivity does not affect the SVR rates in treatment-naïve CHC patients with high pretreatment viral load, receiving the currently approved combination treatment.

Is there a meaningful serum hepatitis B virus DNA cutoff level for therapeutic decisions in hepatitis B e antigen-negative chronic hepatitis B virus infection?

UNLABELLED: The diagnosis of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B indicating therapeutic intervention currently requires serum hepatitis B virus (HBV) DNA >or=2,000 IU/mL. We evaluated the severity of liver histology and the presence of histological indication for treatment in patients with HBeAg-negative chronic HBV infection focusing on those with low viremia and/or normal alanine aminotransferase (ALT). In total, 399 patients with increased ALT and detectable serum HBV DNA (chronic hepatitis B patients) and 35 cases with persistently normal ALT and HBV DNA >2,000 IU/mL (inactive carriers) were included. Histological indication for treatment (grading score >or=7 and/or stage >or=2 in Ishak's classification) was found in 91% (185/203), 82% (75/91), 75% (47/63), and 62% (26/42) of chronic hepatitis B patients with HBV DNA >or=200,000, 20,000-199,999, 2,000-19,999, and <2,000 IU/mL, respectively (P < 0.001). Histological indication for treatment was more frequent in chronic hepatitis B patients with persistently elevated ALT (86% or 275/321), but it was also found in 74% (58/78) of those with transiently normal ALT (P = 0.025). All inactive carriers had HBV DNA <20,000 IU/mL. Histological indication for treatment was present in 17% (6/35) of inactive carriers always due to moderate (stage 2) fibrosis without active necroinflammation. CONCLUSION: HBeAg-negative chronic HBV patients with persistently or transiently increased ALT and HBV DNA >or=20,000 IU/mL almost always require therapeutic intervention, but histological indications for treatment are also present in the majority of such cases with HBV DNA <20,000 and even <2,000 IU/mL. In contrast, minimal histological lesions are observed in the majority of HBeAg-negative patients with persistently normal ALT and HBV DNA >2,000 IU/mL, who may not require immediate liver biopsy and treatment but only close follow-up.

New data concerning the epidemiology of Hepatitis B virus infection in Greece.

There is an obvious, significant, and diachronic reduction of the prevalence of HBV infection in Greece, concerning the general population as well as some traditionally high-risk groups, mainly as a result of constant informing and the widespread initiation of preventive and prophylactic measures, as well as the improvement of health care services. Nevertheless, there are special groups and populations (economical refugees, religious minorities, HIV-positive patients, abroad pregnant women, prostitutes, etc.) who represent sacs of high HBV endemicity and need epidemiological supervision and intervention, in order to limit the spread of the infection and to further improve the existing epidemiological data.

Atypical autoimmune polyglandular syndrome type 3 overlapped by chronic HCV infection resulting in carcinogenesis and fatal infection.

The case of a woman with insulin-dependent diabetes mellitus, autoimmune thyroiditis, atrophic gastritis, pernicious anemia, and immunologic thrombocytopenic purpura consisting of autoimmune polyglandular syndrome type 3 associated with a history of gonadal failure is reported. Hepatitis C viral infection added xerophthalmia, lymphocytic sialadenitis, and exacerbation of idiopathic thrombocytopenic purpura. This unique disease constellation was complicated with splenic marginal zone lymphoma and gastric carcinoids. A lung infection, initially treated on an outpatient basis, proved fatal to the patient.

Patient's age modifies the impact of the proposed predictors of sustained virological response in chronic hepatitis C patients treated with PEG-interferon plus ribavirin.

BACKGROUND: The aim of this study was to investigate the effect of patient's age on the impact of typically proposed predictors of sustained virological response (SVR) in treatment-naïve, high-pretreatment viral load (>700.000 IU/ml), chronic hepatitis C (CHC) patients treated under real-life conditions in Greece. METHODS: We retrospectively analyzed 185 CHC patients (14.4% cirrhotics) who had been treated with weight-adjusted dosing (1.5 microg/kg per week) of pegylated interferon-a2b (PEG) plus genotype-based ribavirin (RIB) for 24 or 48 weeks of treatment, based on viral genotype. SVR was confirmed by undetectable serum HCV-RNA 6 months after the end of treatment. RESULTS: Overall, 68.5% of patients exhibited SVR and 31.5% were non-responders (non-SVRs). Among the non-SVRs, 71.4% were infected with HCV genotype-1. Importantly, 71.4% of genotype 4-infected treated patients exhibited SVR. In the multivariate analyses, only the early histological stage of liver disease (p=0.015) and the presence of genotype non-1 infection (p=0.003) were independent predictors of SVR. For patients younger than 35 years, none of the baseline parameters and neither viral genotype (p=0.284) nor the stage of liver disease (p=0.351) was an independent predictor of non-SVR, whereas for patients between 35 and 55, only the presence of genotype-1 infection independently predicted non-SVR (p=0.008). For older patients (>55 years), only the histological stage of liver disease (p=0.047) and not the viral genotype (p=0.275) independently predicted non-SVR. CONCLUSIONS: The impact of the typical predictors of SVR, such as viral genotype and liver histopathology, is modified according to patient's age in currently approved combination treatment.

Case report: mixed cholestatic/hepatocellular liver injury induced by the herbicide quizalofop-p-ethyl.

CONTEXT: Quizalofop-p-ethyl is an often applied, slightly toxic herbicide for which no severe toxicity has been reported in humans. CASE PRESENTATION: We present the case of a farmer exposed to quizalofop-p-ethyl who presented with obstructive cholestasis. A complete workup disclosed no other cause of liver pathology, but liver biopsy established drug-induced hepatotoxicity. The patient was treated with ursodeoxycholic acid and prednisolone, and was recovered fully 70 days after his exposure to the herbicide. The patient was followed for the next 9 months. CONCLUSION: Quizalofop-p-ethyl can induce a mixed cholestatic/hepatocellular liver injury. We discuss possible mechanisms implicated in liver injury after exposure to quizalofop-p-ethyl. RELEVANCE TO CLINICAL OR PROFESSIONAL PRACTICE: In patients presenting with mixed cholestatic/ hepatocellular liver injury, occupational exposure to quizalofop-p-ethyl in the course of agricultural use should be investigated.

Serological and virological profile of chronic HBV infected women at reproductive age in Greece. A two-year single center study.

OBJECTIVE: Seroprevalence of HBsAg in 26,746 women at reproductive age in Greece and evaluation of HBeAg/anti-HBe serological status as well as serum HBV-DNA levels in a subgroup of HBsAg(+) women at labor. STUDY DESIGN: Serological markers were detected using enzyme immunoassays. Serum HBV-DNA was calculated using a sensitive quantitative PCR assay, with a lower limit of quantification of 200 copies/ml. RESULTS: Overall, 1.53% of women were HBsAg(+) and the majority of them (64.96%) were Albanian. Among Albanian women the mean prevalence of HBsAg was 4.9%, 5.57% among Asian women, and 1.29% among women from Eastern European countries. The prevalence of HBsAg among African (0.29%) and Greek women (0.57%) was very low and significantly lower in comparison with the mean value of the studied population. Only 2.67% of HBsAg(+) women were HBeAg(+). Of a subgroup of women in labor with available serum samples 28.6% had undetectable levels of viremia (<200 copies/ml) and 15.9% had extremely low levels of viral replication (<400 copies/ml). Only 12.7% of pregnant women evaluated at labor exhibited extremely high serum HBV-DNA levels (>10,000,000 copies/ml) whereas 42.8% of them exhibited HBV-DNA levels between 1500 and 40,000 copies/ml. CONCLUSIONS: The overall prevalence of HBsAg is relatively low among women at reproductive age in Greece but is higher among specific ethnic populations (Asian, Albanian). The HBeAg(-)/antiHBe(+) serological status is a finding observed in the vast majority of HBsAg(+) women of our study population, and a significant percentage of them (approximately 44.5%) exhibit extremely low or even undetectable levels of viral replication at labor, suggesting possibly that only a proportion of HBsAg(+) women in Greece exhibit an extremely high risk of vertical transmission of the infection.

Impact of shorter duration of treatment on virological response rate in genotype 2 or 3 chronic hepatitis C virus infection.

OBJECTIVE: To evaluate the effect of shortened duration of pegylated interferon (PEG-IFN) and ribavirin (RIB) treatment on sustained virological response (SVR) rates in treatment-naomicronve patients with chronic hepatitis due to genotype 2 or 3 hepatitis C virus (HCV) infection and high pre-treatment viral load (>800,000 IU/mL). METHODS: Records of 142 patients with chronic hepatitis C (22 with cirrhosis) who had been treated with PEG-IFN and RIB for 24 weeks (Group A, n=88), both drugs for 12-16 weeks (Group B, n=39), or with PEG-IFN for 12-16 weeks and RIB for 24 weeks (Group C, n=15), were analyzed retrospectively. RESULTS: Overall, 81.7% of patients had SVR (Group A: 88.6%, Group B: 69.2% and Group C: 73.3%, p=0.02). Failure to achieve SVR was significantly related to treatment group (p=0.026 for Group B and p=0.002 for Group C, versus Group A), older age (p=0.023), higher liver biopsy stage (p=0.001) and presence of cirrhosis (p< 0.0001). In patients without cirrhosis, only the treatment group (p=0.018 for Group B and p=0.002 for Group C, compared to Group A) independently predicted failure to achieve SVR. CONCLUSION: Shorter duration of PEG-IFN treatment (12-16 weeks) adversely affected the SVR rate in patients with genotype 2 or 3 HCV infection. However, increasing the duration of RIB administration (12-16 weeks versus 24 weeks) in such patients did not have any beneficial effect on SVR in patients receiving short-duration PEG-IFN.