A baseline tool for predicting response to peginterferon alfa-2a in HBeAg-positive patients with chronic hepatitis B.

BACKGROUND: Peginterferon induces off-treatment responses in approximately one-third of patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B. AIM: To develop an easy-to-use baseline prediction score to identify hepatitis B virus (HBV) genotype B-/C-infected HBeAg-positive Asian patients likely to respond to peginterferon alfa-2a. METHODS: Generalised additive models, multiple logistic regression (MLR) analysis and internal validation methods were applied to data from 647 HBeAg-positive patients from China, Hong Kong and Taiwan to develop a scoring system to predict response 24 weeks after completing a 48-week course of peginterferon alfa-2a. RESULTS: Five baseline factors (age, sex, alanine aminotransferase ratio, hepatitis B surface antigen (HBsAg) level and HBV DNA level) were retained in the final MLR for HBeAg seroconversion and used to develop a scoring system from 0 to 7. Among patients with scores of 0-1, 2-3, 4 or ≥5, HBeAg seroconversion was achieved in 6.4% (6/94), 23.0% (61/265), 36.4% (67/184) and 54.8% (57/104), respectively, and a combined response (HBeAg seroconversion plus HBV DNA <2000 IU/mL) in 5.3% (5/94), 12.8% (34/265), 25.0% (46/184) and 36.5% (38/104), respectively. Among patients with scores of 0-1, 2-3, 4 or ≥5, 57.0% (53/93), 12.3% (31/253), 3.4% (6/178) and 1.0% (1/100) had HBsAg ≥20 000 IU/mL at treatment Week 12; only 3/91 (3.3%) with HBsAg ≥20 000 IU/mL experienced a combined response at 24 weeks post-treatment (negative predictive value = 97% [88/91]). CONCLUSION: A pre-treatment scoring system using readily available baseline characteristics identifies HBeAg-positive Asian patients likely to experience sustained HBeAg seroconversion after treatment with peginterferon alfa-2a.

Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases.

Thromboembolic disease during pregnancy is an important cause of obstetric morbidity and mortality. Pregnant patients with venous thromboembolism are usually managed by conventional anticoagulation. However, this must be discontinued during vaginal or caesarian delivery to avoid haemorrhage and to reduce the risk of possible epidural haematoma. Retrievable inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during this high-risk period, when anticoagulation is discontinued, while avoiding potential long-term sequelae of a permanent IVCF. Here we report two patients who presented in the third trimester of pregnancy with floating ileofemoral deep vein thrombosis. Both patients were initially treated with standard anticoagulation; however, shortly before delivery both patients had a retrievable IVCF placed in a suprarenal position. In both patients, retrieval failed at 28 days after insertion because of filter tilt. The timing and mechanism of filter tilt remains uncertain. We believe that a number of factors could have been involved, including change in the anatomic configuration with lateral displacement of the IVCF as a result of the gravid uterus as well as forceful uterine contractions during labour, which modified the shape and diameter of the IVC. We showed that failure to retrieve the IVCF has had considerable implications for the two young patients regarding long-term anticoagulation and have highlighted the need for further clinical trials regarding the safe use of retrievable IVCFs during pregnancy.

The expression and function of NKG2D molecule on intrahepatic CD8+ T cells in chronic viral hepatitis.

The natural killer (NK) cell receptor, NKG2D is a member of the c-type lectin-activating receptor family. It is expressed by all NK cells and by a sub-population of CD8+ T cells. NKG2D engagement with its ligands directly activates NK cells and acts as a co-stimulator on CD8+ T cells. Recent reports, however, have demonstrated a role for NKG2D in direct T-cell activation in chronic inflammation. The aim of this study was to investigate the pattern of expression and the functional role of NKG2D on circulating and intrahepatic CD8+ T cells in chronic viral hepatitis. Peripheral blood lymphocytes and intrahepatic lymphocytes from 45 patients with chronic viral hepatitis (HBV and HCV) were studied. Phenotypic NKG2D expression and its functional ability to activate intrahepatic and circulating lymphocytes were analysed. Intrahepatic CD8+ T cells display increased NKG2D expression in chronic viral hepatitis in comparison with circulating CD8+ T cells. NKG2D co-stimulates intrahepatic CD8+ T cells and hepatitis B virus-specific CD8+ T cells. However, we could not demonstrate an ability to directly activate CD8+ T cells through the NKG2D signalling pathway alone. NKG2D is up-regulated on intrahepatic CD8+ T cells in type B and C chronic viral hepatitis; however, its function appears to be restricted to that of a co-stimulatory molecule.

Anchoring a migrating inferior vena cava stent with use of a T-fastener.

An attempt to treat symptomatic stenosis of the inferior vena cava in a patient with metastatic liver disease was complicated by migration of a Wallstent into the right atrium. Effective palliation was achieved by insertion of a second stent, which was anchored by transhepatic insertion of a T-fastener into the intracaval stent. This anchoring maneuver was performed safely under sonographic and fluoroscopic guidance.

Conscious sedation and analgesia for routine aortofemoral arteriography: a prospective evaluation.

PURPOSE: To compare the effectiveness of temazepam and midazolam hydrochloride with or without fentanyl citrate versus a placebo in promoting patient acceptance of diagnostic aortofemoral arteriography. MATERIALS AND METHODS: One hundred twenty-five patients undergoing aortofemoral arteriography were prospectively and randomly assigned to one of four treatment arms: placebo (group A), oral temazepam (group B), intravenous midazolam (group C), or intravenous midazolam and fentanyl (group D). Patients were blinded to the administered sedative. Five-point scales were used to assess degree of patient discomfort, willingness to undergo the same procedure again, patient compliance, and preprocedural anxiety. RESULTS: There was no difference between patient groups in willingness to return for a repeat procedure (P: =.89). Group C patients were less compliant during the procedure (P: =.034). Mean patient discomfort scores were 1.81 for group A, 1.84 for group B, 1. 53 for group C, and 1.27 for group D. Discomfort experienced during the procedure was not related to the degree of preprocedural anxiety (P: =.42). Patients who had previously undergone arteriography reported a higher level of pain than did those who had not (P: =. 021). CONCLUSION: Most patients experienced only low-level discomfort during diagnostic aortofemoral arteriography. In the authors' opinion, conscious sedation should only be used selectively, not routinely, for diagnostic aortofemoral arteriography.

Ultrasonography of intratesticular lesions: its role in clinical management.

Ultrasound is the primary imaging modality in the investigation of patients with symptoms related to the scrotum, and is pivotal to the diagnosis of suspected testicular malignancy. This retrospective study analysed the results of testicular ultrasound at a large teaching hospital over a five year period. We wished to examine the clinical consequences for patients in whom ultrasound findings were suspicious of testicular cancer, and the accuracy of the ultrasound diagnosis. Real time ultrasound examinations were performed, providing multiplanar imaging of the testis and para testicular tissues. Over a five year period 661 examinations were carried out. An intratesticular lesion was identified in 44 patients; nineteen of these patients were shown to have testicular malignancy following tissue diagnosis. When ultrasound was used to identify testicular malignancy in those patients with an intratesticular lesion, it had a sensitivity of 94.7% and a specificity of 59.1%. A tissue diagnosis was obtained in 93% of those patients thought likely to have a testicular malignancy on sonographic assessment, and in 40% of those in whom a diagnosis of malignancy was possible, but less likely. Our study shows that this modality can be used to aid the clinician in deciding which patients should undergo orchidectomy, invasive biopsy or clinical surveillance.

Early experience using duplex ultrasonography in the diagnosis of deep venous thrombosis; a prospective evaluation.

Duplex ultrasound is used in many radiology departments as the first line of investigation for symptomatic deep venous thrombosis. Before changing the practice of our department from venography to duplex ultrasonography, we wanted to assess our ability to identify deep venous thrombosis on ultrasound. Thirty-eight patients were investigated for suspected deep venous thrombosis by venography and duplex ultrasound. The results were compared using venography as the 'gold standard'. Duplex ultrasound correctly identified 13 out of 16 limbs with deep venous thrombosis. Four of the 38 duplex ultrasound examinations (11%) were described as inadequate at the time of examination, and when these are excluded from the analysis a sensitivity of 93 %, and specificity of 80 % are achieved. We conclude that there is a significant learning curve when performing duplex ultrasound of the lower limb, and that change-over from venography to ultrasound should include a period during which both examinations are routinely performed.