Short-term risk of hepatocellular carcinoma after hepatitis C virus eradication following direct-acting anti-viral treatment

BACKGROUND

With the development of direct-acting anti-virals (DAAs), almost all patients with chronic hepatitis C virus (HCV) infection can achieve sustained viral response (SVR).

AIM

To evaluate the short-term risk of HCC among patients with SVR by DAAs, including those with cirrhosis or previous HCC.

METHODS

This large-scale, multicentre cohort study included 1,675 consecutive patients who achieved SVR by treatment with interferon-free sofosbuvir-based regimens, divided into groups with (n = 152) or without previous HCC (n = 1,523). The Kaplan-Meier method and Cox proportional hazard analysis were used to calculate the cumulative HCC incidence and related factors of HCC.

RESULTS

During the follow-up period (median: 17 months), 46 (2.7%) patients developed HCC. The 1-year cumulative rates of de novo HCC were 0.4% and 4.9% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P < 0.001). For cirrhotic patients, serum α-fetoprotein level at the end of treatment (EOT-AFP) was the strongest predictor of de novo HCC. The 1-year cumulative de novo HCC rates were 1.4% and 13.1% in the EOT-AFP < 9.0 ng/mL and ≥ 9.0 ng/mL groups (cut-off value) respectively (log-rank test: P < 0.001). The 1-year cumulative rates of HCC recurrence were 6.5% and 23.1% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P = 0.023). For cirrhotic patients, previous HCC characteristics were significantly associated with HCC recurrence. In contrast, sex, age and metabolic features did not influence de novo HCC or recurrence.

CONCLUSIONS

For cirrhotic patients after elimination of HCV, serum EOT-AFP level and previous HCC characteristics would be useful markers for predicting de novo HCC or recurrence.

[Safe Handling of Cancer Chemotherapy Drugs in Pharmacy(Preparations, Transport and Safe Deposit)]

Recently, 1 out of 2 people are diagnosed as cancer, the number of patients who are given chemotherapy increases year by year. As a result, amount of anticancer drugs used also increases. Anticancer drug preparation work is one of pharmacist work. In many hospital, pharmacists prepare anticancer drugs at pharmacy. However, it is enough to take steps to exposure measures at all facilities. According to the United States Pharmacopeial(USP)and the handling standards of hazardous and drugs, there are 3 levels, the first level(safety cabinet), the second level(anticancer agent preparation room in pharmacy) and supplemental engineering control(CSTD). It is described that exposure control should be carried out with exposure control. Strict standards are stated for each. In Japan, efforts to cope with exposure gradually are spreading gradually after exposure GL is published. Proper preparation environment/equipment, personal protective equipment, procedures and supplementary equipment are required for adequate exposure control measures. Also, it is important for exposure control to focus not only on anticancer drug preparation work but also on transportation and storage. This time, we describe exposure preparation, transportation to storage from dispensing.

Retrospective analysis of premedication, glucocorticosteroids, and H1-antihistamines for preventing infusion reactions associated with cetuximab treatment of patients with head and neck cancer

Objectives

We evaluated infusion-related reactions associated with cetuximab combination chemotherapy comprising an H1-receptor antagonist plus dexamethasone as anti-allergy premedications for patients with head and neck cancer.

Methods

We retrospectively evaluated 248 patients who received a cetuximab combination regimen between December 2012 and August 2015. All patients received 5 mg intravenous dichlorpheniramine (H1-receptor antagonist), and dexamethasone (DEX) was adjusted from 6.6 mg to 13.2 mg according to the emetogenic risk.

Results

We identified 248 subjects, including 13 (5.2%) with infusion-related reactions (grade 1 in five [2.0%], grade 2 in seven [2.8%], and grade 4 in one [0.4%]). The incidence of these reactions in cetuximab combination regimens, each employing an H1-receptor antagonist, using a higher dose of dexamethasone (13.2 mg) was not significantly lower compared with those using 6.6 mg DEX (2.4% vs 8.3%, respectively; p = 0.43). Twelve patients experienced infusion-related reactions associated with the first cetuximab administration, and one reaction occurred after the third administration.

Conclusions

The incidence of infusion-related reactions was lower compared with those of previous studies. Dexamethasone combined with an H1-receptor antagonist was useful for preventing allergic responses. The incidence of infusion-related reactions was not lower with 13.2 mg dexamethasone, and 6.6 mg DEX prevented infusion-related reactions.

Salient Features and Outline of the Joint Japanese Guidelines for Safe Handling of Cancer Chemotherapy Drugs

The purpose of this paper is to introduce the outline and describe the salient features of the “Joint Guidelines for Safe Handling of Cancer Chemotherapy Drugs” (hereinafter, “Guideline”), which were published in July 2015. The purpose of this Guideline is to provide guidance to protect against occupational exposure to hazardous drugs (HDs) to all medical personnel involved in cancer chemotherapy, including physicians, pharmacists, and nurses and home health-care providers. The Guideline was developed according to the Medical Information Network Distribution Service guidance for developing clinical practice guidelines, with reference to five authoritative guidelines used worldwide. PubMed, Cumulative Index to Nursing and Allied Health Literature, Ichushi-Web, and Cochrane Central Register of Controlled Trials were used for a systematic search of the literature. Eight clinical questions (CQs) were eventually established, and the strength of recommendation for each CQ is presented based on 867 references. The salient features of the Guideline are that it was jointly developed by three societies (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, and Japanese Society of Pharmaceutical Oncology), contains descriptions including the definition of HDs and the concept of hierarchy of controls, and addresses exposure control measures during handling of chemotherapy drugs. Our future task is to collect additional evidence for the recommended exposure control measures and to assess whether publication of the Guideline has led to adherence of measures to prevent occupational exposure.

Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy

Background

Computerized provider order entry (CPOE) has been developed and implemented within cancer center hospitals nationwide in Japan. To ensure that high-quality services are routinely provided by oncology pharmacists, this study was designed to evaluate the interventions through reviewing the orders that are generated by CPOE.

Methods

The objective of this retrospective chart review was to evaluate how pharmacists contributed to safe cancer treatment using paper-based pharmacy records. Data were collected from a total of 35,062 chemotherapy regimens for 18,515 outpatients between January and December 2013.

Results

Of these 35,062 chemotherapy regimens, the rate of pharmacists’ interventions was 1.1% ( n = 408). Among them, 53.1% (217/408) of the chemotherapy prescriptions were modified due to pharmacist interventions. The reasons for interventions included “changes in the chemotherapy regimen were unclear” in 49.5%, “physicians’ prescription errors” (22.0%), “pharmacist suggestions to improve chemotherapy” (15.1%), and “finding differences between physicians’ chemotherapy records and their chemotherapy prescriptions” (13.2%). The top three reasons for the 217 prescription modifications due to pharmacist interventions were “finding prescription errors” (34.5%), “reasons for change in the chemotherapy regimen were unclear” (32.7%), and “finding differences between physicians’ chemotherapy records and their chemotherapy prescriptions” (28.5%).

Conclusion

The computer could not evaluate chemotherapy protocols or adjust doses of anticancer medicines according to patients’ conditions. Therefore, oncology pharmacists should continue to ensure safe and appropriate administration of cancer chemotherapy.

Risk Factors for the Discontinuation of Home Medical Care among Low-functioning Older Patients

OBJECTIVES

Older patients receiving home medical care often have declining functional status and multiple disease conditions. It is important to identify the risk factors for care transition events in this population in order to avoid preventable transitions. In the present study, therefore, we investigated the factors associated with discontinuation of home medical care as a potentially preventable care transition event in older patients.

METHODS

Baseline data for participants in the Observational study of Nagoya Elderly with HOme MEdical (ONEHOME) study and data on the mortality, institutionalization, or hospitalisation of the study participants during a 2-year follow-up period were used. Discontinuation of home care was defined as admission to a hospital for any reason, institutionalization, or death. Univariate and multivariate Cox hazard models were used to assess the association of each of the factors with the discontinuation of home care during the observational period. The covariates included in the multivariate analysis were those significantly associated with the discontinuation of home care at the level of P<0.05 in the univariate analysis.

RESULTS

The univariate Cox hazard model revealed that a low hemoglobin level (< 11g/dL), low serum albumin level (< 3g/dL), higher Charlson Comorbidity Index score, and low Mini Nutritional Assessment Short Form score (< 7) were significantly associated with the discontinuation of home care. A multivariate Cox hazard model including these four factors demonstrated that all four were independently associated with home-care discontinuation.

CONCLUSIONS

The present results demonstrated that anemia, hypoalbuminemia, malnourishment, and the presence of serious comorbidities were associated with the discontinuation of home medical care among low-functioning older patients.

[Evaluation of Drug Interaction between S-1 and Warfarin]

Prolonged prothrombin time is observed in patients taking warfarin (WF) with a fluoropyrimidine, such as S-1. When WF is combined with S-1, the prothrombin time-international normalized ratio (PT-INR) and dose adjustment of WF should be closely monitored. To date, no clinical data have been reported in terms of the relation between temporal variation of PT-INR and its therapeutic range. In this study, we retrospectively collected patients' clinical data including PT-INR. We identified 21 patients receiving WF therapy before the start of S-1 treatment. Patient characteristics were male/female: 18/3, median age: 69 (range 48-81) years old, cancer of gastric/lung/pancreatic/other: 8/5/4/4, and history of deep vein thrombosis (DVT)/atrial fibrillation (AF)/cerebral infarction (CI)/other: 11/6/2/2. The PT-INR of 16 patients exceeded normal upper limits after taking S-1 with WF. The median time to exceed the PT-INR upper therapeutic range is 25 (range 3-77) days. Patients receiving WF anticoagulant therapy concomitant with S-1 should have their PT-INR closely monitored and WF doses adjusted accordingly.

Effectiveness of triple therapy with simeprevir for chronic hepatitis C genotype 1b patients with prior telaprevir failure

Favourable efficacy and safety profiles for simeprevir in combination with pegylated interferon alpha (PEG-IFNα) and ribavirin (triple therapy) have been shown in clinical trials. This study was carried out to evaluate the effectiveness of simeprevir-based triple therapy for patients with prior telaprevir treatment failure. This multicentre, observational cohort consisted of 345 consecutive Japanese patients infected with HCV genotype 1b, including 20 who had experienced telaprevir-based triple therapy. Amino acid substitutions in the NS3/4A region were identified by direct sequencing at the time of relapse or breakthrough in treatment with telaprevir and at the initiation of treatment with simeprevir. Patients were stratified according to prior response to PEG-IFNα and ribavirin. Of the 20 patients with telaprevir treatment failure, 10 (50.0%) achieved sustained virological response at week 12 after the end of treatment (SVR12). For patients treatment naïve [3/4 (75.0%)] or with prior relapse [1/1 (100%)] or partial response [5/6 (83.3%)] to PEG-IFNα and ribavirin, almost all achieved SVR12, mainly because of the improvement of treatment adherence, especially to direct-acting antiviral agent and ribavirin. However, of the nine patients with prior null response to PEG-IFNα and ribavirin, only one (11.1%) achieved SVR12, despite all having received an adequate treatment dosage, and five (55.6%) achieved rapid virological response. The treatment outcome of simeprevir-based triple therapy for HCV genotype 1b patients with prior telaprevir failure depended on the prior response to PEG-IFNα and ribavirin. For patients with prior null response to PEG-IFNα and ribavirin, retreatment with simeprevir-based triple therapy is not a useful option.

Anisotropic multi-step etching for large-area fabrication of surface microstructures on stainless steel to control thermal radiation

Controlling the thermal radiation spectra of materials is one of the promising ways to advance energy system efficiency. It is well known that the thermal radiation spectrum can be controlled through the introduction of periodic surface microstructures. Herein, a method for the large-area fabrication of periodic microstructures based on multi-step wet etching is described. The method consists of three main steps, i.e., resist mask fabrication via photolithography, electrochemical wet etching, and side wall protection. Using this method, high-aspect micro-holes (0.82 aspect ratio) arrayed with hexagonal symmetry were fabricated on a stainless steel substrate. The conventional wet etching process method typically provides an aspect ratio of 0.3. The optical absorption peak attributed to the fabricated micro-hole array appeared at 0.8 μm, and the peak absorbance exceeded 0.8 for the micro-holes with a 0.82 aspect ratio. While argon plasma etching in a vacuum chamber was used in the present study for the formation of the protective layer, atmospheric plasma etching should be possible and will expand the applicability of this new method for the large-area fabrication of high-aspect materials.