Recombinant activated factor VII in patients with acute liver failure with UNOS Status 1A: a single tertiary academic centre experience

BACKGROUND AND OBJECTIVES

Recombinant activated factor VII (rFVIIa) is often used in off-label indications, including many situations in which the patients are at risk of thrombosis. In this study, we retrospectively reviewed the use of rFVIIa in patients with acute liver failure - UNOS Status 1A (ALF-1A) to determine its efficacy and safety profile.

MATERIALS AND METHODS

Using the transplantation records, all adult patients with ALF-1A were identified from 6/2001 to 3/2009. From patients' medical charts, rFVIIa dose, blood component usage, short-term outcomes [length of intensive care unit (ICU) and hospital stay, ability to undergo orthotopic liver transplant (OLT) and in-hospital survival rate] and adverse events were examined.

RESULTS

Forty-two patients with ALF-1A were identified. Fifteen patients received rFVIIa with doses ranging between 24·4 μg/kg and 126·8 μg/kg. Three patients received two doses of rFVIIa. The age, baseline activated partial thromboplastin time (aPTT) and platelet (PLT) count were not statistically different between the group receiving rFVIIa versus the group that did not. However, the prothrombin time (PT) was significantly higher in the rFVIIa group. Although the rFVIIa group stayed in the ICU longer and required significant more blood products during admission, there was no statistical difference between the two groups in terms of length of hospital stay, ability to undergo OLT and survival rate. There was no increase in complications, including thrombosis, after receiving rFVIIa.

CONCLUSION

Recombinant activated factor VII (rFVIIa) appears to be safe in patients with ALF-1A, but to elucidate its full role, a randomized controlled trial would be ideal.

Acute respiratory health effects of urban air pollutants in adults with different patterns of underlying respiratory disease

OBJECTIVE

Whether underlying chronic respiratory diseases are susceptible factors for symptomatic episodes, which lead to primary-level care, in association with air pollutant exposures is unknown. We evaluated and compared association lag structures between daily ambient levels of nitrogen dioxide (NO(2)) and total suspended particulates (TSP) and respiratory symptom-related doctor visits in adults with different patterns of underlying chronic respiratory disease.

METHODS

In a time-stratified case-crossover analysis nested within a diary panel study, 459 Swiss adult participants with asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD) and healthy participants recorded occurrence of respiratory-symptom related doctor visits (n = 1,048) in one to six four-week intervals over two years. For each disease subgroup, odds ratios (ORs) for doctor visit were estimated as a function of NO(2) or TSP concentrations (per 10 micrograms per cubic meter [µg/m(3)]) lagged between 0-13 days in a polynomial distributed lag model.

RESULTS

Higher ORs for NO(2) in participants with COPD (OR: 1.17, 95%CI: 1.02-1.35) and asthma (OR: 1.15, 95%CI: 1.02-1.30) occurred at exposure lags of two and five days, respectively. Doctor visits increased by 9.1% (95%CI: 3.2-15.4%) and 4.2% (95%CI: 1.2-7.2%) over the first week following a 10 µg/m(3) increase in NO(2) concentration in the COPD and chronic bronchitis subgroups, respectively. The percent increase in the COPD subgroup was significantly greater (p <0.05) when compared with the healthy subgroup. Observed findings were similar for TSP.

CONCLUSIONS

Respiratory problems leading to a doctor visit, associated with an increase in exposure to NO(2) and TSP, may have a faster dynamic in individuals with COPD.

Potentially curative treatment in patients with hepatocellular cancer--results from the liver cancer research network

BACKGROUND

The extent to which potentially curative therapies are used in patients with hepatocellular cancer (HCC) and their related outcomes are unknown in the US.

AIM

To determine the rate and outcomes of potentially curative treatment in patients with HCC.

METHODS

Eleven US centers followed patients with HCC between 2001 and 2007. We determined rates of liver transplantation, surgical resection, or tumour ablation during follow-up, examined differences in adjusted survival of patients receiving these treatments, and determined the factors associated with receipt of potentially curative treatment.

RESULTS

Of the 267 patients, 76 (28%) patients had early HCC, defined as Child A or B cirrhosis, with a solitary HCC or ≤ 3 nodules, each ≤ 3 cm. Of these, 53 (69.7%) received curative treatment. Thirty six percent of patients with non-early HCC received curative treatment. Compared to patients with non-early HCC who did not receive curative treatment, patients with early HCC and curative treatment had the best survival [hazard ratio, HR = 0.19 (95% CI, 0.08-0.42)] followed by patients with advanced HCC who received curative treatment [HR = 0.37 (95% CI, 0.22-0.64)]. Baseline performance status was significantly associated with receipt of curative treatment as well as survival after adjusting for demographics, clinical characteristics, and HCC stage.

CONCLUSIONS

In this multicenter database, most of the patients with early HCC received potentially curative treatment. However, only 28% of patients had early HCC. One-third of patients with non-early HCC also underwent curative therapy. Potentially curative treatment improved survival and this effect was seen in patients with early as well as non-early HCC.

Repeatability of SUV measurements in serial PET

PURPOSE

The standardized uptake value (SUV) is a quantitative measure of FDG tumor uptake frequently used as a tool to monitor therapeutic response. This study aims to (i) assess the reproducibility and uncertainty of SUV max and SUV mean, due to purely statistical, i.e., nonbiological, effects and (ii) to establish the minimum uncertainty below which changes in SUV cannot be expected to be an indicator of physiological changes.

METHODS

Three sets of measurements were made using a GE Discovery STE PET/CT Scanner in 3D mode: (1) A uniform 68Ge 20 cm diameter cylindrical phantom was imaged. Thirty serial frames were acquired for durations of 3, 6, 10, 15, and 30 min. (2) Esser flangeless phantom (Data Spectrum, approximately 6.1 L) with fillable thin-walled cylinders inserts (diameters: 8, 12, 16, and 25 mm; height: approximately 3.8 mm) was scanned for five consecutive 3 min runs. The cylinders were filled with 18FDG with a 37 kBq/cc concentration, and with a target-to-background ratio (T/BKG) of 3/1. (3) Eight cancer patients with healthy livers were scanned approximately 1.5 h post injection. Three sequential 3 min scans were performed for one bed position covering the liver, with the patient and bed remaining at the same position for the entire length of the scan. Volumes of interest were drawn on all images using the corresponding CT and then transferred to the PET images. For each study (1-3), the average percent change in SUV mean and SUV max were determined for each run pair. Moreover, the repeatability coefficient was calculated for both the SUV mean and SUV max for each pair of runs. Finally, the overall ROI repeatability coefficient was determined for each pair of runs.

RESULTS

For the 68Ge phantom the average percent change in SUV max and SUV mean decrease as a function of increasing acquisition time from 4.7 +/- 3.1 to 1.1 +/- 0.6%, and from 0.14 +/- 0.09 to 0.04 +/- 0.03%, respectively. Similarly, the coefficients of repeatability also decrease between the 3 and 30 min acquisition scans, in the range of 10.9 +/- 3.9% - 2.6 +/- 0.9%, and 0.3 +/- 0.1% - 0.10 +/- 0.04%, for the SUV max and SUV mean, respectively. The overall ROI repeatability decreased from 18.9 +/- 0.2 to 6.0 +/- 0.1% between the 3 and 30 min acquisition scans. For the l8FDG phantom, the average percent change in SUV max and SUV mean decreases with target diameter from 3.6 +/- 2.0 to 1.5 +/- 0.8% and 1.5 +/- 1.3 to 0.26 +/- 0.15%, respectively, for targets from 8-25 mm in diameter and for a region in the background (BKG). The coefficients of repeatability for SUV max and SUV mean also decrease as a function of target diameter from 7.1 +/- 2.5 to 2.4 +/- 0.9 and 4.2 +/- 1.5 to 0.6 +/- 0.2, respectively, for targets from 8 mm to BKG in diameter. Finally, overall ROI repeatability decreased from 12.0 +/- 4.1 to 13.4 +/- 0.5 targets from 8 mm to BKG in diameter. Finally, for the measurements in healthy livers the average percent change in SUVmax and SUV mean were in the range of 0.5 +/- 0.2% - 6.2 +/- 3.9% and 0.4 +/- 0.1 and 1.6 +/- 1%, respectively. The coefficients of repeatability for SUV max and SUV men are in the range of 0.6 +/- 0.7% - 9.5 +/- 12% and 0.6 +/- 0.7% - 2.9 +/- 3.6%, respectively. The overall target repeatability varied between 27.9 +/- 0.5% and 41.1 +/- 1.0%.

CONCLUSIONS

The statistical fluctuations of the SUV mean are half as large as those of the SUV max in the absence of biological or physiological effects. In addition, for clinically applicable scan durations (i.e., approximately 3 min) and FDG concentrations, the SUV max and SUV mean have similar amounts of statistical fluctuation for small regions. However, the statistical fluctuations of the SUVmean rapidly decrease with respect tothe SUVmax as the statistical power of the data grows either due to longer scanning times or as the target regions encompass a larger volume.

Lipid and endothelium-related genes, ambient particulate matter, and heart rate variability--the VA Normative Aging Study

BACKGROUND

Many studies have shown that exposures to air pollution are associated with cardiovascular events, although the mechanism remains to be clarified. To identify whether exposures to ambient particles act on autonomic function via the lipid/endothelial metabolism pathway, whether effects of particulate matter <2.5 mum in aerodynamic diameter (PM(2.5)) on heart rate variability (HRV) were modified by gene polymorphisms related to those pathways were evaluated.

METHODS

HRV and gene data from the Normative Aging Study and PM(2.5) from a monitor located a kilometre from the examination site were used. A mixed model was fitted to investigate the associations between PM(2.5) and repeated measurements of HRV by gene polymorphisms of apolipoprotein E (APOE), lipoprotein lipase (LPL) and vascular endothelial growth factor (VEGF) adjusting for potential confounders chosen a priori.

RESULTS

A 10 microg/m(3) increase in PM(2.5) in the 2 days before the examination was associated with 3.8% (95% CI 0.2% to 7.4%), 7.8% (95 CI 0.4% to 15.3%) and 10.6% (95% CI 1.8% to 19.4%) decreases of the standard deviation of normal-to-normal intervals, the low frequency and the high frequency, respectively. Overall, carriers of wild-type APOE, LPL and VEGF genes had stronger effects of particles on HRV than those with hetero- or homozygous types. Variations of LPL-N291S, LPL-D9N and APOE-G113C significantly modified effects of PM(2.5) on HRV.

CONCLUSION

Associations between PM(2.5) and HRV were modified by gene polymorphisms of APOE, LPL and VEGF; the biological metabolism remains to be identified.

The use of hepatitis B core antibody-positive donor livers does not appear to have a deleterious effect on graft survival in liver transplantation for hepatitis C

INTRODUCTION

The use of hepatitis B core antibody-positive donor livers (HBcAb(+)) has steadily increased. According to a recent multivariate analysis of United Network for Organ Sharing (UNOS) data, there was no significant increase in the risk of using these donors. The increased risk among the hepatitis C virus (HCV)-positive subgroup noted in a univariate model disappeared upon multivariate analysis. However, deeper scrutiny may show that HCV-positive recipients may be at increased risk with HBcAb(+) donor livers, as they require simultaneous treatment with two antiviral regimens there may be deleterious interactions between the two viruses. Thus, the issue of HBcAb(+) donors for HCV-positive recipients merits more detailed analysis.

METHODS

Using UNOS registry data of all liver transplantations performed during the Model for End-Stage Liver Disease era from February 2002 through November 2007, we analyzed graft survival using Kaplan-Meier and Cox regression analyses.

RESULTS

Of the 12,543 HCV-positive recipients, 2,543 received HBcAb(-) livers and 853 received HBcAb(+) livers. While Kaplan-Meier analysis showed significantly lower graft survival among HCV-negative recipients of HBcAb(+) livers (P = .0001), there was no significant effect on graft survival among the HCV-positive population (P = .2). To detect an early effect in HCV-positive recipients, we examined 1-year graft survival, observing no significant difference (P = .3). To exclude a possible late effect, we examined graft survival in the HCV-positive population conditional upon surviving at least 1 year after transplantation; no significant difference was observed (P = .6). The elimination of potentially confounding codiagnoses, such as hepatitis B virus, alcoholism, acute graft failure, and hepatocellular cancer did not alter the findings. On univariate analysis, the lack of a significant effect persisted among the HCV population. However, the significant effect observed in the univariate model for the HCV-negative population became insignificant when combined with other risk factors in the multivariate model.

CONCLUSION

The use of HBcAb(+) livers in recipients with HCV did not appear to have a significant impact on graft survival.