1
|
Valenti L, Pelusi S, Aghemo A, Gritti S, Pasulo L, Bianco C, Iegri C, Cologni G, Degasperi E, D'Ambrosio R, Del Poggio P, Soria A, Puoti M, Carderi I, Pigozzi MG, Carriero C, Spinetti A, Zuccaro V, Memoli M, Giorgini A, Viganò M, Rumi MG, Re T, Spinelli O, Colombo MC, Quirino T, Menzaghi B, Lorini G, Pan A, D'Arminio Monforte A, Buscarini E, Autolitano A, Bonfanti P, Terreni N, Aimo G, Mendeni M, Prati D, Lampertico P, Colombo M, Fagiuoli S. Dysmetabolism, Diabetes and Clinical Outcomes in Patients Cured of Chronic Hepatitis C: A Real-Life Cohort Study. Hepatol Commun 2021; 6:867-877. [PMID: 34811949 PMCID: PMC8948549 DOI: 10.1002/hep4.1851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/21/2021] [Accepted: 09/26/2021] [Indexed: 12/14/2022] Open
Abstract
The aim of this study was to examine the impact of features of dysmetabolism on liver disease severity, evolution, and clinical outcomes in a real‐life cohort of patients treated with direct acting antivirals for chronic hepatitis C virus (HCV) infection. To this end, we considered 7,007 patients treated between 2014 and 2018, 65.3% with advanced fibrosis, of whom 97.7% achieved viral eradication (NAVIGATORE‐Lombardia registry). In a subset (n = 748), liver stiffness measurement (LSM) was available at baseline and follow‐up. Higher body mass index (BMI; odds ratio [OR] 1.06 per kg/m2, 1.03‐1.09) and diabetes (OR 2.01 [1.65‐2.46]) were independently associated with advanced fibrosis at baseline, whereas statin use was protective (OR 0.46 [0.35‐0.60]; P < 0.0001 for all). The impact of BMI was greater in those without diabetes (P = 0.003). Diabetes was independently associated with less pronounced LSM improvement after viral eradication (P = 0.001) and in patients with advanced fibrosis was an independent predictor of the most frequent clinical events, namely de novo hepatocellular carcinoma (HCC; hazard ratio [HR] 2.09 [1.20‐3.63]; P = 0.009) and cardiovascular events (HR 2.73 [1.16‐6.43]; P = 0.021). Metformin showed a protective association against HCC (HR 0.32 [0.11‐0.96]; P = 0.043), which was confirmed after adjustment for propensity score (P = 0.038). Diabetes diagnosis further refined HCC prediction in patients with compensated advanced chronic liver disease at high baseline risk (P = 0.024). Conclusion: Metabolic comorbidities were associated with advanced liver fibrosis at baseline, whereas statins were protective. In patients with advanced fibrosis, diabetes increased the risk of de novo HCC and of cardiovascular events. Optimization of metabolic comorbidities treatment by a multi‐disciplinary management approach may improve cardiovascular and possibly liver‐related outcomes.
Collapse
Affiliation(s)
- Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy.,Precision Medicine Lab, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Serena Pelusi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy.,Precision Medicine Lab, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Alessio Aghemo
- Department of Internal Medicine and Hepatology, Humanitas University and Research Hospital, Rozzano, Italy
| | - Sara Gritti
- Fondazione Ricerca Ospedale di Bergamo, Papa Giovanni Hospital, Bergamo, Italy
| | - Luisa Pasulo
- Department of Gastroenterology and Hepatology, Papa Giovanni Hospital, Bergamo, Italy
| | - Cristiana Bianco
- Precision Medicine Lab, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Claudia Iegri
- Department of Gastroenterology and Hepatology, Papa Giovanni Hospital, Bergamo, Italy
| | - Giuliana Cologni
- Department of Internal Medicine, Papa Giovanni Hospital, Bergamo, Italy
| | - Elisabetta Degasperi
- Division of Gastroenterology & Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Roberta D'Ambrosio
- Division of Gastroenterology & Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Paolo Del Poggio
- Department of Gastroenterology and Hepatology, Papa Giovanni Hospital, Bergamo, Zingonia, Italy
| | - Alessandro Soria
- Division of Infectious Diseases, San Gerardo Hospital-ASST Monza, Monza, Italy
| | - Massimo Puoti
- Department of Infectious Diseases, Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | | | - Canio Carriero
- Department of Infectious Diseases, Spedali Civili Hospital-ASST Brescia, Brescia, Italy
| | - Angiola Spinetti
- Department of Infectious Diseases, Spedali Civili Hospital-ASST Brescia, Brescia, Italy
| | - Valentina Zuccaro
- Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo di Pavia, Pavia, Italy
| | - Massimo Memoli
- Liver Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Alessia Giorgini
- Department of Gastroenterology and Hepatology, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Mauro Viganò
- Department of Gastroenterology and Hepatology, San Giuseppe Hospital, Milan, Italy
| | - Maria Grazia Rumi
- Department of Gastroenterology and Hepatology, San Giuseppe Hospital, Milan, Italy
| | - Tiziana Re
- Department of Gastroenterology and Hepatology, Legnano Hospital-ASST Milano Ovest, Milan, Italy
| | - Ombretta Spinelli
- Department of Gastroenterology and Hepatology, Lariana Como Hospital, Milan, Italy
| | - Maria Chiara Colombo
- Department of Gastroenterology and Hepatology, Lariana Como Hospital, Milan, Italy
| | - Tiziana Quirino
- Department of Gastroenterology and Hepatology, Busto Arsizio Hospital ASST Valle Olona, Milan, Italy
| | - Barbara Menzaghi
- Department of Gastroenterology and Hepatology, Busto Arsizio Hospital ASST Valle Olona, Milan, Italy
| | - Gianpaolo Lorini
- Department of Gastroenterology and Hepatology, ASST Franciacorta, Milan, Italy
| | - Angelo Pan
- Department of Internal Medicine, Ospedale di Cremona, Cremona, Italy
| | | | | | | | - Paolo Bonfanti
- Division of Infectious Diseases, ASST Lecco, Lecco, Italy
| | | | | | | | - Daniele Prati
- Precision Medicine Lab, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Pietro Lampertico
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy.,Division of Gastroenterology & Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy.,CRC "AM. and A. Migliavacca" Center for Liver Disease, Università degli Studi di Milano, Milano, Italy
| | - Massimo Colombo
- Liver Center, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | - Stefano Fagiuoli
- Department of Gastroenterology and Hepatology, Papa Giovanni Hospital, Bergamo, Italy
| | | |
Collapse
|
2
|
Sangiovanni A, Alimenti E, Gattai R, Filomia R, Parente E, Valenti L, Marzi L, Pellegatta G, Borgia G, Gambato M, Terreni N, Serio I, Belli L, Oliveri F, Maimone S, Brunacci M, D'Ambrosio R, Forzenigo LV, Russo FP, Rumi M, Barone M, Fracanzani AL, Raimondo G, Giannini EG, Brunetto MR, Villa E, Biganzoli E, Colombo M, Lampertico P. Undefined/non-malignant hepatic nodules are associated with early occurrence of HCC in DAA-treated patients with HCV-related cirrhosis. J Hepatol 2020; 73:593-602. [PMID: 32243959 DOI: 10.1016/j.jhep.2020.03.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM An unexpected early increase in incidence, recurrence and clinical aggressiveness of hepatocellular carcinoma (HCC) has been reported (and refuted) in patients with HCV-related cirrhosis following direct-acting antiviral (DAA) treatment. To address this controversy, we performed a prospective multicenter study on consecutively enrolled cirrhotic patients, with or without a history of HCC, undergoing DAA therapy. PATIENTS AND METHODS A total of 1,161 HCC-free cirrhotics (group 1) and 124 cirrhotics who had received a curative treatment for an HCC (group 2) were enrolled. Clinical features, including presence of undefined/non-malignant liver nodules (UNMNs), were analyzed with respect to HCC incidence and recurrence. RESULTS During a median study time of 17 months in group 1 and 16 months in group 2, de novo HCC developed in 48 patients (yearly incidence 3.1/100 patient-years, 75% BCLC 0-A) and recurred in 40 (mean yearly incidence 29.9/100 patient-years, 83% BCLC 0-A). A peak of HCC instant incidence was observed at 4.2 months in group 1 patients with UNMNs, and at 7.7 months in group 2. By multivariable Cox regression models, UNMNs (hazard ratio [HR] 3.11; 95% CI 1.47-6.57: p = 0.003), ascites detected any time before enrolment (HR 3.04; 95% CI 1.23-7.51; p = 0.02), and alpha-fetoprotein log-value (HR 1.90; 95% CI 1.05-3.44; p = 0.03) were the variables independently associated with the incidence of de novo HCC, while history of alcohol abuse (HR 2.10; 95% CI 1.08-4.09; p = 0.03) and history of recurrence of HCC (HR 2.87; 95% CI 1.35-6.09; p = 0.006) were associated with HCC recurrence. CONCLUSION An early high incidence of both de novo HCC, in patients with UNMNs, and recurrent HCC was observed in DAA-treated patients; this was not accompanied by increased tumor aggressiveness. LAY SUMMARY This prospective study focuses on the risk of developing de novo or recurrent hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) treatment in patients with hepatitis C-related cirrhosis. We found that DAA treatment was associated with an early high HCC incidence in patients with undefined or non-malignant nodules, as well as in those with a history of complete response to HCC treatment. Whether this is related to the presence of clinically undetectable nests of cancer cells or to precancerous lesions that may progress to overt HCC upon DAA treatment remains unanswered. No evidence of increased clinical aggressiveness was reported in de novo or recurrent HCC.
Collapse
Affiliation(s)
- Angelo Sangiovanni
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy.
| | - Eleonora Alimenti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Riccardo Gattai
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Elisabetta Parente
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Luca Valenti
- Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luca Marzi
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Gaia Pellegatta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples 'Federico II', Naples, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | | | - Ilaria Serio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Belli
- UOC Epatologia e Gastroenterologia, Ospedale Niguarda, Milan, Italy
| | - Filippo Oliveri
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Sergio Maimone
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Matteo Brunacci
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Roberta D'Ambrosio
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | | | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Mariagrazia Rumi
- Division of Hepatology, Ospedale San Giuseppe, Università degli Studi di Milano, Milan, Italy
| | - Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Raimondo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | | | - Maurizia Rossana Brunetto
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy; Internal Medicine, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erica Villa
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Elia Biganzoli
- Department of Clinical Sciences and Community Health & DSRC, University of Milan, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Massimo Colombo
- Center of Translational Research in Hepatology, Humanitas Hospital, Rozzano, Italy
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Soria A, Fava M, Bernasconi DP, Lapadula G, Colella E, Valsecchi MG, Migliorino GM, D'Ambrosio R, Landonio S, Schiavini M, Spinetti A, Carriero C, Degasperi E, Cologni G, Gatti F, Viganò P, Hasson H, Uberti-Foppa C, Pasulo L, Baiguera C, Rossotti R, Vinci M, Puoti M, Giorgini A, Menzaghi B, Lombardi A, Pan A, Aghemo A, Grossi PA, Boldizzoni R, Colombo S, Viganò M, Rumi MG, Del Poggio P, Valenti L, Giglio O, De Bona A, d'Arminio Monforte A, Colombo A, Spinelli O, Pigozzi MG, Molteni C, Bonfanti P, Terreni N, Perini P, Capretti A, Bella D, Liani C, Polo S, Aimo G, Pagnucco L, Bhoori S, Centenaro R, Graffeo M, Ciaccio A, Dionigi E, Lazzaroni S, Carderi I, Di Marco M, Rizzardini G, Noventa F, Lampertico P, Fagiuoli S. Comparison of three therapeutic regimens for genotype-3 hepatitis C virus infection in a large real-life multicentre cohort. Liver Int 2020; 40:769-777. [PMID: 31970845 DOI: 10.1111/liv.14386] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS In the direct-acting antiviral era, treatment of genotype-3 HCV (HCV-GT3) is still challenging. Real-life comparisons between recommended regimens, sofosbuvir (SOF)+daclatasvir (DAC), SOF/velpatasvir (VEL), glecaprevir/pibrentasvir (GLE/PIB), are scarce. We aimed at filling this data gap. METHODS Sustained virological response 12 weeks after treatment completion (SVR12) was assessed for all HCV-GT3 patients consecutively treated within the Lombardia web-based Navigatore HCV-Network; differences in SVR12 across regimens were evaluated by logistic regression. RESULTS Of the 2082 subjects with HCV-GT3, 1544 were evaluable for comparisons between regimens: SOF + DAC (1023, 66.2%), SOF/VEL (369, 23.9%), GLE/PIB (152, 9.8%). Patients treated with former regimens were more frequently male, cirrhotic, HIV-positive, pretreated, used ribavirin in their regimen, and had lower baseline HCV-RNA. SVR12 was similar across groups: 94.8% in SOF + DAC, 97.6% in SOF/VEL, 96.7% in GLE/PIB (P = .065). At univariate analysis, SVR12 was associated with female gender (97.9% vs 94.8%, P = .007) and lower median pretreatment Log10 HCV-RNA (5.87 vs 6.20, P = .001). At multivariate logistic regression analysis, treatment with SOF/VEL was associated with a higher likelihood of SVR12 than SOF + DAC, but only in the absence of ribavirin (98% vs 90.3%). Female gender and lower pretreatment HCV-RNA were independently associated with SVR12. CONCLUSIONS In a large real-life setting of HCV-GT3-infected patients with a high proportion of cirrhosis, the success rate was remarkable. The slight advantage of SOF/VEL on SOF + DAC was significant only without ribavirin. The current prescription shift towards novel regimens (ie SOF/VEL and GLE/PIB) in easier-to-treat patients allows ribavirin-free and shorter schedules without mining SVR12 in this <<difficult-to-treat>> genotype.
Collapse
Affiliation(s)
- Alessandro Soria
- Division of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | - Marco Fava
- Division of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy.,Medical School, University of Milano-Bicocca, Milan, Italy
| | - Davide P Bernasconi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giuseppe Lapadula
- Division of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | - Elisa Colella
- Division of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | - Maria G Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Roberta D'Ambrosio
- Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | - Simona Landonio
- Infectious Diseases, Ospedale Luigi Sacco - ASST Fatebenefratelli Sacco, Milano, Italy
| | - Monica Schiavini
- Infectious Diseases, Ospedale Luigi Sacco - ASST Fatebenefratelli Sacco, Milano, Italy
| | - Angiola Spinetti
- Infectious Diseases, Spedali Civili - ASST Brescia, Brescia, Italy
| | - Canio Carriero
- Infectious Diseases, Spedali Civili - ASST Brescia, Brescia, Italy
| | - Elisabetta Degasperi
- Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | | | | | - Paolo Viganò
- Ospedale di Legnano - ASST Ovest Milano, Legnano, Italy
| | - Hamid Hasson
- Infectious Diseases, San Raffaele Scientific Institute IRCCS, Milano, Italy
| | | | - Luisa Pasulo
- ASST Papa Giovanni XXIII, Bergamo HCV Network, Bergamo, Italy
| | - Chiara Baiguera
- Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Roberto Rossotti
- Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Maria Vinci
- Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Massimo Puoti
- Hepatitis Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Barbara Menzaghi
- Division of Infectious Diseases, Ospedale di Busto Arsizio - ASST Valle Olona, Busto Arsizio, Italy
| | - Andrea Lombardi
- Infectious Diseases, Fondazione IRCCS Policlinico San Matteo di Pavia, Pavia, Italy
| | - Angelo Pan
- Division of Infectious Diseases, ASST Cremona, Cremona, Italy
| | - Alessio Aghemo
- Internal Medicine and Hepatology, Humanitas Research Hospital IRCCS and Humanitas University, Rozzano, Italy
| | - Paolo A Grossi
- Ospedale di Circolo e Fondazione Macchi Varese - ASST Sette Laghi, Infectious Diseases, Università dell'Insubria, Varese, Italy
| | | | | | - Mauro Viganò
- Ospedale San Giuseppe, University of Milan, Milano, Italy
| | - Maria G Rumi
- Ospedale San Giuseppe, University of Milan, Milano, Italy
| | | | - Luca Valenti
- Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | | | - Anna De Bona
- Ospedale San Paolo - ASST Santi Paolo e Carlo, Milano, Italy
| | | | | | | | - Marie G Pigozzi
- Infectious Diseases, Spedali Civili - ASST Brescia, Brescia, Italy
| | - Chiara Molteni
- Division of Infectious Diseases, ASST Lecco, Lecco, Italy
| | - Paolo Bonfanti
- Division of Infectious Diseases, ASST Lecco, Lecco, Italy
| | | | - Paolo Perini
- Policlinico San Pietro, Bergamo HCV Network, Ponte San Pietro, Italy
| | - Andrea Capretti
- San Carlo Hospital - ASST Santi Paolo e Carlo, Milano, Italy
| | | | | | | | | | - Layla Pagnucco
- Infectious Diseases, Fondazione IRCCS Policlinico San Matteo di Pavia, Pavia, Italy
| | - Sherrie Bhoori
- Gastro-Hepato-Pancreatic Surgery and Liver Transplant Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Riccardo Centenaro
- Ospedale di Vizzolo Predabissi - ASST Melegnano e Martesana, Vizzolo Predabissi, Italy
| | - Massimo Graffeo
- UO Gastroenterologia ed Endoscopia Digestiva, Epatologia, Fondazione Ospedaliera Poliambulanza, Rete HCV Brescia, Brescia, Italy
| | - Antonio Ciaccio
- Division of Gastroenterology, San Gerardo Hospital - ASST Monza, Monza, Italy
| | - Elena Dionigi
- Ospedale di Cernusco sul Naviglio - ASST Melegnano e Martesana, Cernusco sul Naviglio, Italy
| | | | | | | | - Giuliano Rizzardini
- Infectious Diseases, Ospedale Luigi Sacco - ASST Fatebenefratelli Sacco, Milano, Italy
| | | | - Pietro Lampertico
- Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milano, Italy
| | | |
Collapse
|
4
|
D'Ambrosio R, Pasulo L, Puoti M, Vinci M, Schiavini M, Lazzaroni S, Soria A, Gatti F, Menzaghi B, Aghemo A, Capelli F, Rumi MG, Morini L, Giorgini A, Pigozzi MG, Rossini A, Maggiolo F, Pan A, Memoli M, Spinelli O, Del Poggio P, Saladino V, Spinetti A, De Bona A, Capretti A, Uberti-Foppa C, Bonfanti P, Terreni N, Menozzi F, Colombo AE, Giglio O, Centenaro R, Borghi M, Baiguera C, Picciotto V, Landonio S, Gori A, Magnani C, Noventa F, Paolucci S, Lampertico P, Fagiuoli S. Real-world effectiveness and safety of glecaprevir/pibrentasvir in 723 patients with chronic hepatitis C. J Hepatol 2019; 70:379-387. [PMID: 30472321 DOI: 10.1016/j.jhep.2018.11.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/19/2018] [Accepted: 11/10/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The efficacy and safety of glecaprevir/pibrentasvir (G/P) for patients infected with hepatitis C virus (HCV) have only been investigated in clinical trials, with no real-world data currently available. The aim of our study was to investigate the effectiveness and safety of G/P in a real-world setting. METHODS All patients with HCV consecutively starting G/P between October 2017 and January 2018 within the NAVIGATORE-Lombardia Network were analyzed. G/P was administered according to drug label (8, 12 or 16 weeks). Fibrosis was staged either histologically or by liver stiffness measurement. Sustained virological response (SVR) was defined as undetectable HCV-RNA 12 weeks after the end of treatment. RESULTS A total of 723 patients (50% males) were treated with G/P, 89% for 8 weeks. The median age of our cohort was 58 years, with a median body mass index of 23.9 kg/m2, and median liver stiffness measurement of 6.1 kPa; 84% were F0-2 and 16% were interferon-experienced. Median HCV-RNA was 1,102,600 IU/ml, and 49% of patients had HCV genotype 1 (32% 1b), 28% genotype 2, 10% genotype 3 and 13% genotype 4. The median estimated glomerular filtration rate was 90.2 ml/min, platelet count 209x103/mm3 and albumin 4.3 g/dl. The SVR rates were 94% in intention-to-treat and 99.3% in per protocol analysis (8-week vs. 12 or 16-week: 99.2% vs. 100%). Five patients failed therapy because of post-treatment relapse; a post-treatment NS5A resistance-associated substitution was detected in 1 case. SVR rates were lower in males (p = 0.002) and in HCV genotype-3 (p = 0.046) patients treated for 8 weeks, but independent of treatment duration, fibrosis stage, baseline HCV-RNA, HIV co-infection, chronic kidney disease stage and viral kinetics. Mild adverse events were reported in 8.3% of the patients, and 0.7% of them prematurely withdrew treatment. Three patients died of drug-unrelated causes. CONCLUSIONS In a large real-world cohort of Italian patients, we confirmed the excellent effectiveness and safety of G/P administered for 8, 12 or 16 weeks. LAY SUMMARY A large number of patients with hepatitis C virus have been treated with glecaprevir/pibrentasvir (G/P) within the NAVIGATORE-Lombardia Network, in Italy. This is the first real-world study evaluating effectiveness and safety of G/P in patients with hepatitis C virus treated according to international recommendations. This study demonstrated excellent effectiveness (with sustained virological response rates of 99.3%) and safety profiles.
Collapse
Affiliation(s)
- Roberta D'Ambrosio
- CRC A.M. e A. Migliavacca Center for Liver Diseases, Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
| | - Luisa Pasulo
- Bergamo HCV Network, ASST Papa Giovanni XXIII, Italy
| | - Massimo Puoti
- Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Vinci
- Gastroenterology and Hepatology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | - Alessandro Soria
- Infectious Diseases, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Federico Gatti
- Hospital Pharmacy, ASST Ovest Milanese, Legnano (MI), Italy
| | - Barbara Menzaghi
- Infectious Diseases, Busto Arsizio Hospital, ASST Valle Olona, Varese, Italy
| | - Alessio Aghemo
- Internal Medicine and Hepatology, Humanitas Research Hospital and Humanitas University, Pieve Emanuele (MI), Italy
| | | | - Maria Grazia Rumi
- Hepatology, San Giuseppe Hospital, Università degli Studi di Milano, Milan, Italy
| | - Lorenzo Morini
- Internal Medicine, ASST Ovest Milanese, Abbiategrasso (MI), Italy
| | | | | | | | | | - Angelo Pan
- Infectious Diseases, ASST Cremona, Cremona (MI), Italy
| | | | | | | | | | | | | | | | - Caterina Uberti-Foppa
- Immunology and Infectious Diseases, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | | | | | - Riccardo Centenaro
- Internal Medicine, Vizzolo Predabissi Hospital, Vizzolo Predabissi (MI), Italy
| | - Marta Borghi
- CRC A.M. e A. Migliavacca Center for Liver Diseases, Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Chiara Baiguera
- Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Viviana Picciotto
- Gastroenterology and Hepatology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Andrea Gori
- Infectious Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Carlo Magnani
- Infectious Diseases, ASST Ovest Milanese, Legnano (MI), Italy
| | | | - Stefania Paolucci
- Molecular Virology Unit, Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pietro Lampertico
- CRC A.M. e A. Migliavacca Center for Liver Diseases, Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | | |
Collapse
|
5
|
Mangia A, Losappio R, Cenderello G, Potenza D, Mazzola M, De Stefano G, Terreni N, Copetti M, Minerva N, Piazzola V, Bacca D, Palmieri V, Sogari F, Santoro R. Real life rates of sustained virological response (SVR) and predictors of relapse following DAA treatment in genotype 3 (GT3) patients with advanced fibrosis/cirrhosis. PLoS One 2018; 13:e0200568. [PMID: 30063745 PMCID: PMC6067691 DOI: 10.1371/journal.pone.0200568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/28/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Treatment of GT3 remains challenging compared to other genotypes. AIMS To explore real life SVR rates and to identify predictors of virological failure across the most recently used Direct acting antiviral (DAA) regimens in a large cohort of Italian patients with cirrhosis or advanced fibrosis (F3 or F4). METHODS Between May 2015 and June 2017, the combinations of sofosbuvir (SOF) plus daclatasvir (DCV) ± RBV and SOF plus velpatasvir (VEL) ± RBV become available in our Country. Patients were treated following Italian guidelines within a protocol implemented by 11 centers working together on genetics. RESULTS Of 336 patients, 38.1% were Peg/IFN-experienced. SOF/DCV was used in 65.1%, SOF/VEL in the remaining. Overall SVR12 was 90.2% ranging from 87.2% after SOF/DCV to 95.7% after SOF/VEL (p = 0.012). No additional benefits of RBV use were observed for both regimens. 155 patients (46.1%) had cirrhosis. SVR12 was 87.1% (135/155) for cirrhotic patients and 92.8% (169/182) for non-cirrhotic (p = 0.09). NS5A-RASs were present at baseline in 6.4% of patients, PNPLA3GG and IL28BCC genotypes in 7.3% and 33.0%, respectively. No association between favorable genetics and SVR12 was observed. Predictors of relapse were: history of Peg/IFN/RBV failure (OR = 6.34, 95% CI 2.04-19.66, P = .001), baseline NS5A-RASs (OR = 8.7, 95% CI 1.58-47.92, P = 0.013) and treatment regimen (OR = 5.57 95% CI 1.64-18.95.96, P = 0.006). CONCLUSIONS Our real-world results validate the efficacy of current GT3 IFN-free regimens suggesting that, among patients with severe disease, Peg/IFN/RBV experience and NS5A associated RASs are predictors of relapse. Their relevance can be expected to decline with the use of SOF/VEL. (250).
Collapse
Affiliation(s)
- Alessandra Mangia
- Liver Unit, “Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo, Italy
| | - Ruggero Losappio
- Infectious Disease Unit “Vittorio Emanuele II” Hospital, Bisceglie, Italy
| | | | | | - Michele Mazzola
- Infectious Disease Unit “Vittorio Emanuele II” Hospital, Bisceglie, Italy
| | - Giulio De Stefano
- Infectious Disease Unit “Madonna delle Grazie” Hospital, Matera, Italy
| | | | - Massimiliano Copetti
- Biostatistic Unit,“Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo, Italy
| | - Nicola Minerva
- Internal Medicine Unit “Caduti di Guerra” Hospital, Canosa, Italy
| | - Valeria Piazzola
- Liver Unit, “Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo, Italy
| | - Donato Bacca
- Gastroenterology and Hepatology Outpatients clinic, Casarano, Italy
| | - Vincenzo Palmieri
- Internal Medicine “A Murri” Pavillion, University of Bari, Bari, Italy
| | - Fernando Sogari
- Internal Medicine “Santissima Annunziata” Hospital, Taranto, Italy
| | - Rosanna Santoro
- Liver Unit, “Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo, Italy
| |
Collapse
|
6
|
Paggi S, Mogavero G, Amato A, Rondonotti E, Andrealli A, Imperiali G, Lenoci N, Mandelli G, Terreni N, Conforti FS, Conte D, Spinzi G, Radaelli F. Linked color imaging reduces the miss rate of neoplastic lesions in the right colon: a randomized tandem colonoscopy study. Endoscopy 2018. [PMID: 29539651 DOI: 10.1055/a-0580-7405] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Linked color imaging (LCI) is a newly developed image-enhancing endoscopy technology that provides bright endoscopic images and increases color contrast. We investigated whether LCI improves the detection of neoplastic lesions in the right colon when compared with high definition white-light imaging (WLI). METHODS Consecutive patients undergoing colonoscopy were randomized (1:1) after cecal intubation into right colon inspection at first pass by LCI or by WLI. At the hepatic flexure, the scope was reintroduced to the cecum under LCI and a second right colon inspection was performed under WLI in previously LCI-scoped patients (LCI-WLI group) and vice versa (WLI-LCI group). Lesions detected on first- and second-pass examinations were used to calculate detection and miss rates, respectively. The primary outcome was the right colon adenoma miss rate. RESULTS Of the 600 patients enrolled, 142 had at least one adenoma in the right colon, with similar right colon adenoma detection rates (r-ADR) in the two groups (22.7 % in LCI-WLI and 24.7 % in WLI-LCI). At per-polyp analysis, double inspection of the right colon in the LCI-WLI and WLI-LCI groups resulted in an 11.8 % and 30.6 % adenoma miss rate, respectively (P < 0.001). No significant difference in miss rate was found for advanced adenomas or sessile serrated lesions. At per-patient analysis, at least one adenoma was identified in the second pass only (incremental ADR) in 2 of 300 patients (0.7 %) in the LCI - WLI group and in 13 of 300 patients (4.3 %) in the WLI - LCI group (P = 0.01). CONCLUSIONS LCI could reduce the miss rate of neoplastic lesions in the right colon.
Collapse
Affiliation(s)
- Silvia Paggi
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Giuseppe Mogavero
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Arnaldo Amato
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Emanuele Rondonotti
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Alida Andrealli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Gianni Imperiali
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Nicoletta Lenoci
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Giovanna Mandelli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Natalia Terreni
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | | | - Dario Conte
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Giancarlo Spinzi
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| | - Franco Radaelli
- Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy
| |
Collapse
|
7
|
Andrealli A, Paggi S, Amato A, Rondonotti E, Imperiali G, Lenoci N, Mandelli G, Terreni N, Spinzi G, Radaelli F. Educational strategies for colonoscopy bowel prep overcome barriers against split-dosing: A randomized controlled trial. United European Gastroenterol J 2018; 6:283-289. [PMID: 29511558 PMCID: PMC5833226 DOI: 10.1177/2050640617717157] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/30/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A split-dose (SD) regimen is crucial for colonoscopy quality. Compliance with SD for early morning colonoscopy is generally poor. The present study evaluated whether pre-colonoscopy counselling, in addition to a dedicated leaflet, might increase SD uptake. METHODS Consecutive 50-69-year-old patients undergoing screening colonoscopy before 10 a.m. were randomized to either receive written information only on bowel preparation (Written Group, WG) or written and oral instructions (Written and Oral Group, WaOG). The leaflet strongly encouraged SD adoption. The primary endpoint was the number of patients adopting SD in each group. The secondary endpoints were predictors of SD uptake, compliance with preparation schemes and cleansing adequacy. RESULTS A total of 286 patients (143 WG, 143 WaOG) were enrolled (mean age 59.6 ± 6.1 years, men 49.3%). SD was adopted by 114 and 125 patients in the WG and WaOG, respectively (79.7% versus 87.4%, p = 0.079). No significant differences were observed for the proportion of patients with full compliance with preparation scheme (97.9% versus 97.2%, p = 0.99) and of procedures with adequate bowel cleansing (95.6% versus 95.1%, p = 0.77). At multivariate analysis, a > 1 h travel time to the endoscopy service was inversely correlated with SD uptake (odds ratio (OR) 0.30, 95% confidence interval (CI) 0.09-0.98). CONCLUSIONS Our leaflet guaranteed satisfactory uptake of SD and excellent adherence to the preparation scheme for early morning colonoscopy. Its use might marginalize the need for additional oral instructions, particularly in open-access settings.
Collapse
Affiliation(s)
- Alida Andrealli
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Silvia Paggi
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Arnaldo Amato
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Emanuele Rondonotti
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Gianni Imperiali
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Nicoletta Lenoci
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Giovanna Mandelli
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Natalia Terreni
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Giancarlo Spinzi
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| | - Franco Radaelli
- Division of Digestive Endoscopy and
Gastroenterology, Valduce Hospital, Como, Italy
| |
Collapse
|
8
|
Mottola L, Cenderello G, Piazzolla VA, Forte P, Carretta V, Mecenate F, Brancaccio G, Minisini R, Zuin M, Terreni N, Monti M, Colombo AE, Nosotti L, Minerva N, Luzzitelli I, Kostandini A, Cuccorese G, Russello M, Santoro R, Mangia A. Interleukin-28B genetic variants in untreated Italian HCV-infected patients: a multicentre study. Liver Int 2015; 35:482-8. [PMID: 25039676 DOI: 10.1111/liv.12630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/26/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Different prevalence of favourable IL28BCC genotype have been reported in studies performed in different countries around the world. Data on distribution of IL28B genotypes in healthy Italian subjects are lacking. METHODS Studies on prospectively collected untreated chronic HCV-infected Italian patients led to conflicting results. To investigate the prevalence of IL28B genotypes in untreated HCV-infected patients and in subjects able to clear HCV, and to compare them to the prevalence registered in healthy Italian controls. To evaluate IL28B prevalence across different HCV genotypes. RESULTS IL28BCC was observed in 30.9% of chronic HCV patients, in 71.0% of subjects able to clear HCV infection and in 41.6% of the Italian controls. The frequency of IL28BCC was higher in HCV genotype 2 and 3 than in 1 (38.3 vs. 28.2) (P = 0.02). Levels of ALT higher in IL28BCC than in non-CC were observed regardless of HCV genotypes (P = 0.0014). CONCLUSIONS IL28BCC frequencies progressively decline from subjects with spontaneous HCV clearance to normal non-infected subjects and to chronically infected. This study suggests that patients with IL28BCC, if genotype 1, are able to clear HCV more often than if genotype 2 and 3 infected, and that CC genotype is associated with higher grade of necro-inflammation.
Collapse
Affiliation(s)
- Leonardo Mottola
- Liver Unit, Hospital 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Rondonotti E, Borghi C, Mandelli G, Radaelli F, Paggi S, Amato A, Imperiali G, Terreni N, Lenoci N, Terruzzi V, Baccarin A, Martegani A, Spinzi G. Accuracy of capsule colonoscopy and computed tomographic colonography in individuals with positive results from the fecal occult blood test. Clin Gastroenterol Hepatol 2014; 12:1303-10. [PMID: 24398064 DOI: 10.1016/j.cgh.2013.12.027] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/29/2013] [Accepted: 12/11/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Computed tomographic colonography (CTC) is a reliable option for screening subjects who are unable or unwilling to undergo optical colonoscopy (OC). A colon capsule (PillCam Colon2 [CC2]; GivenImaging Ltd., Yokneam, Israel) has shown promising results in detecting polyps larger than 6 mm. We compared the accuracy of CC2 and CTC in identifying individuals with at least 1 polyp greater than 6 mm and subjects' attitude toward the procedures. METHODS Fifty individuals (mean age, 59.2 ± 5.8 y; 58% male) with positive results from the immunochemical fecal occult blood test (iFOBT-positive) underwent CC2, CTC, and OC. The unblinded colonoscopy, integrating OC, CTC, and CC2 results, was used as the reference standard. In a per-patient analysis, the accuracy of CC2 and CTC were assessed for individuals with at least 1 polyp 6 mm or larger. Individuals were asked to choose which procedure they would be willing to repeat between CTC and CC2. RESULTS The combination of OC, CTC, and CC2 identified 16 cases with at least 1 polyp 6 mm or larger (reference standard). CTC identified the polyps with 88.2% sensitivity, 84.8% specificity, a 3.0 positive likelihood ratio, and a 0.07 negative likelihood ratio. CC2 identified the polyps with 88.2% sensitivity, 87.8% specificity, a 3.75 positive likelihood ratio, and a 0.06 negative likelihood ratio. Thirty-nine subjects (78%) said they preferred CC2 to CTC. CONCLUSIONS CC2 and CTC detect polyps 6 mm and larger with high levels of accuracy; these techniques are effective in selecting iFOBT-positive individuals who do not need to be referred for colonoscopy. CC2 seems to be better tolerated than CTC, and could be a reliable alternative to CTC for iFOBT-positive individuals who are unable or unwilling to undergo OC. ClinicalTrials.gov number: NCT01744509.
Collapse
Affiliation(s)
| | | | | | | | - Silvia Paggi
- Gastroenterology Unit, Ospedale Valduce, Como, Italy
| | - Arnaldo Amato
- Gastroenterology Unit, Ospedale Valduce, Como, Italy
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Borroni G, Cazzaniga M, Andreoletti M, Ceriani R, Guerzoni P, Omazzi B, Pich MGL, Prada A, Spinzi G, Terreni N, Salerno F. Low glomerular filtration rate is a risk factor for ribavirin-associated anaemia in old patients with chronic hepatitis C. J Viral Hepat 2013; 20:e90-5. [PMID: 23490395 DOI: 10.1111/jvh.12015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 07/01/2012] [Indexed: 01/28/2023]
Abstract
Elderly patients with chronic hepatitis C have a reduced responsiveness to antiviral therapy with Peg-interferon and ribavirin. The dose reduction or the discontinuation of ribavirin due to the occurrence of anaemia is one of the most important causes for the low sustained viral response observed in older patients. We aimed to evaluate the relationship between baseline renal function and the early onset of ribavirin-associated anaemia in older (≥60 years) patients. Using data from 348 patients with chronic hepatitis C consecutively treated with peg-interferon plus ribavirin, we investigated which factors were associated with the occurrence of anaemia in elderly patients (≥60 years). Ribavirin-induced anaemia occurred in 40.5% of patients. Older patients showed a rate of anaemia significantly higher than younger patients (51.5% vs 36.3%; P = 0.009). Consequently, the rate of ribavirin dose reduction or discontinuation due to anaemia was 35.1% in older patients and 23.5% in younger patients (P = 0.029). A significantly higher proportion of older patients had a low baseline glomerular filtration rate (GFR) compared with younger patients (56.7% vs 27.1%; P < 0.001). At the multivariate regression analysis, low baseline GFR (<70 mL/min) was associated with an increased risk of ribavirin-associated anaemia only in the older patients (OR: 3.526; 95% CI: 1.385-8.979; P = 0.008). In this subset, baseline GFR was significantly correlated with both absolute (r = -0.320; P < 0.001) and relative (r = -0.324; P < 0.001) haemoglobin decrease within the first 8 weeks of treatment. In patients aged >60 years, a low pre-treatment GFR was strongly associated with the risk to develop ribavirin-related anaemia with consequent reduction in ribavirin doses.
Collapse
Affiliation(s)
- G Borroni
- Unità Organizzativa Alcoldipendenze, ASL Provincia di Milano 1, Abbiategrasso, Milan, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Paggi S, Rondonotti E, Amato A, Terruzzi V, Imperiali G, Mandelli G, Terreni N, Lenoci N, Spinzi G, Radaelli F. Resect and discard strategy in clinical practice: a prospective cohort study. Endoscopy 2012; 44:899-904. [PMID: 22859259 DOI: 10.1055/s-0032-1309891] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS Narrow-band imaging (NBI) has shown promising results in discriminating adenomatous from non-adenomatous colonic polyps. In patients with small polyps (< 10 mm), the application of NBI within a "resect and discard" strategy, might allow post-polypectomy surveillance intervals to be determined independently from histopathology. The aim of the present study was to assess the feasibility and safety of this approach in routine clinical practice. PATIENTS AND METHODS Consecutive colonoscopy outpatients with one or more polyps smaller than 10 mm were prospectively included. Each polyp was categorized by the endoscopist as adenoma or non-adenoma according to simplified NBI criteria, and future post-polypectomy surveillance interval was assigned accordingly. Following histopathology, post-polypectomy surveillance interval was subsequently re-assigned, and the accordance between endoscopy- and histology-directed surveillance strategies was calculated. RESULTS Among 942 colonoscopy patients, 286 (30.4 %) with only small polyps were included. In total, 511 small polyps were evaluated; 350 (68.5 %) were adenomas and 18 of these (5.1 %) had histologic features of advanced neoplasia. For the in vivo diagnosis of adenoma, NBI sensitivity, specificity, accuracy, and positive and negative likelihood ratios were 94.9 %, 65.8 %, 85.7 %, 2.80, and 0.08, respectively. The endoscopy-directed surveillance strategy was in accordance with the histology-directed strategy in 237 of 286 patients (82.9 %). In 9.8 % and 7.3 % patients, the endoscopy-directed approach would have resulted in early and delayed surveillance, respectively. CONCLUSIONS The resect and discard strategy seems to be a viable, safe, and cost-effective approach for the management of patients with small polyps. However, caution in the application of the strategy should be advocated for patients with polyps 6 - 9 mm in size and those with right-sided lesions, due to their malignant potential. The study was registered on Clinicaltrials.gov (NCT01462123).
Collapse
Affiliation(s)
- S Paggi
- Division of Gastroenterology, Valduce Hospital, Como, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Radaelli F, Paggi S, Terreni N, Toldi A, Terruzzi V. Acute reversible gastroparesis and megaduodenum after botulinum toxin injection for achalasia. Gastrointest Endosc 2010; 71:1326-7. [PMID: 20304403 DOI: 10.1016/j.gie.2009.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 10/22/2009] [Indexed: 02/08/2023]
|
14
|
Spinzi G, Amato A, Imperiali G, Lenoci N, Mandelli G, Paggi S, Radaelli F, Terreni N, Terruzzi V. Constipation in the elderly: management strategies. Drugs Aging 2009. [PMID: 19591521 DOI: 10.2165/00002512-200926060-00003.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2022]
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.
Collapse
|
15
|
Mandelli G, Radaelli F, Amato A, Terreni N, Paggi S, Spinzi G, Ceretti E, Terruzzi V. The spectrum of small-bowel lesions of AL-type amyloidosis at capsule endoscopy. Endoscopy 2009; 41 Suppl 2:E51-2. [PMID: 19319776 DOI: 10.1055/s-2007-995543] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- G Mandelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.
Collapse
|
17
|
Andriulli A, Neri M, Loguercio C, Terreni N, Merla A, Cardarella MP, Federico A, Chilovi F, Milandri GL, De Bona M, Cavenati S, Gullini S, Abbiati R, Garbagna N, Cerutti R, Grossi E. Clinical trial on the efficacy of a new symbiotic formulation, Flortec, in patients with irritable bowel syndrome: a multicenter, randomized study. J Clin Gastroenterol 2008; 42 Suppl 3 Pt 2:S218-23. [PMID: 18685503 DOI: 10.1097/mcg.0b013e31817fadd6] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Efficacy of symbiotics in patients with irritable bowel syndrome (IBS) remains unknown. METHODS Patients were randomized to a prebiotic (n=135), or a symbiotic formulation containing Lactobacillus paracasei B21060 (Flortec, n=132). Primary efficacy was the responder rate for pain and global relief of symptoms in the overall population and in patients with predominant diarrhea (n=47). Post hoc time-trend analyses for changes within each treatment were carried out. RESULTS Patients with absent/mild pain amounted to 54.7% in the symbiotic group and to 57.4% in the prebiotic group at treatment week 4, and to 53.9% and 53.4% at the end of treatment. Patients with amelioration of well-being were, respectively, 60.7% versus 61.7% at treatment week 4, and 63.3% versus 60.9% at the end of treatment. Within each treatment group, patients with absent/mild pain increased in the Flortec and the prebiotic group, but time trend analyses were significant only for Flortec (P=0.019). In IBS-predominant diarrhea, Flortec significantly reduced bowel movements, pain, and IBS scores. CONCLUSIONS To improve pain and well-being, Flortec is encouraging in patients with diarrhea predominant IBS. To establish its efficacy for the majority of IBS patients, Flortec has to be compared with an inert placebo in future work.
Collapse
Affiliation(s)
- Angelo Andriulli
- Division of Gastroenterology, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Spinzi G, Terreni N, Mandelli G, Paggi S. Comment on a prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology 2008; 48:1017; author reply 1017-8. [PMID: 18756474 DOI: 10.1002/hep.22449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
19
|
Borroni G, Andreoletti M, Casiraghi MA, Ceriani R, Guerzoni P, Omazzi B, Terreni N, Salerno F. Effectiveness of pegylated interferon/ribavirin combination in 'real world' patients with chronic hepatitis C virus infection. Aliment Pharmacol Ther 2008; 27:790-7. [PMID: 18298638 DOI: 10.1111/j.1365-2036.2008.03657.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Clinical trials have shown that the combination of pegylated interferon/ribavirin induces a sustained virological response in 54-63% of patients with chronic hepatitis C virus infection, but its effectiveness in day-to-day clinical practice is less clear. AIM To verify if the efficacy of pegylated interferon/ribavirin combination in 'real world' patients is comparable to that observed in trials. Methods The medical records of 397 consecutive naïve patients with chronic hepatitis C virus infection treated with pegylated interferon/ribavirin combination in nontertiary hospital settings were reviewed in order to assess the response to anti-viral treatment. RESULTS The sustained virological response rate achieved in this population was similar to that recorded in registration trials (total population: 64%; genotype 1: 46%; genotypes 2-3: 84%). Also, the premature discontinuation rate (15%) was similar to that observed in registration trials, but there were fewer dose reductions in one or both medications (26%). We confirmed the association between adherence and sustained virological response among the patients infected with hepatitis C virus genotype 1 who were treated for > or =80% of the planned duration of treatment. CONCLUSION The effectiveness of pegylated interferon/ribavirin therapy and factors predicting an sustained virological response in everyday clinical practice mirror those reported in randomized-controlled studies.
Collapse
Affiliation(s)
- G Borroni
- Unità Organizzativa Alcoldipendenze, ASL Provincia di Milano 1, Abbiategrasso, Milan, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Terreni N, Vangeli M, Raimondo ML, Tibballs JM, Patch D, Burroughs AK. Late intrahepatic hematoma complicating transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome. Cardiovasc Intervent Radiol 2007; 30:1065-9. [PMID: 17546402 DOI: 10.1007/s00270-007-9067-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 09/27/2006] [Accepted: 10/03/2006] [Indexed: 10/23/2022]
Abstract
Late intrahepatic hematoma is a rare complication of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We describe a patient with Budd-Chiari syndrome (BCS), who presented with a large inrahepatic hematoma 13 days after TIPS. Review of the literature reveals only two previous cases, both occurring in patients with BCS and presenting after a similar time interval. This potentially serious complication appears to be specific for TIPS in BCS.
Collapse
Affiliation(s)
- Natalia Terreni
- The Sheila Sherlock Hepatobiliary Pancreatic and Liver Transplantation Unit, Royal Free Hospital, Pond Street, HampsteadLondon NW3 2QG, UK
| | | | | | | | | | | |
Collapse
|
21
|
Terreni N, Vangeli M, Raimondo ML, Tibballs JM, Patch D, Burroughs AK. Late Intrahepatic Hematoma Complicating Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome. Cardiovasc Intervent Radiol 2007; 30:335-8. [PMID: 17206393 DOI: 10.1007/s00270-005-0229-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Late intrahepatic hematoma is a rare complication of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We describe a patient with Budd-Chiari syndrome (BCS) who presented with a large intrahepatic hematoma 13 days after TIPS. Review of the literature revealed only 2 previous cases, both occurring in patients with BCS and presenting after a similar time interval. This potentially serious complication appears to be specific for TIPS in BCS.
Collapse
Affiliation(s)
- Natalia Terreni
- Department of Hepatology, Royal Free Hospital, Pond Street, Hampstead, London, NW3 2QG, UK
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
BACKGROUND AND AIM The potential prognostic value for survival of nutritional status in cirrhotics after adjusting Child-Pugh classification and Model for End-Stage Liver Disease has not been evaluated. METHODS We used Kaplan-Meier and Cox proportional hazards regression models to identify factors associated with mortality in a cohort of 222 cirrhotics [M/F:145/77 median age 52 (18-68) years] with prospectively collected nutritional parameters as well as modified subjective global nutritional assessment, Royal Free Hospital-Subjective Global Assessment index. Follow-up was censored at the time of transplantation. Other variables were ones in Child-Pugh and Model for End-Stage Liver Disease scores, age, aetiology of cirrhosis and renal function. RESULTS Pretransplant mortality (Kaplan-Meier) was 21% by 2 years (135 patients were transplanted). Among the nutritional parameters, only Royal Free Hospital-Subjective Global Assessment remained significantly associated with mortality in multivariable models (P = 0.0006). The final model included the following variables: urea (P = 0.0001), Royal Free Hospital-Subjective Global Assessment (P = 0.003), age (P = 0.0001), Child-Pugh grade (P = 0.009) and prothrombin time (P = 0.003). The results were similar when the Child-Pugh grade was replaced by the Model for End-Stage Liver Disease score in the model, and whether a competing risks model was used. CONCLUSIONS Nutritional indices add significantly to both Child-Pugh grade and Model for End-Stage Liver Disease scores when assessing the patient prognosis.
Collapse
Affiliation(s)
- F Gunsar
- Department of Liver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, London, UK
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Cholongitas E, Papatheodoridis GV, Vangeli M, Terreni N, Patch D, Burroughs AK. Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis? Aliment Pharmacol Ther 2005. [PMID: 16305721 DOI: 10.1111/j.1365-2036.2005.02691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis. AIM To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings. RESULTS Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score. CONCLUSIONS Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.
Collapse
Affiliation(s)
- E Cholongitas
- Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, London, UK.
| | | | | | | | | | | |
Collapse
|
24
|
Cholongitas E, Papatheodoridis GV, Vangeli M, Terreni N, Patch D, Burroughs AK. Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis? Aliment Pharmacol Ther 2005; 22:1079-89. [PMID: 16305721 DOI: 10.1111/j.1365-2036.2005.02691.x] [Citation(s) in RCA: 276] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis. AIM To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings. RESULTS Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score. CONCLUSIONS Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.
Collapse
Affiliation(s)
- E Cholongitas
- Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, London, UK.
| | | | | | | | | | | |
Collapse
|
25
|
Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, Burroughs AK. Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 2004; 41:560-6. [PMID: 15464235 DOI: 10.1016/j.jhep.2004.06.024] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2004] [Revised: 05/30/2004] [Accepted: 06/25/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS). METHODS We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5). RESULTS TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding. CONCLUSIONS Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.
Collapse
Affiliation(s)
- Marcello Vangeli
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital and NHS Hampstead Trust, London, UK
| | | | | | | | | | | | | |
Collapse
|
26
|
Radaelli F, Meucci G, Terruzzi V, Spinzi G, Imperiali G, Strocchi E, Lenoci N, Terreni N, Mandelli G, Minoli G. Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2003; 57:329-35. [PMID: 12612511 DOI: 10.1067/mge.2003.104] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The aim of this study was to determine whether a single bolus of meperidine in addition to midazolam improves patient tolerance during colonoscopy. METHODS Consecutive patients undergoing outpatient colonoscopy were randomly assigned in double-blind fashion to receive a single rapid intravenous bolus of 5 mg of midazolam and placebo (Group A, n = 125) or 5 mg midazolam plus 50 mg meperidine (Group B, n = 128). Tolerance (4-point scale: 1 excellent, 4 unbearable), pain (4-point scale: 1 none, 4 severe) and willingness to undergo another colonoscopy were assessed 24 to 48 hours later in a telephone interview conducted by an independent observer blinded to the regimen of sedative medication. RESULTS Significantly more patients in Group A reported moderate or severe pain (28% vs. 9%; p < 0.001), poor or unbearable tolerance (18% vs. 6%; p < 0.01) and unwillingness to undergo colonoscopy again in the future (14% vs. 5%; p < 0.05). By multivariate analysis, randomization to the midazolam group and younger age were the only variables independently associated with the risk of reporting at least one of these outcomes. Recovery time, frequency of oxygen desaturation, and need for supplemental oxygen were not significantly different between the 2 groups. CONCLUSIONS The addition of a single bolus of meperidine to midazolam improves patient tolerance and lessens pain during colonoscopy without significantly increasing the frequency of side effects or prolonging recovery time.
Collapse
|
27
|
Terruzzi V, Meucci G, Radaelli F, Terreni N, Minoli G. Routine versus "on demand" sedation and analgesia for colonoscopy: a prospective randomized controlled trial. Gastrointest Endosc 2001. [PMID: 11474385 DOI: 10.1067/mge.2001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The safety and tolerance of routine sedation and analgesia versus "on demand" sedation were compared in patients undergoing colonoscopy. METHODS Two hundred forty-nine outpatients were randomly assigned to one of two groups. Group A (n = 125) received midazolam, 0.07 mg/kg intravenously plus meperidine, 0.77 mg/kg intravenously immediately preceding the colonoscope insertion. Group B (n = 124) received the same medication upon request during the procedure. Tolerance was assessed 24 hours later by phone interview performed by a nurse blinded to the medication regimen administered. RESULTS Eighty-three patients (66%) in Group B required sedation during colonoscopy. Among men in Group B more than 60 years of age, only 23% required sedation. The proportion of patients reporting moderate or severe pain (34% vs. 12.1%, p < 0.001) and of those stating they would not be willing to undergo colonoscopy again in the future (22% vs. 9.7%, p < 0.005) was significantly higher in the "on demand" sedation group. By multivariate analysis the randomization group was the single variable independently associated with both such outcomes. The frequency of side effects was similar in the two groups. CONCLUSIONS Administration of sedative and analgesic drugs routinely before colonoscopy is superior to "on demand" sedation in terms of tolerance and is not associated with an increase in side effects.
Collapse
Affiliation(s)
- V Terruzzi
- Division of Gastroenterology, Valduce Hospital, Como, Italy
| | | | | | | | | |
Collapse
|
28
|
Terruzzi V, Meucci G, Radaelli F, Terreni N, Minoli G. Routine versus "on demand" sedation and analgesia for colonoscopy: a prospective randomized controlled trial. Gastrointest Endosc 2001; 54:169-74. [PMID: 11474385 DOI: 10.1067/mge.2001.113923] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The safety and tolerance of routine sedation and analgesia versus "on demand" sedation were compared in patients undergoing colonoscopy. METHODS Two hundred forty-nine outpatients were randomly assigned to one of two groups. Group A (n = 125) received midazolam, 0.07 mg/kg intravenously plus meperidine, 0.77 mg/kg intravenously immediately preceding the colonoscope insertion. Group B (n = 124) received the same medication upon request during the procedure. Tolerance was assessed 24 hours later by phone interview performed by a nurse blinded to the medication regimen administered. RESULTS Eighty-three patients (66%) in Group B required sedation during colonoscopy. Among men in Group B more than 60 years of age, only 23% required sedation. The proportion of patients reporting moderate or severe pain (34% vs. 12.1%, p < 0.001) and of those stating they would not be willing to undergo colonoscopy again in the future (22% vs. 9.7%, p < 0.005) was significantly higher in the "on demand" sedation group. By multivariate analysis the randomization group was the single variable independently associated with both such outcomes. The frequency of side effects was similar in the two groups. CONCLUSIONS Administration of sedative and analgesic drugs routinely before colonoscopy is superior to "on demand" sedation in terms of tolerance and is not associated with an increase in side effects.
Collapse
Affiliation(s)
- V Terruzzi
- Division of Gastroenterology, Valduce Hospital, Como, Italy
| | | | | | | | | |
Collapse
|
29
|
Saracco G, Ciancio A, Olivero A, Smedile A, Roffi L, Croce G, Colletta C, Cariti G, Andreoni M, Biglino A, Calleri G, Maggi G, Tappero GF, Orsi PG, Terreni N, Macor A, Di Napoli A, Rinaldi E, Ciccone G, Rizzetto M. A randomized 4-arm multicenter study of interferon alfa-2b plus ribavirin in the treatment of patients with chronic hepatitis C not responding to interferon alone. Hepatology 2001; 34:133-8. [PMID: 11431744 DOI: 10.1053/jhep.2001.25636] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
To determine whether a higher dosage of interferon (IFN) associated with ribavirin and/or prolonged time of administration may improve therapeutic efficacy, we conducted a 4-arm randomized trial on patients with chronic hepatitis C not responding to one or more previous treatment courses with IFN monotherapy. Group 1 (n = 139) received 3 million units (MU) IFN-alpha2b 3 times a week (t.i.w.) plus ribavirin 1,000 mg/d for 12 months; group 2 (n = 162) received 5 MU t.i.w. plus ribavirin for 12 months; group 3 (n = 142) received 3 MU t.i.w. plus ribavirin for 6 months; and group 4 (n = 151) received 5 MU t.i.w. plus ribavirin for 6 months. The primary end point was hepatitis C virus (HCV)-RNA clearance at the end of 6-month follow-up. HCV-RNA was negative in 15% of group 1, 23% of group 2, 11% of group 3, 16% of group 4 (group 2 vs. group 3, P =.04). Among patients with genotypes 1 and 4, sustained response was significantly higher in group 2 vs. group 3 (18% vs. 7%, P =.03; group 1 = 9%, group 4 = 12%, P = not significant [NS]). In patients with genotypes 2 and 3, sustained virologic response was not affected by the different regimens (group 1 = 32%, group 2 = 30%, group 3 = 30%, group 4 = 35%, P = NS). In conclusion, about 23% of nonresponders to IFN monotherapy may achieve a sustained response if re-treated by 5 MU t.i.w. IFN plus ribavirin 1,000 mg/d for 1 year. Patients with genotype 1 should receive a high dosage of IFN plus ribavirin for 12 months, whereas therapy for patients with genotype 2 or 3 should be less aggressive.
Collapse
Affiliation(s)
- G Saracco
- Dipartimento di Gastroenterologia, Ospedale Molinette, Torino, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Spinzi G, Pellicano R, Minoli G, Terreni N, Cutufia MA, Fagoonee S, Rizzetto M, Ponzetto A. Helicobacter pylori seroprevalence in hepatitis C virus positive patients with cirrhosis. The Como cross-sectional study. Panminerva Med 2001; 43:85-7. [PMID: 11449177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND Liver cirrhosis is a significant cause of death in Italy and one of the most frequent causes of hospitalization. Acute peptic ulcer and upper gastrointestinal bleeding reportedly occur in over 15% of cirrhotic patients. Since Helicobacter pylori (H. pylori) infection strongly correlates with peptic ulcer, we sought to ascertain the seroprevalence of H. pylori infection in cirrhotic patients. METHODS In a cross-sectional study, we examined 52 consecutive patients (31 female and 21 male, age range 54-82, mean 68.7 years) suffering from hepatitis C virus (HCV)-related cirrhosis attending the Unit of Gastroenterology of the Valduce Hospital of Como (Italy). RESULTS The prevalence of antibodies against H. pylori was 86.5% (45/52) in the cirrhotics. Of female patients 28/31 (90.3%) were seropositive as compared to 17 of 21 (80.9%) of male patients. CONCLUSIONS The very high prevalence of H. pylori infection may explain the frequent occurrence of gastroduodenal ulcer in cirrhotic patients.
Collapse
Affiliation(s)
- G Spinzi
- Gastroenterology Unit, Valduce Hospital, Como, Italy
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Saracco G, Ciancio A, Ghisetti V, Rocca G, Cariti G, Andreoni M, Tabone M, Roffi L, Calleri G, Ballaré M, Terreni N, Sartori M, Tappero GF, Traverso A, Poggio A, Orani A, Maggi G, Di Napoli A, Arrigoni A, Rizzetto M. Treatment with interferon-alpha2b of naive non-cirrhotic patients with chronic hepatitis C according to viraemia and genotype. Results of a randomized multicentre study. The North West Italian Hepatological Group. Eur J Gastroenterol Hepatol 2001; 13:149-55. [PMID: 11246614 DOI: 10.1097/00042737-200102000-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To establish whether tailoring the dosage of interferon (IFN)-alpha2b in non-cirrhotic naive patients with chronic hepatitis C according to hepatitis C virus (HCV) genotype and viraemic level improves the rate of sustained response (normal alanine aminotransferase values and HCV-RNA negativity 6 months after the end of therapy). PATIENTS A total of 538 consecutively collected HCV-positive patients with non-cirrhotic chronic hepatitis who had not been previously treated. METHODS Quantitative viraemia and genotype were determined in each patient by a core laboratory. The patients were randomized to: Group 1, 86 patients with genotype non-1 and viraemia < 1,000,000 HCV genome equivalents/ml (GenEq/ml) treated with 3 Million Units (MU) IFN three times weekly (t.i.w.) for 1 year; Group 2, 42 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 3 MU IFN t.i.w. for 1 year; Group 3, 46 patients with genotype 1 and viraemia < 1,000,000 GenEq/ ml treated with 5 MU IFN t.i.w. for 1 year; Group 4, 85 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 5, 88 patients with genotype non-1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN t.i.w. for 1 year; Group 6, 94 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 3 MU IFN t.i.w. for 1 year; Group 7, 97 patients with genotype 1 and viraemia > 1,000,000 GenEq/ml treated with 5 MU IFN daily for 2 months followed by 5 MU t.i.w. for a further 10 months. RESULTS According to an intention-to-treat analysis, a sustained virological response (negative HCV-RNA by polymerase chain reaction 6 months after the end of therapy) was observed in 42% of Group 1 patients, in 21% of Group 2 patients versus 24% of Group 3 patients [P = not significant (NS)], in 28% of Group 4 patients versus 35% of Group 5 patients (P = NS), and in 8.5% of Group 6 patients versus 12% of Group 7 patients (P = NS). CONCLUSIONS Even though a trend towards a therapeutic improvement is observed, the adoption of more aggressive IFN protocols, such as induction therapy, does not appear to significantly improve the rate of sustained response in patients with chronic hepatitis C associated with HCV genotype 1 and highly viraemic levels compared with standard therapy. Moreover, patients with only one unfavourable predictive factor (genotype 1 or high viraemia) do not gain major therapeutic benefits when treated with high doses of IFN.
Collapse
Affiliation(s)
- G Saracco
- Dipartimento di Gastroenterologia, Ospedale Molinette, Torino, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Radaelli F, Meucci G, Spinzi G, Terruzzi V, Imperiali G, Lenoci N, Strocchi E, Sangiovanni A, Terreni N, Quarenghi M, Minoli G. Acute self-limiting jejunitis as the first manifestation of microscopic polyangiitis associated with Sjogren's disease: report of one case and review of the literature. Eur J Gastroenterol Hepatol 1999; 11:931-4. [PMID: 10514131 DOI: 10.1097/00042737-199908000-00022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
We report a case of acute self-limiting ulcerative jejunitis of unknown aetiology in a 72-year-old female patient in which a subsequent diagnosis of microscopic polyangiitis and Sjogren's syndrome was made. All known causes of jejunal ulceration and inflammation were excluded. Previously reported cases of acute self-limiting jejunitis are reviewed and the possibility that acute jejunitis in this patient had been the first manifestation of systemic vasculitis is discussed.
Collapse
Affiliation(s)
- F Radaelli
- Divisione di Medicina II, Ospedale Valduce, Como, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|