Delay in treatment of early-stage hepatocellular carcinoma using radiofrequency ablation may impact survival of cirrhotic patients in a surveillance program.

BACKGROUND: The aim of this study was to evaluate the impact of the interval between diagnosis and treatment using radiofrequency (RF) ablation on the survival of patients with HCC detected through a surveillance program. METHODS: Between January 2004 and July 2007, 121 cirrhotic patients with 157 tumours detected through a surveillance program underwent RF ablation. A delay in treatment was defined as >5 weeks. The mean length of follow-up was 25 months (range 8-55 months). Cumulative survival of patients was analysed using the Kaplan-Meier method. Cox regression models were used to identify factors associated with patient survival. RESULTS: The 1-, 2- and 3-year survival rates were 92.5%, 78.5% and 67.2%. The independent predictors of poorer patient survival were time from diagnosis to treatment >5 weeks (pooled odds ratio [OR], 3.59; 95% confidence interval [CI], 1.58-8.18; P = 0.002), absence of complete ablation after the initial RF session (OR, 2.42; 95% CI 1.07-5.45; P = 0.033) and Child-Pugh B liver cirrhosis (OR, 2.46; 95% CI 1.06-5.70; P = 0.036). CONCLUSIONS: Delay in the start of effective treatment for HCC using RF ablation may be associated with poorer patient survival.

Clinical outcomes of lamivudine-adefovir therapy in chronic hepatitis B cirrhosis.

GOALS: To determine the clinical outcome of chronic hepatitis B cirrhotics on antiviral therapy. BACKGROUND: The long-term outcome of hepatitis B cirrhotics on therapy remains to be characterized. METHODS: A large clinic cohort of chronic hepatitis B cirrhotic patients were enrolled in a treatment program of lamivudine ± adefovir therapy. Patients were analyzed for clinical outcomes, and predictors of these outcomes were evaluated by multivariate analysis. Clinical outcomes of ascites, encephalopathy, hepatocellular carcinoma (HCC), and progression in Child-Pugh score, Model for End-stage Liver Disease score, and mortality were assessed. Data were analyzed by Kaplan-Meier graphs, log-rank test, and Cox regression. RESULTS: Of 143 chronic hepatitis B cirrhotics, 19.6% had decompensated cirrhosis. At 5 years, the mean survival was 83.6%, development of ascites, HCC, encephalopathy, and deterioration in Child-Pugh score were 7.0%, 15.9%, 10.8%, and 16.9%, respectively. The overall progression of liver-related complications was 32.8% at 5 years. Multivariate analysis showed that ascites, albumin ≤28 g/L, Child-Pugh score ≥7.9, Model for End-stage Liver Disease score ≥10.9 were significantly associated with liver-related complications. Low albumin and low hepatitis B virus DNA were independent factors for liver-associated mortality. Lamivudine resistance did not affect mortality or liver disease progression. When stratified by Child-Pugh status, the mean survival of those with Child C cirrhosis was worse than Child A and B cirrhosis (P<0.001, log-rank test). Early deaths (≤12 mo) were due to liver failure or sepsis, whereas deaths ≥12 mo were mainly due to HCC. CONCLUSION: Decompensated chronic hepatitis B cirrhotics may suffer early mortality despite antiviral treatment, and therefore should be considered for early liver transplantation.

Prospective study of a 'popping' sound during percutaneous radiofrequency ablation for hepatocellular carcinoma.

PURPOSE: To prospectively evaluate the occurrence of a 'popping' sound during radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) and its association with early tumor progression and patient survival. MATERIALS AND METHODS: Seventy-six patients with 100 tumors underwent RF ablation by using an internally cooled electrode. A popping sound was defined as an audible sound or tactile vibration detected by the operator during RF ablation. Follow-up ranged from 6 to 38 months (mean, 19 months) and included 3-6 month ultrasonography, serum alpha-fetoprotein measurements, and computed tomography or magnetic resonance imaging. Early local and distant intrahepatic tumor progression within 12 months and survival were analyzed. RESULTS: A popping sound occurred during 58 of the 100 (58%) tumor ablations. Primary technique effectiveness was achieved in 97 of the 100 (97%) tumors. Major complications occurred in 2 of the 76 patients (2.6%). The cumulative rate of early local tumor progression was 20.8%. At multivariate analysis, early local tumor progression was associated with tumor size larger than 3 cm (odds ratio [OR] = 4.08, P = .012) and inversely associated with a popping sound (OR = 0.267, P = .026). The cumulative rate of early distant intrahepatic tumor progression was 21.4%, and the cumulative survival of the whole cohort at 6, 12, 18, and 24 months was 98.7%, 96%, 92.7%, and 83.6%, respectively. A popping sound was not significantly associated with either early distant intrahepatic tumor progression (P = .341) or patient survival (P = .975). CONCLUSIONS: A popping sound during RF ablation is not associated with an increased risk of early tumor progression or poorer patient survival.

Problemas de nervos: a multivocal symbol of distress for Portuguese immigrants.

This article outlines research on a previous unstudied form of suffering specific to the Portugese immigrant community: problemas de nervos. Thirty-two Portuguese immigrant women (in Waterloo, ON and Boston, MA) were interviewed and each completed a questionnaire. Cluster analysis demonstrated that problemas de nervos has many meanings. The study profiled symptoms, causes and therapies associated with four variations of this culture-specific form of distress: "mal da cabeca" meaning problems with/in the head (e.g., lack of control, visions); " aflição" meaning affliction (e.g., nervous attacks, heart problems); immigration stress (causing sleep disturbances); and, conflicts with others (resulting in pressure within the body). None of the symptom clusters reported matched criteria for a DSM-IV-TR diagnosis, suggesting that problemas de nervos represents an idiomatic rather than universal expression of distress.

Alanine aminotransferase is an inadequate surrogate marker for detecting lamivudine resistance.

AIM: To investigate the accuracy of serum alanine aminotransferase (ALT) in diagnosing lamivudine resistance and factors that contributed to abnormal serum ALT. METHODS: This was a retrospective study of chronic hepatitis B patients on lamivudine therapy who were followed for 3-mo with liver function tests and hepatitis B virus (HBV) DNA measurement. Lamivudine resistance was defined as HBV DNA ≥ 1 log from nadir on at least 2 occasions, confirmed by genotyping. Serum ALT levels in patients with lamivudine resistance were compared to serum ALT levels in those without lamivudine resistance. RESULTS: There were 111 patients with and 117 without lamivudine resistance. The area under the receiver operating characteristic of serum ALT to diagnose lamivudine resistance was 0.645 ± 0.037. Serum ALT > 42.5 U/L gave the best diagnostic accuracy with sensitivity = 61%, specificity = 60%, positive predictive value = 60%, negative predictive value = 61%, positive likelihood ratio = 1.53 and negative likelihood ratio = 0.65 for predicting lamivudine resistance, missing 39% of resistant patients. Using other serum ALT cutoffs, diagnostic accuracy was lower. By multivariate analysis, baseline abnormal serum ALT was associated with abnormal ALT during resistance (OR = 5.98, P = 0.003), and males were associated with serum ALT flares during resistance (OR = 8.9, P = 0.016). CONCLUSION: Serum ALT is inadequate for diagnosing lamivudine resistance and has implications where viral resistance testing is suboptimal and for reimbursement of rescue therapy.

Opposing trends in incidence of esophageal squamous cell carcinoma and adenocarcinoma in a multi-ethnic Asian country.

OBJECTIVES: To describe the incidence trends in esophageal squamous cell carcinoma (SCC) and adenocarcinoma among the three major ethnic groups in Singapore from 1968 to 2002. METHODS: Esophageal cancer cases in Singapore citizens and permanent residents obtained from the Singapore Cancer Registry and population data derived from the national census were used to calculate the incidence rates from 1968 to 2002. RESULTS: The age-standardized incidence rates (ASRs) for SCC decreased progressively from 8.31 to 3.85 per 100,000 men (p = 0.017) and from 3.43 to 0.81 per 100,000 women (p = 0.027). The rates fell for all three ethnic groups. The ASR for adenocarcinoma rose from 0 to 0.54 per 100,000 men and from 0.03 to 0.13 per 100,000 women, although these time trends did not achieve statistical significance. The frequency of regular smoking in the population decreased from 23% in 1966/1977 to 12.6% in 2004. The percentage of obesity in adults rose from 4.3% in 1982-1985 to 6.9% in 2004. The frequency of esophagitis in Singapore based on endoscopic findings increased from 3.9% in 1992 to 9.8% in 2001. CONCLUSIONS: The decline in the incidence of SCC is likely to be associated with the known decrease in the frequency of smoking among Singaporeans. In contrast, there appears to be a trend toward an increase in the incidence of adenocarcinoma in Singapore, although the absolute incidence remains relatively low. This may be due to the associated rise in the frequency of reflux esophagitis and obesity in Singapore.

A novel ambulatory intravenous holder: preliminary findings.

IMPLICATIONS: Many devices serve as portable systems for IV equipment but are expensive and use complex electronic controls. We present a novel device to facilitate safe ambulation of IV-dependent patients. This device was effective in delivering required therapeutic flow rates over time periods desired for unattended operation.