Search

The hepatitis B (HBV) vaccine is recommended in unvaccinated adults with cirrhosis, despite its low efficacy. We aimed to evaluate the response to a double-dose/accelerated vaccine schedule in patients with cirrhosis admitted into a hepatology ward. All patients with cirrhosis admitted to the hepatology ward without exclusion criteria were offered the HBV HBVAXPRO 40mcg vaccine at months 0, 1 and 2. Non-responders received a second cycle. We evaluated 468 patients and only 19% were seroprotected against HBV. In 196 patients without exclusion criteria for HBV vaccination, the per protocol response rate (anti-HBs >10 U/ml) was 23% after a first cycle and 59% after a second cycle. The overall response per intention to treat was only 23%. We have not identified predictors of response. Only one patient had a mild adverse event. Most patients with cirrhosis admitted in the hepatology ward are unprotected against HBV. Although a second HBV vaccination cycle increases the response rate, the poor overall response reinforces the implementation of HBV vaccination before the development of cirrhosis.

Resumen Introduccion En un estudio previo demostramos que un pequeno programa de formacion mejoraba los indicadores de calidad de la esofagogastroduodenoscopia (EGD) que llegaban a los estandares recomendados. Sin embargo, desconocemos el efecto de esta formacion a largo plazo. El objetivo de este estudio fue valorar la calidad de las EGD despues de 3 anos de haber realizado un programa de mejora. Material y metodos Estudio comparativo de 2 cohortes: EGD posteriores a un programa de formacion realizado en 2016 (grupo A) y EGD en enero-marzo de 2019 (grupo B). El grupo B se dividio en 2 subgrupos: endoscopistas que habian participado en el programa de formacion previo (B1) y los que no (B2). Se utilizaron los indicadores de calidad intraprocedimiento recomendados por la ASGE-ACG. Resultados Se analizaron un total de 1.236 EGD, 600 en el grupo A y 636 en el B (439 subgrupo B1 y 197 subgrupo B2). El numero de exploraciones completas fue inferior en el grupo B (566 [94,3%] vs. 551 [86,6%]; p Conclusiones La mejora observada en 2016 tras un programa de formacion no perdura a los 3 anos. Es necesario hacer programas de formacion continuados para mantener la calidad de la EGD por encima de los estandares recomendados.

Complications of cirrhosis are the main cause of hospital admissions in liver units. In areas where HCV is prevalent, most of these admissions are attributable to HCV-related cirrhosis (HCV-cirrhosis). This study assessed the impact of direct-acting antivirals (DAA) in the profile of patients with liver disease admitted to a referral liver unit from a university hospital.We registered hospital admissions resulting from cirrhosis to the Liver Unit of the Hospital Clinic of Barcelona, from 2011 to 2014 (pre-DAA period) and from 2015 to 2019 (post-DAA period).From a total of 14,865 hospital admissions, 10,053 resulted from cirrhosis (corresponding to 6,272 patients). The number and proportion of hospital admissions because of HCV-cirrhosis remained stable during the period 2011-2014 (525 per year, 48.8% of the total), but decreased progressively after 2015 (p0.001), reaching300 (27.1%) admissions in 2019. Similarly, HCV-cirrhosis accounted for 3,885 inpatient days per year (44.9%) during the pre-DAA period and decreased steadily after 2015 (p0.001), reaching only 1,909 inpatient days (22%) in 2019. The figures for intensive care unit admissions followed a similar pattern. By means of a slope analysis (binomial regression model), we predicted that HCV-cirrhosis hospital admissions will be residual by 2025 (2.3%, 95% CI 0-10.9%). By contrast, we observed a significant increase in hospital admissions because of metabolic-associated fatty liver disease (5-fold) and autoimmune hepatitis (4-fold) during the study period.In summary, our data showed a profound reduction in HCV-cirrhosis hospitalisation burden since 2015, coincident with the wide use of DAAs in Spain. Our predictions suggest that, by 2025, HCV-cirrhosis will be a marginal cause of hospital admissions for patients with liver disease.Over the past few years, the wide use of antiviral drugs that cure HCV has had a significant effect on patients being admitted to hospital. Most patients with HCV and cirrhosis are treated (and often cured) in the community and, thus, the number of hospital admissions because of severe forms of HCV has decreased drastically. HCV is no longer the first cause of admission into liver units and, in only a few years from now, it is likely to be only a residual cause of hospitalisation.

Supplemental Digital Content is available in the text., Objectives: Infection by severe acute respiratory syndrome coronavirus-2 can induce uncontrolled systemic inflammation and multiple organ failure. The aim of this study was to evaluate if plasma exchange, through the removal of circulating mediators, can be used as rescue therapy in these patients. Design: Single center case series. Setting: Local study. Subjects: Four critically ill adults with coronavirus disease 19 pneumonia that failed conventional interventions. Interventions: Plasma exchange. Two to six sessions (1.2 plasma volumes). Human albumin (5%) was used as the main replacement fluid. Fresh frozen plasma and immunoglobulins were administered after each session to avoid coagulopathy and hypogammaglobulinemia. Measurements and Main Results: Serum markers of inflammation and macrophage activation. All patients showed a dramatic reduction in inflammatory markers, including the main cytokines, and improved severity scores after plasma exchange. All survived to ICU admission. Conclusions: Plasma exchange mitigates cytokine storm, reverses organ failure, and could improve survival in critically ill patients with coronavirus disease 2019 infection.

Background Hepatitis C virus (HCV) is a risk factor for porphyria cutanea tarda (PCT), a rare disease originating in the liver characterised by overproduction of porphyrins. Although hepatitis C infection is highly prevalent among patients with porphyria, only a minority of hepatitis C patients develop PCT. Aims To explore the presence of porphyrin abnormalities in a cohort of asymptomatic hepatitis C-infected patients and the impact of anti-viral therapy. Methods Eighty-four consecutive patients with HCV infection treated with direct-acting antivirals after 1 January 2018 were longitudinally evaluated for the presence of porphyrin abnormalities. Those patients with biochemical abnormalities at baseline were additionally evaluated at follow-up. Porphyrins in urine were screened by fluorometry and isomer separation was performed by liquid chromatography. Results In five patients, all of them asymptomatic, porphyrin profile abnormalities were detected: three presented significant increased urinary porphyrins with a typical PCT profile, and two showed normal levels of urinary porphyrins, but abnormal porphyria-like profiles. Urine evaluation after hepatitis C cure showed complete normalisation of the urinary porphyrins in all patients, confirming the biochemical cure of the disease. Conclusions We document the existence of rare cases of hepatitis C-infected patients with significant uroporphyrinuria in the absence of dermatological manifestations. Anti-viral therapy normalises the biochemical disorder, preventing patients from presenting PCT associated complications.

Hepatitis E virus (HEV) and hepatitis A virus (HAV) are both secreted in feces. Despite HEV transmission in Europe is mainly zoonotic, person-to-person transmission has not been completely excluded. Men who have sex with men (MSM) constitute a high-risk group for HAV mostly due to oral sex. We investigated the potential transmission of HEV during an acute hepatitis A (AHA) outbreak mainly affecting MSM. One hundred and two patients were diagnosed with AHA. Sixty-nine (68%) self-reported to be MSM, 75% of whom had high-risk sexual behaviors and 46% had suffered previous sexually transmitted diseases. We collected serum from 85 (83%) patients during AHA. HEV-IgG seroprevalence was not different among MSM (7%) compared with non-MSM (8%) patients. Two patients had positive anti-HEV-IgM, but all samples tested negative for HEV-RNA. These results suggest that HEV does not spread by sexual contact or person-to-person in our area.

In some areas of the world, antiviral therapy for chronic hepatitis C (CHC) is not available for all patients. The optimal interval for liver stiffness measures (LSM) and noninvasive scores to assess fibrosis progression has not been studied. We evaluated the usefulness of consecutive LSM, APRI, FIB-4 and Forns scores to predict disease progression.Patients with CHC and at least two annual LSM within 3 years were followed for a minimum of 5 years. Noninvasive scores were assessed. Evolution of LSM and scores were expressed as change/year (Delta).623 non-cirrhotic patients were included. Median baseline LSM was 6.6 kPa (IQR 5.4-8.4). During a median follow-up of 6 years, 61(9.7%) patients developed cirrhosis. Baseline LSM ≥ F2 and Forns ≥ 6.9 were the main predictors of cirrhosis (C-index 0.97). The addition of Delta variables did not improve its prediction. In patients with mild fibrosis (F0-1), progression to ≥F2 occurred in 80 (23%) within the first 3 years. Baseline BMI ≥ 24 kg/mBaseline LSM and Forns are highly predictive of cirrhosis development. In patients with mild CHC, BMI 24 and LSM 5.9, the likelihood of progression is very low, allowing for a significant spacing of noninvasive assessments over time.

Simple Summary Gastric cancer is one of the most common cancers worldwide, showing high mortality rates. A small portion of gastric cancer patients, known as early onset gastric cancer (EOGC) patients, develop the disease before age 50, and their characteristics are poorly described. Thus, our main objective was to describe the clinical, molecular, and genetic characteristics of EOGC in a large multicenter cohort of patients. We were able to identify that most EOGC cases have similar characteristics: diagnosed at advanced stage, diffuse type, and infrequent DNA mismatch repair somatic deficiency. Although familial aggregation of gastric cancer was uncommon, a germline genetic mutation was identified in 25% of the patients tested. Our results show that EOGC has a marked genetic heterogeneity. Thus, it is essential to consider familial history of tumors, not only GC, in order to select adequate patients to perform a suitable genetic counseling and enhance the emerging use of multigene panels. Abstract Gastric adenocarcinoma (GC) is a common tumor with high morbidity and mortality. Only 7% of patients with GC are diagnosed before age 50 (early onset gastric cancer (EOGC)), and their characteristics have been poorly described. We aimed to describe clinical, molecular, and genetic characteristics of EOGC. A total of 309 patients with EOGC were retrospectively studied in four Spanish centers. Personal information, family history, and tumor information were registered. Germinal genetic analysis was performed in patients who met current criteria of a hereditary syndrome at the time of diagnosis. The median age at diagnosis was 44 years. The majority (73.3%) of tumors were diffuse, and 78.3% were diagnosed in an advanced stage. Familial aggregation of GC was present in 18/117 (15.4%) cases, and 5/117 (4.3%) met criteria for familial GC. MMR-IHC was performed in 126/309 (40.7%) tumors: 4/126 (3.1%) had loss of expression in MLH1/PMS2, without an associated germline mutation. Sixteen germline genetic analyses were performed, detecting a pathogenic variant in four (25%) cases: one in BRCA2, one in TP53, and two in CDH1. Most EOGC are diffuse and diagnosed in an advanced stage. In these patients, DNA MMR system deficiency is uncommon. Although familial aggregation was observed in only 15% of cases, a germline mutation was found in 25% of patients tested with clinical criteria. This demonstrates that EOGC has a marked genetic heterogeneity, reinforcing the importance of an accurate genetic counseling and enhancing the emerging use of multigene panels.

A significant proportion of patients infected with SARS‐CoV‐2 develop severe respiratory symptoms due to an excessive immune response. Treatment of this condition may include immunosuppressive therapies, such as IL‐6 receptor antagonists and corticosteroids, which poses a risk for patients with active or past hepatitis B virus (HBV) infection. In this prospective cohort study we analyzed the risk of HBV reactivation in patients with severe COVID‐19 and resolved HBV infection undergoing immunosuppressive therapy. From March 15thto April 30th2020, 600 patients with severe COVID‐19 were admitted into our Hospital and treated with immune‐modulators. Data regarding HBV infection was available in 484, of whom 69 (14%) were HBsAg negative/anti‐HBc positive. For these patients, HBV reactivation prophylaxis with entecavir was strongly recommended. Complete follow‐up was available in 61 patients: 72% were male, median age was 67 years, and anti‐HBs was >10 IU/mL in 72%. The immunosuppressive drug most used was tocilizumab (72%). Despite HBV prophylaxis recommendation, 38 (62%) patients received entecavir and 23 (38%) did not. Baseline features of both groups were similar. At follow‐up, we found no cases of HBsAg seroreversion and only 2 (3%) patients (no prophylaxis group) had detectable serum HBV‐DNA (

Background and Aims Since the introduction of direct-acting antivirals (DAAs), few data have been published about kidney outcome in hepatitis C virus related mixed cryoglobulinaemia (HCV-MC) patients treated with combined DAAs and rituximab. We aimed to asses if combined treatment with DAAs and rituximab in patients with HCV-MC improves kidney survival and immunological response. Method Observational, multicentre, cohort study of 100 patients with HCV-MC from 14 Spanish centres treated with DAAs. Patients were followed up for a median duration of 138 months (11.5 years). Long-term kidney survival and immunological response were evaluated based on immunosuppressive treatment received. Kidney event was defined as duplication of creatinine level or 50% decrease in glomerular filtration rate, dependence on renal replacement therapy or non-reduction of proteinuria by 50% compared to baseline. Immunological response was defined as the decrease in cryocrit ≤1%. Results Sustained virological response was attained in 98 (98%) patients. 49 patients were treated with immunosuppressive treatment associated with DAAs, 26 with rituximab and the rest (23) with steroids and/or cyclophosphamide. Patients receiving immunosuppressive treatment had higher basal cryocrit (6.3±4.5 vs 3.8±3.9%, p=0.011), lower glomerular filtration rate (55±27 vs 68±25 ml/min/1.73 m2) and more haematuria (p=0.001). The 26 patients treated with rituximab had more severe disease: higher viral load (p=0.001), cryocrit (p=0.011), proteinuria (p=0.004), microhaematuria (p=0.012) and hypertension (p=0.012) and lower glomerular filtration rate (p=0.001). 15 patients had a kidney event at the end of follow-up. Predictive variables of kidney events were lower age (HR 0.94, 95%CI 0.89-0.99; P= 0.038) and lower glomerular filtrate rate (HR 0.97, 95%CI 0.94-0.99; p=0.026), in a model adjusted to proteinuria and microhaematuria. Immunosuppressive treatment with or without rituximab did not change kidney survival. Regarding the immunological response, only 19 patients had a cryocrit >1% at the end of follow-up. There were no differences in age, viral load, proteinuria and basal glomerular filtration rate between these patients with no immunological response and those who had a sustained immunological response over time. The only differences between these two groups were a higher basal cryocrit and a minor C4 levels. Immunosuppressive treatment with or without rituximab did not changed the immunological response. Conclusion Patients with more severe HCV-MC are those receiving immunosuppressive treatment. However, immunosuppressive treatment does not change kidney survival nor immunological response of these patients in the long term.

Background Direct-acting antiviral agents (DAAs) have shown high rates of sustained virological response in chronic hepatitis C virus (HCV) infection. However, the influence of DAAs on the course of kidney involvement in HCV-associated mixed cryoglobulinaemia (HCV-MC) has been little studied. The aim of this study was to analyse the effects of antiviral treatment on kidney prognosis and evolution in patients diagnosed with HCV-MC. Methods The RENALCRYOGLOBULINEMIC study is an observational multicentre cohort study of 139 patients with HCV-MC from 14 Spanish centres. Clinical and laboratory parameters were measured before and after antiviral treatment. Primary endpoints were kidney survival and mortality after HCV-MC diagnosis. Secondary endpoints were clinical, immunological and virological responses after antiviral treatment. Results Patients were divided into three groups based on the treatment received: treatment with DAAs (n = 100) treatment with interferon (IFN) and ribavirin (RBV) (n = 24) and no treatment (n = 15). Patients were followed up for a median duration of 138 months (interquartile range 70–251. DAA treatment reduced overall mortality {hazard ratio [HR] 0.12 [95% confidence interval (CI) 0.04–0.40]; P Conclusions Results from the RENALCRYOGLOBULINEMIC study indicated that DAA treatment in patients with HCV-MC improves kidney survival and reduces mortality.

In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme.A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used.A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p0.001), photo documentation of the lesion (94% vs. 90%; p0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p0.001). There were no differences between subgroups B1 and B2.The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

Objective There is scarce data with regard to the effectiveness and safety of direct-acting antivirals and possible drug-drug interactions between antiviral therapy and the multiple drugs frequently assumed by older patients. The aim is to evaluate the impact of comorbidities and drug-drug interactions on the efficacy and tolerability of direct-acting antivirals in this population. Methods Observational retrospective study of patients at least 65 years old receiving all-oral antiviral therapy between April 2015 and March 2016. Results Two hundred sixty-one patients were identified. Age distribution: 65-74 (73.9%), 75-79 (18.4%) and ≥80 (7.7%) years. Average age was 71 years, 38.7% were male, and 90% of patients took concomitant medication (43% patients taking ≥ 5 medicines). Predicted clinically significant drug-drug interactions were present in 72.8% of patients. The sustained viral response 12 weeks after end of treatment was 96.9%. Patients with serious adverse events received more concomitant drugs and all of them presented a clinical risk group ≥06/5. Conclusions Direct antiviral agents are highly effective also in older patients with advanced liver disease, comorbidities and concomitant medications. Serious adverse events increased with the number of concomitant medications and the severity of comorbidity. A clinical risk group score ≥06/5 may help to decide the indication of antiviral therapy in this difficult-to-treat population.

Resumen Contexto La disfagia es una alteracion de la deglucion altamente prevalente que afecta a personas de todas las edades, siendo la gente mayor y los pacientes con enfermedades neurologicas los de mas riesgo. Frecuentemente las personas mayores con disfagia no consultan por este motivo y acaban presentando complicaciones como desnutricion, deshidratacion o neumonias por aspiracion. Presentacion del caso Mujer de 88 anos, independiente para las actividades basicas de la vida diaria, con antecedentes de bocio multinodular, fibrilacion auricular permanente con mal control de la anticoagulacion en el ultimo ano y disfagia a solidos de 2 anos de evolucion no estudiada. Consulta por afagia de 24 h de evolucion. Una gastroscopia urgente resuelve la impactacion alimentaria y evidencia una estenosis esofagica. Asi se observa una progresiva normalizacion de los controles de la anticoagulacion, que se vuelven a alterar tras varios meses de tratamiento conservador. Se interpreta como una absorcion erratica del acenocumarol debido a la estenosis esofagica y ello obliga a realizar dilataciones esofagicas periodicas. Conclusiones La disfagia no solo puede alterar el estado nutricional del paciente, sino que tambien puede afectar la absorcion de los medicamentos prescritos. Cualquier actitud terapeutica requiere un seguimiento posterior para evaluar su efectividad y la posible aparicion de complicaciones.