Size Matters! Anti-HBs Titer and HBV Reactivation During Anti-TNF Therapy.

BACKGROUND AND AIMS: We and others have previously described that hepatitis B surface antibody (anti-HBs) seems to protect against clinically significant HBV reactivation in cohort studies of patients undergoing anti-tumor necrosis factor (TNF) therapy. However, there were too few cases of HBV reactivation within cohort studies to assess the role of anti-HBs titer on reactivation. The purpose of this study was to systematically review the correlation between anti-HBs titer and the degree of clinically relevant HBV reactivation in patients undergoing anti-TNF therapy. METHODS AND RESULTS: We systemically reviewed all studies discussing anti-TNF therapy in patients with resolved HBV infection, defined as hepatitis surface antigen (HBsAg) negative and hepatitis B core antibody (anti-HBc) positive. We identified a total of 48 cases of reactivation from 5 cohort studies and 10 case reports or case series; 21 were anti-HBs negative, 7 were only reported as anti-HBs positive, 16 were anti-HBs positive with titer below 100, and 4 were anti-HBs positive with titer above 100. HBsAg sero-reversion was dominantly seen in patients with negative, low and/or declining anti-HBs titers. There was a significant trend toward less clinically relevant form of reactivation with increase in baseline anti-HBs titer (p = 0.022). CONCLUSION: Anti-HBs titers greater than 100 iU/L protect against clinically relevant HBV reactivation, while patients with low anti-HBs titers or negative anti-HBs had more clinically relevant HBV reactivation and higher rates of HBsAg sero-reversion. This suggests the importance of baseline quantitative anti-HBs prior to starting anti-TNF therapy and consideration vaccination for boosting anti-HBs titers prior to and/or during therapy.

Role of Hepatitis B Surface Antibodies in Risk for Hepatitis B Virus Reactivation During Anti-Tumor Necrosis Factor Therapy.

An estimated 250 million people are chronically infected with hepatitis B virus (HBV), with more than 800,000 deaths related to HBV.1 Although the prevalence of HBV has been decreasing, reactivation remains a cause for concern.2 Reactivation is defined by the resurgence of HBV DNA and/or HBV surface antigen (HBsAg) seroreversion in patients with resolved HBV or an increase in HBV viral load in chronic hepatitis.3 Anti-tumor necrosis factor (TNF) therapies have been shown to place patients at a risk for HBV reactivation.4.

Disseminated herpes simplex infection induced hepatitis during pregnancy mimicking HELLP syndrome, a diagnostic challenge.

The disseminated herpes simplex virus 2 (HSV-2) carries a high mortality rate in pregnant women if left unrecognized. It often presents as unrelieved fever and hepatitis. Diagnosis is challenging due to vague symptoms and potential overlap with other conditions. Pregnancy is a risk factor as it conforms to a partially immunocompromised state. Dissemination to the brain could be devastating, and the treatment requires intravenous antivirals like acyclovir. Fetal outcomes are variable based on previous case reports. We present a case of young female gravida 1 para 1 who presented with disseminated HSV infection mimicking HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome. She responded well to intravenous acyclovir, and the fetus had a viable outcome at the 26th week of gestation. Early diagnosis can prevent progression to fulminant liver failure and the need for a liver transplant.

Facilitators and barriers to colorectal cancer screening in an outpatient setting.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related deaths in the United States. Still, 1 in 3 adults aged 50 years to 75 years have not been screened for CRC. Early detection and management of precancerous or malignant lesions has been shown to improve overall mortality. AIM: To determine the most significant facilitators and barriers to CRC screening in an outpatient clinic in rural North Carolina. The results of this study can then be used for quality improvement to increase the rate of patients ages 50 to 75 who are up to date on CRC screening. METHODS: This retrospective study examined 2428 patients aged 50 years to 75 years in an outpatient clinic. Patients were up to date on CRC screening if they had fecal occult blood test or fecal immunochemical test in the past one year, Cologuard in the past three years, flexible sigmoidoscopy/virtual colonoscopy in the past five years, or colonoscopy in the past ten years. Data on patient socioeconomic status, comorbid conditions, and other determinants of health compliance were included as covariates. RESULTS: Age [odds ratio (OR) = 1.058; P = 0.017], no-show rate percent (OR= 0.962; P < 0.05), patient history of obstructive sleep apnea (OR = 1.875; P = 0.025), compliance with flu vaccinations (OR = 1.673; P < 0.05), compliance with screening mammograms (OR = 2.130; P < 0.05), and compliance with screening pap smears (OR = 2.708; P < 0.05) were important factors in determining whether a patient will receive CRC screening. Race, gender, insurance or employment status, use of blood thinners, family history of CRC, or other comorbid conditions including diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease were not found to have a statistically significant effect on patient adherence to CRC screening. CONCLUSION: Patient age, history of sleep apnea, and compliance with other health maintenance tests were significant facilitators to CRC screening, while no-show rate percent was a significant barrier in our patient population. This study will be of benefit to physicians in addressing and improving the CRC screening rates in our community.