Risk factors for early death in severe non-brain- injured trauma patients

Severe trauma is one of the main causes of premature death,posing a significant challenge to public health systems.[1]At present,there is a lack of universally accepted guidelines for rapid detection of life-threatening severe trauma,[2]and the accuracy of existing prognostic models in predicting early death is limited.[3,4]Severe non-brain-injured trauma(SNT)patients account for approximately 70%of all trauma-related deaths.Moreover,there is a lack of studies on early death in SNT patients.[5]This study aims to identify risk factors associated with early death(≤72 h post-admission)in SNT patients.

Analysis of risk factors for trauma-induced coagulopathy in elderly major trauma patients

BACKGROUND:Trauma-induced coagulopathy(TIC)due to serious injuries significantly leads to increased mortality and morbidity among elderly patients.However,the risk factors of TIC are not well elucidated.This study aimed to explore the risk factors of TIC in elderly patients who have major trauma.METHODS:In this retrospective study,the risk factors for TIC in elderly trauma patients at a single trauma center were investigated between January 2015 and September 2020.The demographic information including gender,age,trauma parts,injury severity,use of blood products,use of vasopressors,need of emergency surgery,duration of mechanical ventilation,length of stay in the intensive care unit(ICU)and hospital,and clinical outcomes were extracted from electric medical records.Multivariate logistic regression analysis was performed to differentiate risk factors,and the performance of the model was evaluated using receiver operating characteristics(ROC)curves.RESULTS:Among the 371 elderly trauma patients,248(66.8%)were male,with the age of 72.5±6.8 years,median injury severity score(ISS)of 24(IQR:17-29),and Glasgow coma score(GCS)of 14(IQR:7-15).Of these patients,129(34.8%)were diagnosed with TIC,whereas 242(65.2%)were diagnosed with non-TIC.The severity scores such as ISS(25[20-34]vs.21[16-29],P<0.001)and shock index(SI),(0.90±0.66 vs.0.58±0.18,P<0.001)was significantly higher in the TIC group than in the non-TIC group.Serum calcium levels(1.97±0.19 mmol/L vs.2.15±0.16 mmol/L,P<0.001),fibrinogen levels(1.7±0.8 g/L vs.2.8±0.9 g/L,P<0.001),and base excess(BE,-4.9±4.6 mmol/L vs.-1.2±3.1 mmol/L,P<0.001)were significantly lower in the TIC group than in the non-TIC group.Multivariate logistic regression analysis revealed that ISS>16(OR:3.404,95%CI:1.471-7.880;P=0.004),SI>1(OR:5.641,95%CI:1.700-18.719;P=0.005),low BE(OR:0.868,95%CI:0.760-0.991;P=0.037),hypocalcemia(OR:0.060,95%CI:0.009-0.392;P=0.003),and hypofibrinogenemia(OR:0.266,95%CI:0.168-0.419;P<0.001)were independent risk factors for TIC in elderly trauma patients.The AUC of the prediction model included all these risk factors was 0.887(95%CI:0.851-0.923)with a sensitivity and specificity of 83.6%and 82.6%,respectively.CONCLUSION:Higher ISS(more than 16),higher SI(more than 1),acidosis,hypocalcemia,and hypofibrinogenemia emerged as independent risk factors for TIC in elderly trauma patients.

Unraveling the Impact of Direct-Acting Antivirals on Hepatitis-Linked Cirrhosis: A Comprehensive Analysis of Fibrosis, Child Score, and Disease Progression

The treatment of hepatitis C has undergone a significant boom since the advent of direct acting antivirals (DAA). Indeed, the interferon-ribavirin combination that has been used to treat hepatitis C has a virological response in only 45% of cases with significant side effects. The advent of direct-acting antivirals has changed the prognosis of cirrhotic patients with hepatitis C. DAAs have ensured a sustained viral response in the majority of patients. Our work aims to see the evolution of hepatitis C patients at the cirrhosis stage under DAA. We conducted a retrospective study over 15 years (January 2009, January 2024) including all patients with post-viral cirrhosis C, whom we divided into two groups: group A, cirrhotic patients who received ribavirin and interferon, and group B, patients on DAA. From January 2009 to January 2024, we conducted a study of 182 patients with viral hepatitis C, including 102 cirrhotic patients. The mean age was 55 years. 66% of patients were initially treated with the ribavirin interferon combination, while 34% received direct-acting antivirals (DAAs). Since the introduction of DAAs, the most commonly used regimens have been sofosbuvir/daclatasvir with or without ribavirin and sofosbuvir/ledipasvir with or without ribavirin. Group A achieved sustained virological response (SVR) in 60% of cases, with notable side effects. In Group B, SVR was 98.18%, with improved tolerability and fewer side effects than previous treatments. Fifteen patients developed hepatocellular carcinoma (HCC), with a significantly lower mortality rate in those treated with DAAs compared with pegylated dual therapy (p: 0.001).

The Impact of Perineal Trauma on Postpartum Women at Ndola Teaching Hospital, Zambia: A Phenomenological Study

Perineal trauma following childbirth affects over two-thirds of women in low and medium-income countries (LMICs) birthing in health facilities. Although it is an unfavourable outcome with the potential to affect many aspects of a woman’s well-being in both the immediate and long-term, it is still a neglected phenomenon of women’s health, particularly in sub-Saharan African countries like Zambia. This study sought to understand the impact of birth perineal trauma on postnatal women at Ndola Teaching Hospital (NTH). This study employed a cross-sectional qualitative design using a descriptive phenomenological approach. Fifteen women who had birthed at NTH and sustained birth perineal trauma were purposively sampled as study participants. Data were collected through face-to-face interviews aided by an interview guide. Four themes, namely, perineal pain, substandard perineal wound management, fear of future reproductive health outcomes and diversion from reality, emerged from the study. Most women experiencing childbirth perineal trauma do not receive adequate care to manage their condition effectively. Therefore, midwives should utilise their professional knowledge and skills when providing postnatal care because morbidity affects women. Thus, it has the potential to negatively affect mother-infant bonding. The study concluded that birth perineal trauma is a distressing phenomenon of childbirth;hence, skillful repair, pain management and sexual counselling can greatly reduce its negative impacts.

Pelvic fractures in blunt trauma patients:A comparative study

BACKGROUND Pelvic fractures(PF)with concomitant injuries are on the rise due to an increase of high-energy trauma.Increase of the elderly population with age related comorbidities further complicates the management.Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones.Presence of contrast blush(CB)on computed tomography in patients with PF is considered a sign of active bleeding,however,its clinical significance and association with outcomes is debatable.AIM To analyze polytrauma patients with PF with a focus on the geriatric population,co-injuries and the value of contrast blush.METHODS This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center(01/2017-01/2023).Analyzed variables included:Age,sex,mechanism of injury(MOI),injury severity score(ISS),Glasgow coma scale(GCS),abbreviated injury scale(AIS),co-injuries,transfusion requirements,pelvic angiography,embolization,laparotomy,orthopedic pelvic surgery,intensive care unit and hospital lengths of stay,discharge disposition and mortality.The study compared geriatric and non-geriatric patients,patients with and without CB and abdominal co-injuries.Propensity score matching was implemented in comparison groups.RESULTS PF comprised 4%of all trauma admissions.89 patients had CB.286(52%)patients had concomitant injuries including 93(17%)patients with abdominal co-injuries.Geriatric patients compared to non-geriatric had more falls as MOI,lower ISS and AIS pelvis,higher GCS,less abdominal co-injuries,similar CB and angio-embolization rates,less orthopedic pelvic surgeries,shorter lengths of stay and higher mortality.After propensity matching,orthopedic pelvic surgery rates remained lower(8%vs 19%,P<0.001),hospital length of stay shorter,and mortality higher(13%vs 4%,P<0.001)in geriatric patients.Out of 89 patients with CB,45(51%)were embolized.After propensity matching,patients with CB compared to without CB had more pelvic angiography(71%vs 12%,P<0.001),higher embolization rates(64%vs 22%,P=0.02)and comparable mortality.CONCLUSION Half of the patients with PF had concomitant co-injuries,including abdominal co-injuries in 17%.Similarly injured geriatric patients had higher mortality.Half of the patients with CB required an embolization.

Traumatized Interpretations of Female Characters in American Southern Culture in The Glass Menagerie

Tennessee Williams is the most famous Southern playwright in the history of 20th century American literature,and southern identity is a thread that runs throughout Williams’work.The Glass Menagerie is one of his highly representative dramatic works.The play tells the story of how an ordinary family in deep identity crisis escapes the harsh reality and cultural trauma during the Great Depression in the United States.Using trauma theory as a tool,this paper explores the complex relationship between the deep-seated causes of the tragedy of the two female characters in the play and the historical context through the traumatic events experienced by the characters in the play and the different attitudes they show in the face of trauma.Through this,the vulnerability and identity crisis of individuals during the period of social change and cultural breaks are analyzed.The purpose of the paper is to arouse human beings’thoughts on how to cope with cultural integration and foreign cultural invasion,and how to obtain salvation when they are amid an identity crisis.

The Association between Perceived Injustice Following Traumatic Injury and Its Impact on Pain-Related, Mental Health and Functional Health Outcomes: A Systematic Review

Background: There is growing evidence suggesting that those who suffer traumatic injury display high levels of perceived injustice which impedes their recovery, both physically and mentally. Aim: The aim of this systematic review was to examine the association between perceived injustice and pain-related, mental health and functional outcomes in patients who have suffered a traumatic injury. Methods: In May 2023, a systematic review of the literature was performed on the electronic databases of PubMed, Google Scholar, Embase, and the Cochrane Database of Systemic Reviews. Papers were collected and analysed as per PRISMA guidelines for systematic reviews. The outcomes of interest were pain intensity, pain interference, disability, depression, anxiety, and quality of life. The initial search identified 59 papers. Of these papers, five studies met the inclusion criteria and were subsequently analysed (N = 1172). Each of the papers was published in peer-reviewed journals in the English language. Individuals with pain or pathology prior to the trauma and those who were not hospitalised following the trauma were excluded from the study. Results: Of the papers reviewed, each study indicated significant associations between perceived injustice and pain, disability, depression, anxiety, post-traumatic stress disorder, as well as reduced return to work status. Conclusion: This systematic review investigated the relationship between perceived injustice and pain-related, mental health, and functional outcomes in trauma patients. The results highlight the negative role that perceived injustice has on recovery following traumatic injury. Further, it provokes the need for future research regarding the implementation of therapeutic interventions and the development of predictive models of injustice.

心房颤动患者射频消融术中首剂肝素ACT预测模型构建

目的:建立并验证心房颤动患者射频消融术中给予首剂肝素30 min后测得活化凝血时间(activated clotting time,ACT)(30 min-ACT)的列线图预测模型。方法:选择2020年1月—2022年12月于南京医科大学第一附属医院心内科导管室行导管射频消融治疗、非瓣膜性心房颤动患者1 090例,以3∶1比例随机分为训练集和测试集,对两组各项指标进行Kruskal-Wallis检验、卡方检验比较其基线特征。通过LASSO回归及单因素、多因素线性回归分析影响30 min-ACT的因素,据此建立心房颤动患者射频消融术中30 min-ACT的预测模型并评估其预测效果。结果:多因素结果分析提示卒中史、华法林、血小板计数、凝血酶原时间、基础ACT、基础ACT^(2)、首剂肝素剂量是房颤患者射频消融术中首剂肝素ACT的独立预测因素,据此构建的列线图预测模型预测具有一定的准确度(训练集65.9%,测试集74.6%)和较高的灵敏度(训练集77.4%,测试集83.0%)。结论:根据卒中史、华法林、血小板计数、凝血酶原时间、基础ACT、基础ACT^(2)、首剂肝素剂量构建的30 min-ACT列线图模型可以预测心房颤动患者射频消融术中首剂肝素的抗凝效果,对临床工作具有一定指导作用。

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center

BACKGROUND:Point-of-care ultrasound(POCUS)has become increasingly integrated into the practice of emergency medicine.A common application is the extended focused assessment with sonography in trauma(eFAST)exam.The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation.The objective of this study was to conduct a review of performed,documented and billed eFAST ultrasounds on trauma activation patients.METHODS:This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center.A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans.Medical records were reviewed to determine whether an eFAST was indicated,performed,and appropriately documented.RESULTS:We found that 1,507 of 1,597 trauma patients had indications for eFAST,but 396(27%)of these patients did not have a billed eFAST.Of these 396 patients,87(22%)had documentation in the provider note that an eFAST was performed but there was no separate procedure note.The remaining 309(78%)did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.CONCLUSION:A significant proportion of trauma patients had eFAST exams performed but were not documented or billed.Lack of documentation was multifactorial.Emergency ultrasound programs require appropriate reimbursement to support training,credentialing,equipment,quality assurance,and device maintenance.Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

Characteristics and visual outcomes of patients hospitalized for ocular trauma in central China: 2006-2011

AIM: To complete the data of ocular trauma in central China, as a well-known tertiary referral center for ocular trauma, we documented the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in this region.METHODS: A retrospective study of patients hospitalized for ocular trauma in central China from 2006 to 2011 was performed.· RESULTS: This study included 5964 eyes of 5799 patients. The average age was 35.5 ±21.8y with a male-to-female ratio of 2.8:1. The most common age was 45-59 y age group. Most patients were farmers and workers(51.9%). The most common injuries were firework related(24.5%), road traffic related(24.2%), and work related(15.0%). Among the most common causative agents were firecrackers(24.5%), followed by metal/knife/scissors(21.4%). Most injuries occurred in January(14.2%),February(27.0%), and August(10.0%). There were 8.5%patients with ocular injuries combined with other injuries.The incidence of open ocular injuries(4585 eyes, 76.9%)was higher than closed ocular injuries(939 eyes, 15.7%).The incidences of chemical and thermal ocular injuries were 1.2% and 0.6%. Ocular trauma score(OTS)predicted final visual acuity at non light perception(NLP), 20/200-20/50 and 20/40 with a sensitivity of 100%,and light perception(LP) /hand motion(HM) and 1/200-19/200 with a specificity of 100%.· CONCLUSION: This study provides recent epidemiological data of patients hospitalized for ocular trauma in central China. Some factors influencing the visual outcome include time interval between injury and visit to the clinic, wound location, open or closed globe injury, initial visual acuity, and OTS.

Risk factors for ventilator-associated pneumonia in trauma patients:A descriptive analysis

BACKGROUND:We sought to evaluate the risk factors for developing ventilator-associated pneumonia(VAP)and whether the location of intubation posed a risk in trauma patients.METHODS:Data were retrospectively reviewed for adult trauma patients requiring intubation for>48 hours,admitted between 2010 and 2013.Patients’demographics,clinical presentations and outcomes were compared according to intubation location(prehospital intubation[PHI]vs.trauma room[TRI])and presence vs.absence of VAP.Multivariate regression analysis was performed to identify predictors of VAP.RESULTS:Of 471 intubated patients,332 patients met the inclusion criteria(124 had PHI and208 had TRI)with a mean age of 30.7±14.8 years.PHI group had lower GCS(P=0.001),respiratory rate(P=0.001),and higher frequency of head(P=0.02)and chest injuries(P=0.04).The rate of VAP in PHI group was comparable to the TRI group(P=0.60).Patients who developed VAP were 6 years older,had significantly lower GCS and higher ISS,head AIS,and higher rates of polytrauma.The overall mortality was 7.5%,and was not associated with intubation location or pneumonia rates.In the early-VAP group,gram-positive pathogens were more common,while gram-negative microorganisms were more frequently encountered in the late VAP group.Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.CONCLUSION:In trauma,the risk of developing VAP is multifactorial.However,the location of intubation and presence of chest injury could play an important role.

Pediatric traumatic cataract and surgery outcomes in eastern China: a hospital-based study

AIM: To evaluate the etiologies, management, and outcomes of pediatric traumatic cataract in eastern China. METHODS: Pediatric traumatic cataract were reviewed for demographic information, type of injury, mode of injury, time of injury, interval between injury and first visiting doctors, hospital of first visiting, surgeries, complications and prognosis. RESULTS: A total of 117 eyes of 117 patients (96 boys and 21 girls) with unilateral injuries (66 right and 51 left eyes) were included in the study. The mean (SEM) age at diagnosis was (6.6 ±3.2) years (range, 1.3-13.8 years). Each cataract was categorized according to the type of trauma: closed-globe (n =26) or open-globe (n =91) injuries. The most common injuring objects were sharp metal objects (37.61%). The most common complication in open-globe injuries was corneal laceration, whereas traumatic mydriasis was most common in closed-globe injuries. Of 68 eyes in patients with open-globe injuries who received cataract extraction, intraocular lens (IOLs) were primarily implanted in 47 eyes (68.12%), whereas 18 eyes with closed-globe injuries received cataract extraction, and IOLs were primarily implanted in 17 eyes (94.4%). The surgical procedures included reconstruction of the anterior segment, synechiolysis, excision of the membrane, lensectomy, vitrectomy and related techniques. Postoperative vision was significantly improved compared with preoperative vision. CONCLUSION: Pediatric traumatic cataract should be treated in time to attenuate the complications, and education on pediatric traumatic cataract and improvements in pediatric health care are needed for the early detection of cataract in children.

基于ACT反馈的延续性护理对老年间质性肺炎患者治疗依从性的影响评价

分析以ACT反馈为基础的延续性护理模式,对老年间质性肺炎患者的影响价值。方法 从2022年7月开始,截至2023年7月,本院总计选入老年间质性肺炎患者60例,经抽签法进行两组均分。30例对照组实施基础护理,30例研究组实施基于ACT反馈的延续性护理。比较两组护理后肺功能水平、临床恢复结果、生活质量以及总依从率。结果 研究组各肺功能结果、生活质量评分高于对照组;恢复时间短于对照组;总依从率高于对照组,差异有统计学意义(P<0.05)。结论 老年间质性肺炎患者,进行基于ACT反馈的延续性护理,可提升生活质量和依从性,稳定肺功能水平。

Impact of direct acting antivirals on occurrence and recurrence of hepatocellular carcinoma: Biologically plausible or an epiphenomenon?

Hepatocellular carcinoma(HCC) is a major cause of morbidity and mortality worldwide. Chronic hepatitis C virus infection(HCV) is the most common cause of HCC in many European countries, Japan and Pakistan. Introduction of the new direct acting antivirals(DAAs) has revolutionized the management of HCV worldwide, with high rates of sustained virologic response in patients who could not have tolerated the previous interferon based treatments. However, recently there have been reports raising caution about the long term effects of DAAs, particularly a possible increased risk of HCC. Therefore this review explores the current molecular studies as well as clinical data that investigate the impact of DAAs on occurrence and recurrence of HCC.

Influence of Intensive Insulin Therapy on Vascular Endothelial Growth Factor in Patients with Severe Trauma

The influence of early-stage intensive insulin therapy on the plasma levels of vascular en- dothelial growth factor （VEGF） and the related parameters in patients with severe trauma and the clini- cal implication were investigated. Sixty-four cases of severe trauma （injury severity score 〉20） with stress hyperglycemia （blood glucose 〉9 mmol/L） were randomly divided into intensive insulin therapy group and conventional therapy group. ELISA method, radioimmunoassay and density gradient grada- tion one-step process were used to determine plasma VEGF, endothelin-1 （ET-1）, and the number of circulating endothelial cells （CECs） at the day of 0, 2, 3, 5 and 7 after admission. Simultaneously, the changes of CRP concentration in plasma were monitored to evaluate inflammatory response. The results showed that plasma levels of observational indexes in patients receiving early-stage intensive insulin therapy were all significantly lower than those in conventional therapy groups 2, 3, 5 and 7 days after admission [for VEGF （ng/L）, 122.2±23.8 vs. 135.9±26.5, 109.6±27.3 vs. 129.0±18.4, 88.7±18.2 vs. 102.6±27.3, 54.2±26.4 vs. 85.7±35.2, P〈0.05, 0.01, 0.05, 0.05 respectively; for ET-1 （ng/L）, 162.8±23.5 vs. 173.7±13.2, 128.6±17.5 vs. 148.8±22.4, 96.5±14.8 vs. 125.7±14.8, 90.7±16.9 vs. 104.9±22.5, P〈0.05, 0.01, 0.01, 0.01 respectively; for CRP （mg/L）, 23.2±13.8 vs. 31.9±16.5, 13.6±17.3 vs. 23.5±18.4, 8.7±10.2 vs. 15.6±13.3, 5.2±9.4 vs. 10.7±11.2, all P〈0.05; for CECs （/0.9 μL）, 10.9±5.6 vs. 13.9±6.2, 8.5±4.9 vs. 11.3±5.3, 6.3±6.4 vs. 9.4±5.7, 4.8±7.1 vs. 7.8±4.8, all P〈0.05]. It was concluded that intensive insulin therapy could antagonize the endothelium injury after trauma and reduce inflammation response quickly, which was one of important mechanisms by which intensive insulin therapy improves the prognosis of trauma patients.

Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit

BACKGROUND: Agitation occurs frequently among critically ill patients admitted to the intensive care unit(ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status.RESULTS: A total of 102 intubated patients were enrolled; of which 46(45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries(P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia(P<0.05). On multivariate analysis, use of propofol alone(OR=4.97; 95% CI=1.35–18.27), subarachnoid hemorrhage(OR=5.11; 95% CI=1.38–18.91) and ICP catheter insertion for severe head injury(OR=4.23; 95% CI=1.16–15.35) were independent predictors for agitation(P<0.01).CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.

A method of elevated temperatures coupled with magnetic stirring to predict real time release from long acting progesterone PLGA microspheres

The object of the study was to develop a quick and reproducible accelerated in vitro release method to predict and deduce the function of the real time(37 °C) release for long acting PLGA microspheres. The method could be described in several steps. First, the release of the microspheres were studied using the sample and separate method at 37 °C with normal orbital shaking and elevated temperatures with magnetic stirring to further accelerate the release. Second, the most similar profile at elevated temperatures with the real time release was chosen with the help of the n value in the fitted Korsmeyer-Peppas Function. Third,the Weibull function and conversion ratio were used to deduce the function of real time release according to the chosen profile at elevated temperatures. The key point in this study was to provide a quick and precise method to predict the real time release for long acting progesterone PLGA microspheres. So the elevated temperatures coupled with magnetic stirring were used to accelerate the release further, and when there have many similar release profiles with the real time release at elevated temperatures, releasing time at elevated temperatures and the R2 of the final deduced function will be used to help choosing the most similar release profile with the real time release. Four different types of progesterone PLGA microspheres were used to verify the method, and all the deduced function correlated well with the real time releases, for R2 = 0.9912, 0.9781, 0.9918 and 0.9972, respectively.

Future of liver disease in the era of direct acting antivirals for the treatment of hepatitis C

Hepatitis C virus(HCV) infection has been a global health problem for decades, due to the high number of infected people and to the lack of effective and welltolerated therapies. In the last 3 years, the approval of new direct acting antivirals characterized by high rates of virological clearance and excellent tolerability has dramatically improved HCV infection curability, especially for patients with advanced liver disease and for liver transplant recipients. Long-term data about the impact of the new direct acting antivirals on liver fibrosis and liver disease-related outcomes are not yet available, due to their recent introduction. However, previously published data deriving from the use of pegylatedinterferon and ribavirin lead to hypothesizing that we are going to observe, in the future, a reduction in mortality and in the incidence of hepatocellular carcinoma, as well as a regression of fibrosis for people previously affected by hepatitis C. In the liver transplant setting, clinical improvement has already been described after treatment with the new direct acting antivirals, which has often led to patients delisting. In the future, this may hopefully reduce the gap between liver organ request and availability, probably expanding liver transplant indications to other clinical conditions. Therefore, these new drugs are going to change the natural history of HCV-related liver disease and the epidemiology of HCV infection worldwide. However, the global consequences will depend on treatment accessibility and on the number of countries that could afford the use of the new direct acting antivirals.

Long acting octreotide in the treatment of advanced hepatocellular cancer and overexpression of somatostatin receptors: Randomized placebo-controlled trial

AIM: To estimate if and to what extent long acting octreotide (LAR) improves survival and quality of life in patients with advanced hepatocellular carcinoma (HCC). METHODS: A total of 127 cirrhotics, stages A-B, due to chronic viral infections and with advanced HCC, were enrolled in the study. Scintigraphy with 111Indium labeled octreotide was performed in all cases. The patients with increased accumulation of radionuclear compound were randomized to receive either oral placebo only or octreotide/octreotide LAR only as follows: octreotide 0.5mg s.c. every 8 h for 6 wk, at the end of wk 4-8 octreotide LAR 20 mg i.m. and at the end of wk 12 and every 4 wk octreotide LAR 30mg i.m.. Follow-up was worked out monthly as well as the estimation of quality of life (QLQ-C30 questionnaire). Patients with negative somatostatin receptors (SSTR) detection were followed up in the same manner. RESULTS: Scintigraphy demonstrated SSTR in 61 patients. Thirty were randomized to receive only placebo and 31 only octreotide. A significantly higher survival time was observed for the octreotide group (49 ± 6 wk) as compared to the control group (28 ± 1 wk) and to the SSTR negative group (28 ± 2 wk), LR = 20.39, df = 2, P < 0.01. The octreotide group presented 68.5% lower hazard ratio [95% CI (47.4%-81.2%)]. During the f irst year, a 22%, 39% and 43% decrease in the QLQ-C30 score was observed in each group respectively.CONCLUSION: The proposed therapeutic approach has shown to improve the survival and quality of life in SSTR positive patients with advanced HCC.

Direct acting antiviral therapy is curative for chronic hepatitis C/autoimmune hepatitis overlap syndrome

Autoimmune phenomena are common in patients with chronic hepatitis C. Management of chronic hepatitis C/autoimmune hepatitis syndrome has until recently been problematic due to the adverse effects of interferon on autoimmune processes and immunosuppression on viral replication. In this report we describe 3 patients with chronic hepatitis C/autoimmune hepatitis overlap syndrome who responded rapidly to direct acting antiviral therapy. The resolution of the autoimmune process supports a direct viral role in its pathophysiology.