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1.
Skinmed ; 19(1): 37-41, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33658111

RESUMO

The association between immunosuppressive therapy for dermatologic conditions and the subsequent reactivation of hepatitis B is of major medical concern. It remains a point of interest across multiple disciplines, including hepatology, dermatology, rheumatology, and infectious disease. Accordingly, we present an evidence-based practice algorithm on how best to approach a patient with presumptively cleared hepatitis B infection when anticipating the initiation of immunosuppressive therapy. This guide delineates the risk of reactivation by taking into account the immunosuppressive agent of choice and presents recommendations for antiviral prophylaxis and laboratory monitoring. Booster vaccination as a potential to decrease the risk of hepatitis B reactivation is likewise discussed. (SKINmed. 2021;19:-0).


Assuntos
Antivirais/administração & dosagem , Hepatite B/prevenção & controle , Imunossupressores/efeitos adversos , Dermatopatias/tratamento farmacológico , Algoritmos , Dermatologistas , Medicina Baseada em Evidências , Hepatite B/etiologia , Hepatite B/imunologia , Vacinas contra Hepatite B/administração & dosagem , Humanos , Imunização Secundária/métodos , Imunossupressores/administração & dosagem
2.
Dig Dis Sci ; 66(7): 2387-2393, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-32757159

RESUMO

BACKGROUND: The development of point-of-care biomarkers of disease has become a major focus of interest in nonalcoholic fatty liver disease (NAFLD). The NAFLD fibrosis score (NFS), BARD, FIB-4, and aspartate aminotransferase-to-platelet ratio index (APRI) are commonly used for advanced NAFLD fibrosis prediction. However, the performance of these scores among in a predominantly Hispanic patient population, a population with the highest prevalence of NAFLD, has not been examined. METHODS: We performed a retrospective study among patients with histologically confirmed and staged NAFLD at the Ben Taub General Hospital, Houston, Texas, to externally validate four noninvasive advanced fibrosis prediction scores. Their discriminatory ability was assessed using the area under the receiver operating characteristic curve (AUROC). Sensitivity, specificity, positive, and negative predictive values were calculated. RESULTS: We included 99 NAFLD patients, of whom 37 (37.4%) had advanced fibrosis. The cohort was predominantly Hispanic (73.7%). The AUROC for detecting advanced fibrosis were: NFS 0.79 (95% confidence interval, 0.69-0.88), BARD 0.76 (0.67-0.86), FIB-4 0.77 (0.68-0.87), and APRI 0.70 (0.59-0.81). Using the low cutoff for the NFS (- 1.455) had the highest sensitivity (81.1%) and the highest negative predictive value (85.4%) among the overall study population. CONCLUSIONS: Noninvasive scores for advanced NAFLD fibrosis have moderate discriminatory ability in Hispanic patients with NFS having a small advantage. The AUROCs of these scores were similar to those reported in Caucasian populations. However, they had uniformly lower negative predictive values among our predominantly Hispanic study population, suggesting that they are not reliable for ruling out advanced fibrosis among this high-risk population.


Assuntos
Hispânico ou Latino , Cirrose Hepática/patologia , Hepatopatia Gordurosa não Alcoólica/patologia , Testes Imediatos , Adulto , Biomarcadores , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos
3.
Cureus ; 11(6): e5042, 2019 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-31497458

RESUMO

Persistent elevation of aspartate aminotransferase (AST) activity in serum due to the presence of a macro-enzyme form of AST (macro-AST) may lead to diagnostic confusion in many clinical conditions, particularly in those associated with chronic liver disease. We present a case of macro-AST in a patient with non-alcoholic fatty liver disease in which polyethylene glycol precipitation confirmed the cause of disproportionately elevated AST as macro-AST.

4.
Cureus ; 11(5): e4598, 2019 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-31281763

RESUMO

A 24-year-old Hispanic woman presented to our facility with a two-week history of abdominal pain, nausea, vomiting, diarrhea, jaundice, and scleral icterus. Initial laboratory workup revealed elevated transaminases, direct hyperbilirubinemia, and positive anti-smooth muscle antibody. Liver biopsy confirmed the diagnosis of autoimmune hepatitis and our patient was started on oral prednisone therapy. Her liver enzymes initially began to normalize but then spontaneously started up-trending. She was subsequently readmitted to the hospital for further management, at which time she also complained of palpitations, heat intolerance, and sweating. Laboratory workup revealed hyperthyroidism secondary to Grave's disease. Our patient was not a candidate for methimazole or propylthiouracil treatment due to her hepatic dysfunction, so she was started on hydrocortisone due to its secondary effect of decreased conversion of thyroxine to triiodothyronine. She achieved biochemical remission of her autoimmune hepatitis on this regimen and was transitioned back to oral prednisone therapy. Her liver enzymes normalized once she underwent radioactive iodine ablation of her thyroid. This clinical course suggests that autoimmune hepatitis with concurrent Grave's disease may be refractory to treatment until the underlying hyperthyroid state is corrected.

5.
Transl Res ; 195: 25-47, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29291380

RESUMO

The application of nontargeted metabolomic profiling has recently become a powerful noninvasive tool to discover new clinical biomarkers. This study aimed to identify metabolic pathways that could be exploited for prognostic and therapeutic purposes in hepatorenal dysfunction in cirrhosis. One hundred three subjects with cirrhosis had glomerular filtration rate (GFR) measured using iothalamate plasma clearance, and were followed until death, transplantation, or the last encounter. Concomitantly, plasma metabolomic profiling was performed using ultrahigh performance liquid chromatography-tandem mass spectrometry to identify preliminary metabolomic biomarker candidates. Among the 1028 metabolites identified, 34 were significantly increased in subjects with high liver and kidney disease severity compared with those with low liver and kidney disease severity. The highest average fold-change (2.39) was for 4-acetamidobutanoate. Metabolite-based enriched pathways were significantly associated with the identified metabolomic signature (P values ranged from 2.07E-06 to 0.02919). Ascorbate and aldarate metabolism, methylation, and glucuronidation were among the most significant protein-based enriched pathways associated with this metabolomic signature (P values ranged from 1.09E-18 to 7.61E-05). Erythronate had the highest association with measured GFR (R-square = 0.571, P <0.0001). Erythronate (R = 0.594, P <0.0001) and N6-carbamoylthreonyladenosine (R = 0.591, P <0.0001) showed stronger associations with measured GFR compared with creatinine (R = 0.588, P <0.0001) even after controlling for age, gender, and race. The 5 most significant metabolites that predicted mortality independent of kidney disease and demographics were S-adenosylhomocysteine (P = 0.0003), glucuronate (P = 0.0006), trans-aconitate (P = 0.0018), 3-ureidopropionate (P = 0.0021), and 3-(4-hydroxyphenyl)lactate (P = 0.0047). A unique metabolomic signature associated with hepatorenal dysfunction in cirrhosis was identified for further investigations that provide potentially important mechanistic insights into cirrhosis-altered metabolism.


Assuntos
Rim/fisiopatologia , Cirrose Hepática/fisiopatologia , Fígado/fisiopatologia , Metabolômica , Adulto , Idoso , Feminino , Taxa de Filtração Glomerular , Humanos , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença
6.
Clin Transplant ; 31(12)2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29044759

RESUMO

An index to predict hospital length of stay after liver transplantation could address unmet clinical needs. Length of stay is an important surrogate for hospital costs and efforts to limit stays can preserve our healthcare resources. Here, we devised a scoring system that predicts hospital length of stay following liver transplantation. We used univariate and multivariate analyses on 73 635 adult liver transplant recipient data and identified independent recipient and donor risk factors for prolonged hospital stay (>30 days). Multiple imputation was used to account for missing variables. We identified 22 factors as significant predictors of prolonged hospital stay, including the most significant risk factors: intensive care unit (ICU) admission (OR 1.75, CI 1.58-1.95) and previous transplant (OR 1.60, CI 1.47-1.75). The length of stay (LOS) index assigns weighted risk points to each significant factor in a scoring system to predict prolonged hospital stay after liver transplantation with a c-statistic of 0.75. The LOS index demonstrated good discrimination across the entire population, dividing the cohort into tertiles, which had odds ratios of 2.25 (CI 2.06-2.46) and 7.90 (7.29-8.56) for prolonged hospital stay (>30 days). The LOS index utilizes 22 significant donor and recipient factors to accurately predict hospital length of stay following liver transplantation. The index further demonstrates the basis for a clear clinical recommendation to mitigate risk of long hospitalization by minimizing cold ischemia time.


Assuntos
Hospitalização/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Falência Hepática/cirurgia , Transplante de Fígado , Modelos Estatísticos , Índice de Gravidade de Doença , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Adulto Jovem
7.
World J Gastrointest Pathophysiol ; 8(2): 51-58, 2017 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-28573067

RESUMO

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease associated with insulin resistance and metabolic syndrome. The spectrum of disease ranges from simple steatosis to steatohepatitis and progression to cirrhosis. Compelling evidence over the past several years has substantiated a significant link between NAFLD and cardiovascular disease ranging from coronary artery disease to subclinical carotid atherosclerosis. Close follow up, treatment of risk factors for NAFLD, and cardiovascular risk stratification are necessary to predict morbidity and mortality in this subset of patients.

8.
Clin Transplant ; 31(2)2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27862340

RESUMO

Calcineurin inhibitors (CNI) are the mainstay of immunosuppression after liver transplantation (LT), but CNIs are associated with significant nephrotoxicity. Recently, mTOR inhibitors such as sirolimus and everolimus (EVR) have been used with or without CNIs in LT recipients for their renal-sparing effect. We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) that examined the effect of EVR with CNI minimization or withdrawal on renal function in LT recipients. RCT of primary adult LT recipients with baseline GFR >30 mL/min who received EVR with CNI minimization or withdrawal were included. Four RCTs (EVR n=465, control n=428) were included. In three RCTs, EVR was initiated 4 weeks following LT; these studies were used to assess the primary outcome. All four studies were used to assess the secondary outcomes. Based on this study, EVR use with CNI minimization in LT recipients is associated with improved renal function at 12 months by GFR of 10.2 mL/min (95% CI: 2.75-17.8). EVR use was not associated with an increased risk of biopsy-proven acute rejection (RR 0.68, 95% CI: 0.31-1.46), graft loss (RR 1.60, 95% CI: 0.51-5.00), or mortality (RR 1.34, 95% CI 0.62-2.90). However, it was associated with an increased risk of overall infections (RR 1.45, 95% CI: 1.10-1.91).


Assuntos
Inibidores de Calcineurina/uso terapêutico , Everolimo/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Nefropatias/prevenção & controle , Transplante de Fígado/efeitos adversos , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Humanos , Imunossupressores/uso terapêutico , Nefropatias/etiologia , Testes de Função Renal , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Sirolimo/uso terapêutico
9.
J Clin Transl Hepatol ; 3(2): 134-9, 2015 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-26357640

RESUMO

The link between chronic hepatitis C virus (HCV) infection and a subset of B-cell non-Hodgkin lymphomas (B-NHL) is strongly supported by epidemiological studies. Evidence demonstrating complete regression of lymphoma after antiviral treatments suggests possible chronic antigenic stimulation for the origin of B-NHL and provides evidence for a virus-mediated lymphomagenesis. B-NHL is a heterogeneous group of lymphomas with varied clinical presentation and may be indolent or aggressive. The optimal management of HCV related B-NHL is not clear. Antiviral treatment may be sufficient for low-grade lymphomas, but chemotherapy is necessary in patients with high grade lymphomas. Interferon (IFN)-based antiviral treatment regimens for HCV infection are limited by poor tolerance and suboptimal antiviral response. Recently approved novel direct acting antiviral (DAA) drugs are highly effective and safe. This has opened a new era for the treatment of HCV related B-NHL alone or in conjunction with chemotherapy. Treatment of HCV associated B-NHL should be performed in an interdisciplinary approach in close consultation with hematologist and hepatologist. In this review, we summarize data regarding clinical features and epidemiology of B-NHL and discuss novel therapeutic approaches, including DAAs, that may prove to be effective in the treatment of HCV associated lymphomas.

10.
World J Gastroenterol ; 20(15): 4115-27, 2014 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-24764650

RESUMO

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Multiple treatment options are available for HCC including curative resection, liver transplantation, radiofrequency ablation, trans-arterial chemoembolization, radioembolization and systemic targeted agent like sorafenib. The treatment of HCC depends on the tumor stage, patient performance status and liver function reserve and requires a multidisciplinary approach. In the past few years with significant advances in surgical treatments and locoregional therapies, the short-term survival of HCC has improved but the recurrent disease remains a big problem. The pathogenesis of HCC is a multistep and complex process, wherein angiogenesis plays an important role. For patients with advanced disease, sorafenib is the only approved therapy, but novel systemic molecular targeted agents and their combinations are emerging. This article provides an overview of treatment of early and advanced stage HCC based on our extensive review of relevant literature.


Assuntos
Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/terapia , Ablação por Cateter/métodos , Quimioembolização Terapêutica/métodos , Ensaios Clínicos como Assunto , Terapia Combinada/métodos , Medicina Baseada em Evidências , Humanos , Transplante de Fígado , Terapia de Alvo Molecular/métodos , Niacinamida/análogos & derivados , Niacinamida/uso terapêutico , Compostos de Fenilureia/uso terapêutico , Transdução de Sinais , Sorafenibe , Resultado do Tratamento
11.
Am J Med Sci ; 340(2): 89-93, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20588181

RESUMO

INTRODUCTION: The safety and efficacy of hydroxymethylglutaryl CoA reductase inhibitors (statins) have been extensively demonstrated, but in clinical practice, there remains significant underutilization of these medications. The authors hypothesized that this underutilization could stem in part from fear of liver damage caused by statins. The purpose was to determine whether concern about hepatotoxicity acts as a barrier among primary care physicians to prescribing statins for patients with elevated liver transaminase values and/or underlying liver disease. METHOD: The survey included 937 primary care physicians from 138 academic centers in the United States, and the following were measured: (1) comparison of statin prescribing for patients with clinical indications and (a) no mention of liver transaminase values, (b) elevated liver transaminase values and (c) underlying liver disease; (2) correlation between perception of statin hepatotoxicity and statin prescribing. RESULTS: Seventy-one percent of respondents would prescribe statins in scenario 1, (45-year-old woman with low-density lipoprotein 240 mg/dL), whereas only 50% would prescribe statins if the baseline liver transaminase values were elevated to 1.5 times upper limit of normal (P < 0.001). This prescribing rate dropped even further to 40% in scenario 3 (55-year-old man with known coronary disease, low-density lipoprotein 250 mg/dL and hepatitis C). Thirty-seven percent of respondents had falsely elevated perceptions of statin hepatotoxicity risk, and these perceptions correlated inversely with statin prescribing. The method of survey administration prevented calculation of response rate, possibility of response bias exists. CONCLUSION: Despite extensive data documenting safety of statins, primary care physicians harbor significant hepatotoxicity concerns, and these concerns act as a barrier to statin utilization.


Assuntos
Doença Hepática Induzida por Substâncias e Drogas/etiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Médicos de Família , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Padrões de Prática Médica/estatística & dados numéricos , Transaminases/sangue , Estados Unidos
12.
J Gastroenterol Hepatol ; 25(5): 880-5, 2010 May.
Artigo em Inglês | MEDLINE | ID: mdl-20074149

RESUMO

BACKGROUND AND AIM: Hepatorenal syndrome (HRS) is a serious complication of advanced liver disease and carries a poor prognosis. Recent trials have indicated that terlipressin may be effective in reversing HRS. Our aim was to evaluate the efficacy of terlipressin therapy in reversing type 1 HRS defined as a serum creatinine <1.5 mg/dL during treatment. METHODS: Randomized controlled trials in which patients with type 1 HRS received at least 3 days of terlipressin therapy and albumin in the intervention arm were included after a systematic search of the published English reports. Studies with other vasoconstrictor therapies in the control group were excluded. RESULTS: A total of 223 patients with HRS type 1 in four different trials, were included in the final analysis. Alcohol-related cirrhosis was the most common underlying etiology. The risk ratio for reversal in type 1 HRS with terlipressin therapy was 3.66 (95% confidence interval 2.15-6.23). Recurrence of HRS was low (8%). Serious side-effects requiring discontinuation of therapy were seen only in 6.8% of patients on terlipressin therapy. There was a trend towards improved transplant-free survival at 90 days in the terlipressin group (relative risk 1.86 95% confidence interval 1.0-3.4, P = 0.05). CONCLUSIONS: Terlipressin is effective in reversing HRS type 1. Recurrence of HRS is rare with at least 14 days of therapy. Serious side-effects requiring discontinuation of therapy are less common. There appears to be a survival benefit in patients with HRS treated with terlipressin.


Assuntos
Síndrome Hepatorrenal/tratamento farmacológico , Lipressina/análogos & derivados , Vasoconstritores/uso terapêutico , Biomarcadores/sangue , Creatinina/sangue , Feminino , Síndrome Hepatorrenal/sangue , Síndrome Hepatorrenal/etiologia , Síndrome Hepatorrenal/mortalidade , Humanos , Lipressina/efeitos adversos , Lipressina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Medição de Risco , Fatores de Risco , Terlipressina , Fatores de Tempo , Resultado do Tratamento , Vasoconstritores/efeitos adversos
13.
Clin Gastroenterol Hepatol ; 8(2): 192-9, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19879972

RESUMO

BACKGROUND & AIMS: The effects of antiviral therapy on prevention of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV)-related cirrhosis are unclear. We performed a systematic review and meta-analysis to assess HCC risk reduction in patients with HCV-related cirrhosis who have received antiviral therapy. METHODS: Twenty studies (4700 patients) were analyzed that compared untreated patients with those given interferon (IFN) alone or ribavirin. Risk ratios (RRs) determined effect size using a random effects model. RESULTS: Pooled data showed reduced HCC risk in the treatment group (RR, 0.43; 95% confidence interval [CI], 0.33-0.56), although the data were heterogenous (chi(2) = 59.10). Meta-regression analysis showed that studies with follow-up durations of more than 5 years contributed to heterogeneity. Analysis of 14 studies (n = 3310) reporting sustained virologic response (SVR) rates with antiviral treatment showed reduced HCC risk in patients with an SVR, compared with nonresponders (RR, 0.35; 95% CI, 0.26-0.46); the maximum benefits were observed in patients treated with ribavirin-based regimens (RR, 0.25; 95% CI, 0.14-0.46). Meta-analysis of 4 studies assessing the role of maintenance IFN in nonresponders did not show HCC risk reduction (RR, 0.58; 95% CI, 0.33-1.03). No publication bias was detected by the Egger test analysis (P > 0.1). CONCLUSIONS: The risk of HCC is reduced among patients with HCV who achieve an SVR with antiviral therapy. Maintenance therapy with IFN does not reduce HCC risk among patients who do not respond to initial therapy. View this article's video abstract atwww.cghjournal.org.


Assuntos
Antivirais/uso terapêutico , Carcinoma Hepatocelular/prevenção & controle , Fibrose/complicações , Hepatite C Crônica/complicações , Hepatite C Crônica/tratamento farmacológico , Humanos , Interferons/uso terapêutico , Ribavirina/uso terapêutico , Medição de Risco
14.
Clin Gastroenterol Hepatol ; 6(12): 1396-402, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-18986848

RESUMO

BACKGROUND & AIMS: Weight loss in overweight or obese individuals results in marked improvement or resolution of hypertension, diabetes mellitus, and hyperlipidemia. However, the overall effect of weight loss on nonalcoholic fatty liver disease (NAFLD) remains unclear. This systematic review and meta-analysis is an effort to explore the effect of weight loss after bariatric surgical procedures on NAFLD. METHODS: We performed an electronic literature search of published articles on bariatric surgery and liver histology since inception to September of 2007. Primary outcome measures were improvement and/or resolution in the 3 components of NAFLD (steatosis, steatohepatitis, and fibrosis) after bariatric surgery-induced weight loss. A pooled proportion of patients with improvement or resolution was calculated for steatosis, steatohepatitis, and fibrosis using a random effects model. Heterogeneity among the studies was assessed using the I(2) (inconsistency) statistic and subgroup analyses. RESULTS: A total of 15 studies (766 paired liver biopsies) were selected for final data extraction. The percentage reduction in mean body mass index after bariatric surgeries ranged from 19.11 to 41.76. The pooled proportion of patients with improvement or resolution in steatosis was 91.6% (95% confidence interval [CI], 82.4%-97.6%), in steatohepatitis was 81.3% (95% CI, 61.9%-94.9%), in fibrosis was 65.5% (95% CI, 38.2%-88.1%), and for complete resolution of nonalcoholic steatohepatitis was 69.5 (95% CI, 42.4%-90.8%). CONCLUSIONS: Steatosis, steatohepatitis, and fibrosis appear to improve or completely resolve in the majority of patients after bariatric surgery-induced weight loss.


Assuntos
Cirurgia Bariátrica , Fígado Gorduroso/patologia , Adulto , Idoso , Índice de Massa Corporal , Feminino , Humanos , Cirrose Hepática/patologia , Masculino , Pessoa de Meia-Idade , Adulto Jovem
15.
Eur J Intern Med ; 19(5): 372-3, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18549944

RESUMO

Drug induced neutropenia as a consequence of intensive chemotherapy for hematological malignancies and solid tumors is known to be associated with severe, life-threatening infections such as neutropenic enterocolitis. However, the neutropenia associated with HCV combination therapy with Pegylated Interferon [PEG-IFN] and ribavirin is considered to be well tolerated in patients without other co-morbidities. We present a case of a severe gastrointestinal complication in a patient receiving HCV combination therapy and advocate caution in continuing therapy in patients with neutropenia, especially in the presence of underlying co-morbidities such as cirrhosis.


Assuntos
Enterocolite Neutropênica/induzido quimicamente , Interferon-alfa/efeitos adversos , Polietilenoglicóis/efeitos adversos , Ribavirina/efeitos adversos , Antibacterianos/uso terapêutico , Antivirais , Quimioterapia Combinada , Enterocolite Neutropênica/diagnóstico , Enterocolite Neutropênica/tratamento farmacológico , Filgrastim , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Hepatite C/tratamento farmacológico , Humanos , Interferon alfa-2 , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes , Tomografia Computadorizada por Raios X
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