Primary Liver Diffuse Large B-Cell Lymphoma following Complete Response for Hepatitis C Infection after Direct Antiviral Therapy.

INTRODUCTION: Hepatitis C infection is highly prevalent worldwide and has a well-known association with B-cell lymphoid malignancies. Antiviral therapy has successfully decreased the rate of liver cirrhosis and improved the outcome in patients with hepatitis C-associated lymphomas. However, although there are a few case reports of aggressive lymphomas after successful hepatitis C therapy, the mechanism behind this association remains unclear. CASE PRESENTATION: We present the case of a 55-year-old man with chronic hepatitis C infection and liver cirrhosis who received antiviral therapy with sofosbuvir and ribavirin and achieved a sustained complete virological response. One year after successful therapy, there was an unexplained decline of his liver function and atypical liver nodularity, which led to the diagnosis of a primary liver diffuse large B-cell lymphoma. DISCUSSION: We review the evidence supporting possible mechanisms of lymphomagenesis after successful hepatitis C therapy, particularly involving late "second-hit" mutations after viral-induced DNA damage and antiviral therapy facilitating the emergence of latent malignant B-cell clones by decreasing local inflammation and immune surveillance. More reports may help elucidate any association between hepatitis C antiviral therapy and late lymphoid malignancies.

Gaps of care in patients with venous thrombotic embolism: a qualitative study.

BACKGROUND: Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT), and results in 100,000 deaths annually in the United States. There is low global VTE awareness, including limited data regarding difficulties patients encounter during their management. This study aims to identify a patient's perspective on VTE gaps of care. METHODS: This is a qualitative study using semi-structured interviews with VTE patients, who had been previously diagnosed and treated for at least one VTE event in their lifetime. Participants were separated in five focused groups; sample size was defined by data saturation. Interviews were audio recorded, transcribed verbatim, and analyzed thematically using framework analysis based on data saturation evaluation. The study was approved by a local institutional review board. We used inductive framework analysis to interpret the data. RESULTS: Twenty participants were included in the analysis. Ten participants (50%) were men. Three major themes were identified: 1) concerned about limited disease knowledge; 2) VTE awareness in healthcare system; 3) incomplete communication during transitional and follow-up care. CONCLUSIONS: Findings suggest that gaps of VTE care extend in different levels of the medical system, including: the patient, physicians, and medical teams. Patients were sensitive to a lack of disease awareness among healthcare providers. There was appreciation for subspecialty care recommended for VTE. In a qualitative study, using the patient perspective, we have detected frustrations and perceived areas of improvement of the care of the patient with VTE. These gaps are anchored in perceived lack of disease awareness and difficult transitional care.

Intermittent pneumatic compression in patients with ESRD. A systematic review.

INTRODUCTION: Patients with end-stage renal disease (ESRD) experience frequent hemodialysis (HD) complications. Intradialytic hypotension (IDH) is a common complication presenting in approximately between 20 and 50% of HD sessions. Available interventions such as volume replacement or vasoactive medications are associated with significant side effects. Intermittent pneumatic compression (IPC) has been proposed as a feasible intervention for the prevention of IDH, treatment of peripheral arterial disease and venous ulcers. These devices apply intermittent pressure to the legs improving arterial blood flow, mobilization of pooled blood with an increase in venous return increasing the effective circulatory volume. Our goal was to identify the published clinical evidence on whether IPC has a circulatory benefit and is it well-tolerated among patients receiving HD. METHODS: We conducted a systematic review to identify studies assessing the efficacy and safety of IPC in patients with ESRD. Our primary outcome was IDH. Secondary outcomes such as HD comfort, ultrafiltration volume, and physical activity were collected. No restrictions where used and we included all observational and interventional studies. Two reviewers performed screening and study quality assessment. FINDINGS: We included seven studies. Out of the seven studies, five addressed IDH, and the rest were included for secondary outcomes such as physical capacity and HD comfort. In one randomized crossover trial comparing exercise against IPC, 21 patients were randomized to 3 different arms (no intervention, cycling, IPC) a decrease in the rates of IDH with IPC was described (43%, 38%, and 24% respectively P = 0.014). The smaller studies corroborated these results. All studies where at high risk of bias. DISCUSSION: IPC might offer significant benefits for patients undergoing HD not limited to prevention of IDH but also improvement of hemodialysis comfort and physical capacity. However, our results should be interpreted in the context of its limitations.

Pancreatic cancer thromboembolic outcomes: rate of thrombosis after adenocarcinoma and non-adenocarcinoma pancreatic cancer surgery.

BACKGROUND: The aim of this study was to define the association of non-adenocarcinoma pancreatic cancer (NACPC) as a risk factor for postoperative cancer-associated thrombosis (CAT). METHODS: We conducted analysis of prospectively collected data of pancreatic cancer surgery. Randomly collected NACPC cases were matched 1:3 to adenocarcinoma cases (ACPC). Variables included comorbidities, demographics, cancer extension, and preoperative Khorana score (KRS). Primary outcome was CAT, which included deep vein thrombosis and pulmonary embolism confirmed by imaging. Categorical variables are presented as percentages, continuous variables as median and range. SPSS, χ2, Cochran-Armitage, and logistic regression were use for analysis. RESULTS: The study included 441 patients. Age 65.9±11.5, male 57% (N.=252), 8% (N.=36) had metastasis. IPMN and neuroendocrine were the most common NACPC. Median follow-up was 449 days in which 90 (20%) patients developed CAT. The odds (Odds Ratio [OR] 1.1, 95% Confidence Interval [CI] 0.6- 1.9, P=0.7) and time to venous thromboembolism were not different between NACPC and ACPC. We analyzed for trends of prophylactic strategies by year of surgery; there was no trend for NACPC (P=0.4) or ACPC (P=0.06). KRS was not associated with CAT. In the multivariate analysis, peripheral artery disease (Adjusted Odds Ratio [ORadj] 5.4, 95% CI: 1.7-17.3), ASA class ≥4 (ORadj 3.6; 95% CI: 1.3-10.4), length of stay >9 days (ORadj: 1.9; 1.2-3.2), and cancer vascular invasion (ORadj: 2.9; 95% CI: 1.6-5.3) were associated with CAT. CONCLUSIONS: The rate of VTE in NACPC after surgery was high and not different than ACPC. Histology type should not govern discrimination in thromboprophylaxis selection or extension.