Limited Fibrosis Progression but Significant Mortality in Patients Ineligible for Interferon-Based Hepatitis C Therapy.

BACKGROUND: Individuals ineligible for interferon-based hepatitis C therapy may have a worse prognosis than patients who have failed or not received treatment. AIMS: To provide information about the limitations of medical treatment of hepatitis C in real-world patients. METHODS: We studied 969 treatment-ineligible patients and 403 treated patients enrolled between 1/1/01 and 6/30/06; data were collected until 3/31/13. Treatment barriers were grouped into five categories and classified as health-related or health-unrelated. Fibrosis stage was assessed initially and at the end of follow-up. Mortality was determined by search of the Social Security database. Death certificates of treatment-ineligible patients were reviewed. RESULTS: Initially, 288 individuals had advanced fibrosis and compensated disease; 87 untreated patients developed advanced fibrosis during follow-up. Health-related treatment barriers were more commonly associated with fibrosis progression and worse survival. During follow-up, 247 untreated patients died: 47% of liver-related and 53% of liver-unrelated causes. Patients with significant comorbid illness had the worst five- (70%) and ten-year (50.5%) survival. Despite high mortality (47%) in persons with decompensated liver disease, no treatment barrier was associated with a greater incidence of liver-related death. Only significant comorbid medical illness was an independent predictor of disease progression; however, it was not associated with a greater incidence of liver-related death. Furthermore, treated patients had better 10-year survival than untreated patients on Kaplan-Meier analysis (80.3% vs. 74.5%, P = 0.005). CONCLUSION: Many patients with hepatitis C will die of non-liver-related causes and may not be helped by anti-viral treatment.

The effect of preoperative vitamin K on the INR in bridging therapy.

We investigated a bridging protocol using oral Vitamin K three days before scheduled surgery. 60 patients in two bridging protocols, 30 cases per protocol. The first cohort (Control group) had its warfarin held on Day-5 (five days before surgery). The intervention cohort (Vitamin K group) routinely received 2.5 mg of oral Vitamin K on Day-3 but was otherwise identically bridged. Primary outcome was INR on Day-1. Secondary outcomes included patients with INRs ≥1.5 on Day-1, bleeding episodes and elevated INR post surgery. Day-1 INR for the Vitamin K group was 1.16, vs. 1.28 for the Control group (p = 0.037). Postoperative INR was similar. Only the Control group had patients with INRs ≥1.5 on Day-1, or patients with significant bleeding. Adding Vitamin K on Day-3 leads to a safe preoperative INR and may limit other complications.

Low molecular weight heparin bridging for atrial fibrillation: is VTE thromboprophylaxis the major benefit?

Paucity of data has led to a lack of consensus regarding indications for, and risk-benefit ratio of, low molecular weight heparin 'bridging' for cardioembolic prevention in patients with atrial fibrillation (AF) until their INR levels are in therapeutic range. Using a hospital database, we compared AF patients ≥65 years who were bridged (n = 265) with patients who were not bridged (n = 4532) after hospital discharge. Patients who failed to achieve a therapeutic INR within 30 days were excluded. CHADS2 scores (congestive heart failure, hypertension, age ≥75, diabetes, stroke), bleeding risk and co-morbidity scores were assessed. Unadjusted and adjusted odds ratios for outcome events (death, stroke, hemorrhage and venous thromboembolism (VTE) within 30 days of discharge were compared. Bridged patients, as compared to those not bridged, were younger (74.7 ± 6.6 vs. 78.5 ± 7.7 years), less likely to be white (36 vs. 51%), and less likely to have CHADS2 scores ≥2 (67 vs. 84%), all P < 0.001. There was no significant difference in bleeding risk (bridged vs. not bridged: 1.5 ± 7 vs. 1.7 ± 6). In logistic models adjusting for age, white race, bleeding risk, CHADS2 and Comorbidity scores, bridging was significantly associated with lower mortality and a decreased odds ratio for VTE (both P < 0.01) but not for stroke or hemorrhage (both P > 0.80). Although we found insufficient evidence of either lower stroke or greater bleeding risk with bridging, our data suggest the possibility that LMWH bridging in patients with AF is associated with lower risks of VTE and death within 30 days of discharge.