The influence of carvedilol posology timing on clinically significant portal hypertension: insights from elastography measurements

BACKGROUND AND AIMS

Carvedilol has emerged as the preferred β-blocker for treating portal hypertension. However, there is still a debate in dosing regimen, with a potential lower bioavailability in once-daily regimens. The aim of this study is to assess the acute effects of carvedilol posology in patients with clinically significant portal hypertension (CSPH), as a surrogate marker of bioavailability.

METHODS

In this experimental study, 34 patients with CSPH receiving carvedilol twice daily were asked to suppress the night dose of carvedilol, creating a standardized 24-hour dose interval. Spleen stiffness measurement (SSM) and liver stiffness measurement (LSM) by transient elastography (TE) were performed, with the exact interval between the last carvedilol administration and TE measurements consistently maintained at 24 hours and compared with values prior and under treatment.

RESULTS

Thirty-four patients were included, predominantly male (82.9%). SSM after suspending carvedilol for 24 hours [mean, 73.9kPa (SD, 17.0)] was significantly higher ( P < 0.001) than under treatment [mean, 56.3kPa (SD, 13.2)] and was not significantly different ( P = 0.908) from SSM prior to introduction of carvedilol [mean, 74.5kPa (SD, 12.4)]. Differences were also found in stratified analysis for carvedilol dosage, D'Amico classification stages, MELDNa scores, MELD3.0 scores, Child-Pugh class A and CSPH due to alcoholic cirrhosis. LSM after suspension was not significantly different from both under treatment and prior to treatment.

CONCLUSION

The differences in SSM after skipping one dose of carvedilol show both the importance of strict adherence to the prescribed dosing regimen to achieve the expected therapeutic benefits and the impact of twice daily prescription in bioavailability throughout the day.

A Rare and Difficult Diagnosis: A Case of Hepatoid Carcinoma of the Gallbladder

Extrahepatic metastasis of hepatocellular carcinoma is usually associated with extensive intrahepatic lesions. Hepatoid adenocarcinoma is a rare variant of extrahepatic malignant adenocarcinoma that exhibits remarkable histological and immunohistochemical similarity to hepatocellular carcinoma, which can result in an underestimated diagnosis. This case report describes a patient with a newly found gallbladder polyp. Following cholecystectomy, the initial histological and immunohistochemical evaluation suggested a metastasis of hepatocellular carcinoma. However, after multiple scans, no primary intrahepatic lesion was found. A subsequent review of the gallbladder specimens showed negative staining for CK7 and CK19, leading to a diagnosis of hepatoid carcinoma of the gallbladder.

Ethics in Authorship: Considerations and Concerns

N/a.

First report of plastic contamination in batoids: Plastic ingestion by Haller's Round Ray (Urobatis halleri) in the Gulf of California

The presence of microplastics has been reported in the marine environment and these pollutants have also been reported in food webs. Information about the presence of microplastics in the Haller's Round Ray (Urobatis halleri) and bottom sediments off the east coast of the Gulf of California is non-existent. The digestive tracts of individuals of this species and sediment samples were examined for plastic particles in this region. In total, 107 plastic particles were found in the sediment. All were fibers and 94.4% were microplastics, the rest were mesoplastics. The gastrointestinal tracts of 142 rays were analysed, and it was determined that this is a benthic feeder. A total of 386 plastic particles were recovered from 46 individuals (32.4%). On average 10.2 (±7.4) plastic particles were found per specimen, with plastic lengths ranging from 0.00821 mm to 0.953 mm. The FTIR-ATR analysis revealed the presence of six types of polymers: polyamide or nylon polyethylene, polypropylene, and polyacrylic were found in both sediments and gastrointestinal tracts of Haller's Round Ray. Polyethylene terephthalate and polyacrylamide were only found in the gastrointestinal tracts of the ray. These polymers are consistent with the human activities undertaken in this area, specifically intensive small-scale and industrial fisheries, as they are used for the elaboration of fishing nets, plastic bags, storage containers, clothing, and fishing boats maintenance. Our results show that benthic feeders are exposed to plastic debris, and its presence is another potential threat to batoids, which are already threatened by bycatch, overfishing, and other pollutants. However, studies on the ingestion of plastic debris in batoids and its presence in the sediment are still scarce or non-existent for this region. As such, these studies are necessary to help in the preservation of these species.

Treating Advanced Hepatocellular Carcinoma with Sorafenib: A 10-Year Single Center Experience

<b><i>Introduction:</i></b> Sorafenib was the first therapy used for systemic treatment of unresectable hepatocellular carcinoma (HCC). Multiple prognosis factors associated with sorafenib therapy have been described. <b><i>Objectives:</i></b> The aim of this work was to evaluate survival and time to progression (TTP) on HCC patients treated with sorafenib, and check for predictive factors of sorafenib benefit. <b><i>Materials and Methods:</i></b> Retrospectively, data from all HCC patients treated with sorafenib in a Liver Unit from 2008 to 2018 were collected and analyzed. <b><i>Results:</i></b> Sixty-eight patients were included; 80.9% were male, the median age was 64.5 years, 57.4% had Child-Pugh A cirrhosis and 77.9% were BCLC stage C. Macrovascular invasion (MVI) was present in 25% of the patients and 25% of the subjects had other extrahepatic metastasis. The median survival was 10 months (IQR 6.0–14.8) and median TTP was 5 months (IQR 2.0–7.0). Survival and TTP were similar between Child-Pugh A and B patients: 11.0 months (IQR 6.0–18.0) for Child-Pugh A and 9.0 months (IQR 5.0–14.0) for Child-Pugh B (<i>p</i> = 0.336). In univariate analysis, larger lesion size (LS &#x3e;5 cm), higher alpha-fetoprotein (AFP &#x3e;50 ng/mL), and no history of locoregional therapy were statistically associated with mortality (HR 2.17, 95% CI 1.24–3.81; HR 3.49, 95% CI 1.90–6.42; HR 0.54, 95% CI 0.32–0.93, respectively), but only LS and AFP were independent predictive factors, as shown in multivariate analysis (LS: HR 2.08, 95% CI 1.10–3.96; AFP: HR 3.13, 95% CI 1.59–6.16). MVI and LS &#x3e;5 cm were associated with TTP shorter than 5 months in univariate analysis (MVI: HR 2.80, 95% CI 1.47–5.35; LS: HR 2.1, 95% CI 1.08–4.11), but only MVI was an independent predictive factor of TTP shorter than 5 months (HR 3.42, 95% CI 1.72–6.81). Regarding safety data, 76.5% of patients reported at least one side effect (any grade), and 19.1% presented grade III–IV adverse effects leading to treatment discontinuation. <b><i>Conclusions:</i></b> We observed no significant difference in survival or TTP in Child-Pugh A or Child-Pugh B patients treated with sorafenib, as compared to more recent real-life studies. Lower primary LS and AFP were associated with a better outcome, and lower AFP was the main predictor of survival. The reality of systemic treatment for advanced HCC has recently changed and continues to evolve, but sorafenib remains a viable therapeutic option.

A rare mutation on alpha-1 antitrypsin deficit and lung fibrosis: case report

Alpha1-antitrypsin deficiency (AATD) is an autosomal codominant disease, and different genetic variants are known, some of which very rare. Usual pulmonary manifestations include emphysema, bronchiectasis and asthma. Pulmonary fibrosis is uncommon. We describe a case of a 64 year old man with an inaugural diagnosis of cirrhosis and lung fibrosis, without emphysema or bronchiectasis, associated with AATD. Further investigation identified a rare variant in heterozigosity (MM_Palermo), usually associated with liver disease. Concomitantly, he had a secondary iron overload, and in the course of the investigation, a type 2 diabetes mellitus installed. The association between AATD and pulmonary fibrosis is rare, however it has been identified in a few studies and case reports, questioning the role of AAT in pulmonary fibrosis. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (4): e2020019)

A case of corticosteroid-responsive SARS-CoV-2 related massive rhabdomyolysis

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SARS-CoV-2 infection may present with massive, non-ischemic rhabdomyolysis.

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COVID-19 related rhabdomyolysis may be a sign of an excessive inflammatory response.

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Corticosteroid use can resolve rhabdomyolysis without aggressive fluid replacement.

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Corticosteroid use may prevent progression of COVID-19 in select cases.

The 2019 coronavirus pandemic has united scientific and medical communities in a worldwide quest for understanding the pathophysiology of this rapidly spreading disease in order to develop effective treatments. We present a case of a 46-year-old woman with breast cancer who was found positive for SARS-CoV-2 in a screening test and developed massive rhabdomyolysis (creatinine kinase 87,456 U/liter) as well as new-onset lymphopenia and signs of lung disease starting on the 16th day of clinical surveillance, one month after the last administration of chemotherapy. Nasopharyngeal swab was still positive for SARS-CoV-2 RNA and serology revealed antibody response against the virus.

Considering the possibility of a systemic inflammatory response in the setting of post-chemotherapy immune reconstitution, we avoided aggressive fluid administration and initiated treatment with methylprednisolone and hydroxychloroquine, resulting in rapid clearance of pulmonary infiltrates and creatinine kinase.

Complete resolution after corticosteroid treatment may provide clinicians with a viable treatment option in similar situations and adds to the growing body of evidence pointing to dysregulated immune response as a major contributing factor to disease severity.

Predictors of hospital readmission 1 year after ischemic stroke

Predictors of short-term readmission after ischemic stroke have been previously identified, but few studies analyzed predictors of long-term readmission, namely early imaging findings and treatment with intravenous thrombolysis (IVT). To characterize predictors of hospital readmission during the first year after hospitalization for ischemic stroke. The study consists of a retrospective cohort of consecutive ischemic stroke patients admitted in a Portuguese university hospital during 2013, who survived index hospitalization. We collected clinical and imaging information using the electronical clinical record. Information concerning 1-year unplanned hospital readmissions was assessed using the Portuguese electronic Health Data Platform. Descriptive and univariate analyses, Kaplan-Meier survival curve and multivariate survival analysis with Cox regression model were used. We included 480 patients, 50.6 % women, median age 79 years (interquartile range = 68-85). One-year hospital readmissions occurred in 165 patients [34.4 %, 95 % confidence interval (95 % CI) 30.2-38.7]. The main causes for readmission were infectious diseases (43.8 %), ischemic stroke or transient ischemic attack recurrence (13.2 %) and cardiac diseases (6.4 %). In-hospital mortality associated with readmission was 23.0 %. The independent predictors of 1-year hospital readmission after ischemic stroke were admission mini-National Institute of Health Stoke Scale [hazards ratio (HR) 1.05, 95 % CI 1.02-1.08, p = 0.002], and mild or absent early signs of ischemia on admission computed tomography (CT) (HR 0.54, 95 % CI 0.32-0.91, p = 0.021) and IVT (HR 0.11, 95 % CI 0.01-0.80, p = 0.029). Hospital readmission during the first year after ischemic stroke occurs in 1/3 of patients and is associated with high in-hospital mortality. Clinical stroke severity, early signs of ischemia on admission CT, and treatment with IVT are independent predictors of 1-year hospital readmission.