RESUMO
BACKGROUND AND GOALS: Hepatitis A (HAV) and hepatitis B (HBV) vaccination in patients with chronic liver disease is an accepted standard of care. We determined HAV and HBV vaccination rates in a tertiary care referral hepatology clinic and the impact of electronic health record (EHR)-based reminders on adherence to vaccination guidelines. METHODS: We reviewed the records of 705 patients with chronic liver disease referred to our liver clinic in 2008 with at least two follow-up visits during the subsequent year. Demographics, referral source, etiology, and hepatitis serology were recorded. We determined whether eligible patients were offered vaccination and whether patients received vaccination. Barriers to vaccination were determined by a follow-up telephone interview. RESULTS: HAV and HBV serologic testing prior to referral and at the liver clinic were performed in 14.5% and 17.7%; and 76.7% and 74% patients, respectively. Hepatologists recommended vaccination for HAV in 63% and for HBV in 59.7% of eligible patients. Patient demographics or disease etiology did not influence recommendation rates. Significant variability was observed in vaccination recommendation amongst individual providers (30-98.6%), which did not correlate with the number of patients seen by each physician. Vaccination recommendation rates were not different for Medicare patients with hepatitis C infection for whom a vaccination reminder was automatically generated by the EHR. Most patients who failed to get vaccination after recommendation offered no specific reason for noncompliance; insurance was a barrier in a minority. CONCLUSIONS: Hepatitis vaccination rates were suboptimal even in an academic, sub-speciality setting, with wide-variability in provider adherence to vaccination guidelines.
Assuntos
Vacinas contra Hepatite A/administração & dosagem , Hepatite A/prevenção & controle , Vacinas contra Hepatite B/administração & dosagem , Hepatite B/prevenção & controle , Hepatopatias/prevenção & controle , Vacinação/normas , Adulto , Doença Crônica , Feminino , Hepatite A/sangue , Anticorpos Anti-Hepatite A/sangue , Vacinas contra Hepatite A/uso terapêutico , Vírus da Hepatite A Humana/imunologia , Hepatite B/sangue , Anticorpos Anti-Hepatite B/sangue , Vacinas contra Hepatite B/uso terapêutico , Vírus da Hepatite B/imunologia , Humanos , Hepatopatias/sangue , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como AssuntoAssuntos
Amônia/sangue , Carcinoma Hepatocelular/diagnóstico , Neoplasias Hepáticas/diagnóstico , Neoplasias Pulmonares/secundário , Doença da Deficiência de Ornitina Carbomoiltransferase/sangue , Adolescente , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/terapia , Confusão/etiologia , Feminino , Humanos , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/terapia , Neoplasias Pulmonares/cirurgia , Metástase Linfática , Náusea/etiologia , Doença da Deficiência de Ornitina Carbomoiltransferase/complicações , Doença da Deficiência de Ornitina Carbomoiltransferase/tratamento farmacológico , Vômito/etiologiaRESUMO
Limited data exist for the use of alemtuzumab (AL) induction in liver transplantation (LT) recipients. We compared the outcomes of hepatitis C virus-negative LT recipients who received AL induction followed by tacrolimus and mycophenolate mofetil without steroids to cohort who received no AL induction, tacrolimus, and a steroid taper. Fifty-five AL-induced recipients were compared to 85 non-AL-induced recipients with similar characteristics. Two-year patient survival (80% versus 88.2%, P = 0.0665) and graft survival (76.4% versus 82.4%, P = 0.1792) were not significantly different between the AL and non-AL groups, respectively. Other outcomes, including acute rejection (20% versus 30.3%), renal dysfunction (creatinine levels: 1.3 ± 0.3 versus 1.4 ± 0.6 mg/dL), and immunosuppressant monotherapy (29.1% versus 44.3%), were not significantly different between the AL and non-AL groups, respectively (P > 0.05). The number of rejection episodes (12 versus 42, P = 0.02) and the number of patients with new-onset hypertension (3 versus 15, P = 0.03) were lower in the AL group, although the incidence of all posttransplant infections was higher with AL (63.6% versus 44.3%, P = 0.03), primarily because of an increase in viral infections. In conclusion, a steroid-free AL induction regimen was associated with less hypertension and rejection but with more infectious complications; thus, the overall benefit of AL induction in LT recipients is called into question.
Assuntos
Anticorpos Monoclonais/administração & dosagem , Anticorpos Antineoplásicos/administração & dosagem , Imunossupressores/administração & dosagem , Transplante de Fígado , Adulto , Alemtuzumab , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados , Anticorpos Antineoplásicos/efeitos adversos , Distribuição de Qui-Quadrado , Chicago , Quimioterapia Combinada , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Hipertensão/etiologia , Hipertensão/prevenção & controle , Imunossupressores/efeitos adversos , Estimativa de Kaplan-Meier , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Ácido Micofenólico/análogos & derivados , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esteroides/administração & dosagem , Tacrolimo/administração & dosagem , Fatores de Tempo , Resultado do Tratamento , Viroses/etiologiaRESUMO
Hepatic cat scratch disease is rarely reported in liver transplant recipients and has never been reported with discrete liver lesions in the graft. A 52-year-old woman was transplanted for hepatitis C cirrhosis and hepatocellular carcinoma. Her posttransplant course was uneventful. She presented 2.7 years after transplantation with fever of unknown origin and went on to develop multiple and diffuse discrete liver lesions. Despite an extensive work-up including percutaneous and laparoscopic biopsies, a subsegmental resection that included one of these masses was required to make the diagnosis of Bartonella henselae infection. Serologic tests were equivocal. Histology was consistent with cat scratch disease of the liver, and polymerase chain reaction (PCR) testing of the resected tissue confirmed the diagnosis. Response to doxycycline was rapid. Fevers resolved within 7 days. Repeat abdominal CT scan showed reduction of the liver masses. Cat scratch disease should be considered in postliver transplant patients presenting with fever and liver lesions, especially if close contact with cats has occurred. Diagnosis by PCR testing of involved tissue is preferred when serologies are equivocal due to immunosuppression.