Clinical outcomes of patients undergoing antiviral therapy while awaiting liver transplantation.

BACKGROUND & AIMS: Antiviral therapy for the treatment of hepatitis C (HCV) infection has proved to be safe and efficacious in patients with cirrhosis awaiting liver transplantation (LT). However, the information regarding the clinical impact of viral eradication in patients on the waiting list is still limited. The aim of the study was to investigate the probability of delisting in patients who underwent antiviral therapy, and the clinical outcomes of these delisted patients. METHODS: Observational, multicenter and retrospective analysis was carried out on prospectively collected data from patients positive for HCV, treated with an interferon-free regimen, while awaiting LT in 18 hospitals in Spain. RESULTS: In total, 238 patients were enrolled in the study. The indication for LT was decompensated cirrhosis (with or without hepatocellular carcinoma [HCC]) in 171 (72%) patients, and HCC in 67 (28%) patients. Sustained virologic response (SVR) rate was significantly higher in patients with compensated cirrhosis and HCC (92% vs. 83% in patients with decompensated cirrhosis with or without HCC, p=0.042). Among 122 patients with decompensated cirrhosis without HCC, 29 (24%) were delisted due to improvement. No patient with baseline MELD score >20 was delisted. After delisting (median follow-up of 88weeks), three patients had clinical decompensations and three had de novo HCC. Only two of the patients with HCC had to be re-admitted onto the waiting list. The remaining 23 patients remained stable, with no indication for LT. CONCLUSIONS: Antiviral therapy is safe and efficacious in patients awaiting LT. A quarter of patients with decompensated cirrhosis can be delisted asa result of clinical improvement, which appears to be remain stable in most patients. Thus, delisting is a safe strategy that could spare organs and benefit other patients with a more urgent need. LAY SUMMARY: Antiviral therapy in patients awaiting liver transplantation is safe and efficacious. Viral eradication allows removal from the waiting list of a quarter of treated patients. Delisting because of clinical improvement is a safe strategy that can spare organs for patients in urgent need.

The utility of the macro-aggregated albumin lung perfusion scan in the diagnosis and prognosis of hepatopulmonary syndrome in cirrhotic patients candidates for liver transplantation.

BACKGROUND: The macro-aggregated albumin lung perfusion scan (99mTc-MAA) is a diagnostic method for hepatopulmonary syndrome (HPS). GOAL: To determine the sensitivity of 99mTc-MAA in diagnosing HPS, to establish the utility of 99mTc-MAA in determining the influence of HPS on hypoxemia in patients with concomitant pulmonary disease and to determine the correlation between 99mTc-MAA values and other respiratory parameters. METHODS: Data from 115 cirrhotic patients who were eligible for liver transplantation (LT) were prospectively analyzed. A transthoracic contrast echocardiography and 99mTc-MAA were performed in 85 patients, and 74 patients were diagnosed with HPS. RESULTS: The overall sensitivity of 99mTc-MAA for the diagnosis of HPS was 18.9% (14/74) in all of the HPS cases and 66.7% (4/6) in the severe to very severe cases. In HPS patients who did not have lung disease, the degree of brain uptake of 99mTc-MAA was correlated with the alveolar-arterial oxygen gradient (A-a PO2) (r = 0.32, p < 0.05) and estimated oxygen shunt (r = 0.41, p < 0.05) and inversely correlated with partial pressure of arterial oxygen (PaO2) while breathing 100% O2 (r = -0.43, p < 0.05). The 99mTc-MAA was positive in 20.6% (7/36) of the patients with HPS and lung disease. The brain uptake of 99mTc-MAA was not associated with mortality and normalized in all cases six months after LT. CONCLUSIONS: The 99mTc-MAA is a low sensitivity test for the diagnosis of HPS that can be useful in patients who have concomitant lung disease and in severe to very severe cases of HPS. It was not related to mortality, and brain uptake normalized after LT.

Hepatopulmonary syndrome: which blood gas analysis criteria and position should we use for diagnosis?

INTRODUCTION: Different blood gas criteria have been used in the diagnosis of hepatopulmonary syndrome (HPS). PATIENTS AND METHODS: Arterial blood gases were prospectively evaluated in 194 cirrhotic candidates for liver transplantation (LT) in the supine and seated position. Three blood gas criteria were analyzed: classic (partial pressure of oxygen [PaO2] < 70 mmHg and/or alveolar-arterial gradient of oxygen [A-a PO2] ≥ 20 mmHg), modern (A-a PO2 ≥ 15 mmHg or ≥ 20 mmHg in patients over 64) and the A-a PO2 ≥ threshold value adjusted for age. RESULTS: The prevalence of HPS in the supine and seated position was 27.8% and 23.2% (classic), 34% and 25.3% (modern) and 22.2% and 19% (adjusted for age), respectively. The proportion of severe and very severe cases increased in a seated position (11/49 [22.4%] vs 5/66 [7.6%], p = 0.02). No difference was observed in the pre-LT, post-LT and overall mortality in patients with HPS, regardless of the criteria used. CONCLUSION: Obtaining blood gas measurements in the supine position and the use of modern criteria are more sensitive for the diagnosis of HPS. Blood gas analysis with the patient seated detects a greater number of severe and very severe cases. The presence of HPS was not associated with an increase in mortality regardless of blood gas criterion used.

Neonicotinoid contamination in wildflowers collected from citrus orchards in a northwestern Mediterranean Region (Spain) after tree foliar treatments.

Ground-cover vegetation attracts and harbors beneficial insects to the agrosystem, playing an important role in conservation biological control. Integrated pest management (IPM) program guidelines recommend the implantation of sowed or resident wild covers in perennial crops. Given the high-quality fruit requirements, even in IPM programs, insecticides can be required in citrus crops. This study presents, over a year, the levels of neonicotinoids (thiamethoxam and imidacloprid) in not-target ground-cover wildflowers growing spontaneously in citrus orchards after foliar treatment of citrus trees. The presence and persistence of these neonicotinoids in different wildflower species were studied. Concentrations of thiamethoxam and imidacloprid in whole wildflowers ranged from < method quantification limit (MQL) to 52.9 ng g-1 and from < MQL to 98.6 ng g-1, respectively. Thiamethoxam was more frequently detected than imidacloprid. Thiamethoxam and imidacloprid were detected up to 336 and 230 days after treatment, respectively. The highest detection frequencies (100%) and highest thiamethoxam and imidacloprid mean concentrations (26.0 ± 7.3 ng g-1 and 11.0 ± 10.6 ng g-1, respectively) occurred in wildflowers collected 9 days after the treatments. Since application, a clear decrease in the concentration of both compounds and differences in the accumulation depending on wildflower species were observed. Cross contamination was detected, indicating a transport from adjacent treated plots. Maintaining a cover crop in citrus orchards may lead to detrimental effects on non-target arthropods if these neonicotinoid compounds are used for pest control since they can entail a chronic exposure during at least 230 days for imidacloprid and 336 days for thiamethoxam.

Specific Quality of Life Assessment by the NutriQoL® Questionnaire Among Patients Receiving Home Enteral Nutrition.

BACKGROUND: Home enteral nutrition (HEN), including tube feeding and oral supplementation, can improve or worsen quality of life (QoL). The specific assessment of factors affecting QoL may identify the inherent problems associated with HEN. The aim of this study was to evaluate whether the validated NutriQoL® questionnaire is useful for assessing the QoL and the factors influencing it in patients receiving HEN. METHODS: A total of 78 patients receiving HEN completed both the NutriQoL and the SF-12 questionnaires during their routine visits to nutrition service at the hospital. RESULTS: Ninety percent of patients receiving HEN had cancer, 58% received oral supplements, and 42% received tube feeding. At recruitment, the mean score ± SD of the NutriQoL was 66 ± 14, whereas that of the SF-12 was 40 ± 9. A positive correlation between NutriQoL and SF-12 scores (ρ = 0.5; P < .001) was found. Multivariate analysis showed that HEN type (oral vs tube) (odds ratio [OR], 5.6; 95% CI 2.0-15.3; P = .001) and the absence of secondary effects (OR, 3.0; 95% CI, 1.2-7.9; P = .024) were both variables explaining NutriQoL results adjusted by sex and age. The SF-12 results did not show associations with nutrition factors. On visit 2, we observed significant improvements in NutriQoL results. CONCLUSION: The NutriQoL questionnaire identifies specific problems that affect the QoL of patients receiving HEN, whereas SF-12 does not. The route of entry and the occurrence of complications influence specific QoL. NutriQoL is a useful tool to identify the factors that worsen the QoL in patients receiving HEN.

Analysis of pesticide residues in honeybee (Apis mellifera L.) and in corbicular pollen. Exposure in citrus orchard with an integrated pest management system.

In the last years, the honeybee population is facing growing threats such as expansion of pathogens, incorrect use of phytosanitary products and environmental contaminants, loss or fragmentation of habitat, invasive species and climate change. The citrus cropping by Integrated Pest Management (IPM) in Spain combines strategies to reduce pest populations preventing environmental problems and reducing levels of damage by using chemicals only when it is strictly necessary. The goal of this study is to develop a simple analytical method to evaluate pesticide residue levels in honeybees and corbicular pollen when honeybees are exposed to plant protection products (PPPs) used in integrated pest management citrus orchards. The proposed method is based in an ultrasound assisted extraction procedure followed by a dispersive solid phase extraction (d-SPE) clean-up with alumina and LC-MS/MS pesticides determination. The method was validated in samples of honeybee and corbicular pollen for 10 pesticides commonly used in citrus orchards under IPM. This procedure was compared with QuEChERS methodologies for these matrices. The developed method was applied to determine pesticides in both matrices in a two -year study in citrus orchards.

Evaluation of Residue Levels of Imidacloprid and Thiamethoxam After Foliar Application to the Citrus Varieties Lane Late, Valencia Late, Rohde Summer, and Nules.

Neonicotinoids are used to protect citrus trees against pests. Dissipation and persistence of neonicotinoids in pollen and nectar of citrus trees after foliar applications and their potential exposure to pollinators have not been well characterized. Field studies were conducted using three orange and one mandarin varieties to compare the imidacloprid and thiamethoxam residue levels and their decline in pollen and nectar after treatments in pre-bloom close to flowering period and their persistence 1 yr after treatment. The possible risk to honeybees was assessed. In nectar, thiamethoxam and imidacloprid residues were between 61 and 99% lower than in pollen, depending on the citrus variety or/and the days after treatment when applied close to blooming. At the end of the flowering period, imidacloprid in pollen and nectar was not detected in the mandarin variety after treatment in pre-bloom, whereas for thiamethoxam, no residues were detected in nectar but 10 ng/g was detected in pollen. There were no quantifiable levels of residues for either neonicotinoids in pollen or nectar during the flowering period of the following year. Neonicotinoid residue levels and their decline in nectar and pollen in citrus depended on the timing of applications relative to flowering and on the citrus variety. The absence of neonicotinoid residues 1 yr out after foliar applications in all varieties assayed demonstrated that none of the neonicotinoids tested were persistent. The results could be different in other citrus varieties, and therefore, also the exposure assessment for managed pollinators.

Clinical characteristics of hepatocellular carcinoma in Spain. Comparison with the 2008-2009 period and analysis of the causes of diagnosis out of screening programs. Analysis of 686 cases in 73 centers. / Características clínicas del carcinoma hepatocelular en España. Comparación con el período 2008-2009 y análisis de las causas del diagnóstico fuera de cribado. Estudio de 686 casos en 73 centros.

BACKGROUND AND OBJECTIVE: In 2010 we published that 53% of cases of hepatocellular carcinoma (HCC) detected in Spain were diagnosed outside the context of standard screening programs, which consequently leads to lower survival rates. The aim of this study was to analyze the current situation and the causes of diagnosis out of screening programs. MATERIAL AND METHODS: Prospective registry of 73 second- and third-level Spanish healthcare centers carried out between October 1, 2014 and January 31, 2015. The baseline characteristics of the disease and the first treatment administered for the incidental primary liver tumors during such period were recorded. RESULTS: A total of 720 patients were included in the study: HCC (n=686), intrahepatic cholangiocarcinoma (n=29), hepatic cholangiocarcinoma (n=2), other (n=3). HCC characteristics: male 82%; mean age 67 years; cirrhosis 87%; main etiologies: alcohol 35%, HCV 30%, alcohol and HCV 15%, non-alcoholic fatty liver disease 6%; tumor stage: BCLC-0 11%, A 43%, B 19%, C 16% and D 11%; first treatment: transarterial chemoembolization (23%), percutaneous ablation (22%), symptomatic treatment (20%), resection (11%), sorafenib (11%). Three hundred and fifty-six patients (53%) were diagnosed outside of screening programs, mainly owing to the fact that they suffered from an undiagnosed liver disease (76%) and to the poor adherence to the screening program (18%). These patients were mainly male (P<.001), with an alcoholic etiology (P<.001) and active alcohol consumption (P<.001). Moreover, the disease was predominantly diagnosed at more advanced stages (P<.001) and was addressed with less radical treatments (P<.001). CONCLUSIONS: In Spain, the main cause of diagnosis of a HCC outside the context of a screening program is the absence of a prior diagnosis of a liver disease, particularly in alcohol-consuming men. Detecting a liver disease in asymptomatic populations and improving adherence to screening programs are the main areas that must be subject to improvement in order to improve the early detection of HCC.

Enumerative and binomial sampling plans for citrus mealybug (Homoptera: pseudococcidae) in citrus groves.

The spatial distribution of the citrus mealybug, Planococcus citri (Risso) (Homoptera: Pseudococcidae), was studied in citrus groves in northeastern Spain. Constant precision sampling plans were designed for all developmental stages of citrus mealybug under the fruit calyx, for late stages on fruit, and for females on trunks and main branches; more than 66, 286, and 101 data sets, respectively, were collected from nine commercial fields during 1992-1998. Dispersion parameters were determined using Taylor's power law, giving aggregated spatial patterns for citrus mealybug populations in three locations of the tree sampled. A significant relationship between the number of insects per organ and the percentage of occupied organs was established using either Wilson and Room's binomial model or Kono and Sugino's empirical formula. Constant precision (E = 0.25) sampling plans (i.e., enumerative plans) for estimating mean densities were developed using Green's equation and the two binomial models. For making management decisions, enumerative counts may be less labor-intensive than binomial sampling. Therefore, we recommend enumerative sampling plans for the use in an integrated pest management program in citrus. Required sample sizes for the range of population densities near current management thresholds, in the three plant locations calyx, fruit, and trunk were 50, 110-330, and 30, respectively. Binomial sampling, especially the empirical model, required a higher sample size to achieve equivalent levels of precision.