Retrieval of HCV patients lost to follow-up as a strategy for Hepatitis C Microelimination: results of a Brazilian multicentre study.

BACKGROUND: Several HCV patients in Brazil were lost to follow-up (LTFU) in the last two decades before achievement of sustained virological response (SVR). Strategies to recall those diagnosed but untreated patients have been used elsewhere with different success rates. AIM: To identify and retrieve LTFU patients in order to offer them the treatment with the current highly effective direct acting antiviral agents (DAAs). METHODS: Registries ofall HCV patients from three large reference centers in Brazil were retrospectively reviewed to identify those with no registry of SVR. Reasons for non-achievement of SVR were elicited in HCV-RNA + patients. All patients who were not treated or cured were contacted to offer the therapy with DAAs. RESULTS: 10,289 HCV patients (50% males, mean age 52 ± 11 years) were identified. Only 4,293 (41.7%) had been successfully treated previously. From the remaining 5,996 most were LTFU (59%), were not treated for other reasons (14.7%) or were non-responders (26.3%). After revision of the charts 3,559 were considered eligible to be retrieved. The callback success of phone calls was 18%, 13% to cellphone messages (SMS or WhatsApp) and 7% to regular mail. Five-hundred sixty patients had been already treatedor were on treatment and 234 were reported to be dead or transplanted. Finally, 201 had made an appointment and initiated antiviral treatment. CONCLUSION: Even considering the low callback rate, retrieval of LTFU patients was shown to be an important strategy forhepatitis C micro-elimination in Brazil.

Recreational Anabolic-Androgenic Steroid Use Associated With Liver Injuries Among Brazilian Young Men.

BACKGROUND: The recreational use of anabolic-androgenic steroids (AAS) has reached alarming levels among healthy people. However, several complications have been related to consumption of these drugs, including liver disorders. OBJECTIVE: To evaluate the prevalence of liver injuries in young Brazilian recreational AAS users. METHODS: Between February/2007 and May/2012 asymptomatic bodybuilders who were ≥18 years old and reported AAS use for ≥6 months were enrolled. All had clinical evaluations, abdominal ultrasound (AUS), and blood tests. RESULTS: 182 individuals were included in the study. The median age (interquartile range) was 26.0 years (22.0-30.0) and all were male. Elevated liver enzyme levels were observed in 38.5% (n = 70) of AAS users, and creatine phosphokinase was normal in 27.1% (n = 19) of them. Hepatic steatosis was observed by AUS in 12.1% of the sample. One individual had focal nodular hyperplasia and another had hepatocellular adenoma. One case each of hepatitis B and C virus infection was found. A diagnosis of toxic liver injury was suggested in 23 (12.6%) AAS users without a history of alcohol or other medications/drugs consumption, or evidence of other liver diseases. CONCLUSIONS/IMPORTANCE: Young Brazilian recreational AAS users presented a wide spectrum of liver injuries that included hepatotoxicity, fatty liver, and liver neoplasm. They also presented risk factors for liver diseases such as alcohol consumption and hepatitis B and C virus infection. The results suggest that the risk of AAS use for the liver may be greater than the esthetic benefits, and demonstrate the importance of screening AAS users for liver injuries.

Anabolic-androgenic steroids: a possible new risk factor of toxicant-associated fatty liver disease.

BACKGROUND: Industrial toxin and drugs have been associated with non-alcoholic fatty liver disease (NAFLD); in these cases, the disease has been termed toxicant-associated steatohepatitis (TASH). AIM: This study hypothesizes that the use of anabolic-androgenic steroids (AAS) could also be a risk factor to TASH or better toxicant-associated fatty liver disease (TAFLD) development. METHODOLOGY: Case-control study including 180 non-competitive recreational male bodybuilders from August/2007 to March/2009. Ninety-five had a history of intramuscular AAS use (cases; G1) and 85 were non-users (controls; G2). They underwent a clinical evaluation and abdominal ultrasound, and their blood levels of aminotransferases, creatine phosphokinase (CPK), lipids, glucose and insulin were measured. TAFLD criteria: history of AAS use >2 years; presence of hepatic steatosis on ultrasound and/or aminotransferase alterations with normal CPK levels; exclusion of ethanol intake ≥20 g/day or use of other drugs; and exclusion of obesity, dyslipidaemia, diabetes and other liver diseases. Homeostasis model assessment for insulin resistance ≥3 was considered insulin resistant. Independent t-test, odds ratio (OR) and 95% confidence intervals (95% CI) were calculated. RESULTS: All cases were asymptomatic. Clinical and laboratorial data were similar in G1 and G2 (P>0.05). TAFLD criteria were observed in 12.6% of the G1 cases and 2.4% of controls had criteria compliant with non-alcoholic fatty liver related to metabolic conditions. OR was 6.0 (95% CI: 1.3-27.6). CONCLUSIONS: These results suggest that AAS could be a possible new risk factor for TAFLD. In this type of fatty liver disease, the individuals had a low body fat mass and they did not present insulin resistance.

Nonalcoholic fatty liver disease in severely obese individuals: the influence of bariatric surgery.

BACKGROUND: Obesity is the most frequent risk factor associated with NAFLD, and bariatric surgery (BAS) is traditionally indicated for the treatment of severely obese individuals. Here, we discuss the behavior and prognosis of this liver disease following post-surgical weight loss. AIM: To evaluate the influence of the BAS on the clinical and biochemical parameters of NAFLD in severely obese patients. METHODOLOGY: An intervention study included obese individuals (BMI > or = 35kg/m2), who had been submitted to liver biopsy during BAS and had NAFLD. HAIR (hypertension, ALT and insulin resistance and BAAT (BMI, ALT, age and triglycerides) scores and FLI (Fatty Liver Index) were used to compare the patients at the time of surgery, and 12-30 months following weight loss. RESULTS: From October 2004 to September 2007, 122 patients were diagnosed with NAFLD, 40 of whom agreed to participate in the study. The mean age was 37.7 +/- 12.5 years, 60% were women and 80% had steatohepatitis (NASH) with fibrosis upon analysis of the liver biopsy performed during BAS. Mean weight loss was 46.0 +/- 2.0 kg. After 21 +/- 5.8 months of follow-up, a significant improvement was found in all the variables analyzed (79.3% according to the HAIR scores, 95.2% as measured by the BAAT score and 72.5% by the FLI. CONCLUSION: The results suggest that treatment of obesity by bariatric surgery may influence the prognosis of NAFLD. In addition to weight loss, we observed improvement in the clinical and biochemical parameters related to NAFLD, such as anthropometrics index, hypertension, aminotransferases, triglycerides and insulin resistance.

Nonalcoholic steatohepatitis in posttransplantation liver: Review article.

INTRODUCTION: Nonalcoholic steatohepatitis (NASH) associated or not with cirrhosis is the third leading indication for liver transplantation (LT) around the world. After transplants, NASH has a high prevalence and occurs as both recurrent and de novo manifestations. De novo NASH can also occur in allografts of patients transplanted for non-NASH liver disease. OBJECTIVE: To evaluate recurrent or de novo NASH in post-LT patients. METHOD: A literature review was performed using search engines of indexed scientific material, including Medline (by PubMed), Scielo and Lilacs, to identify articles published in Portuguese and English until August 2016. Eligible studies included: place and year of publication, prevalence, clinical characteristics, risk factors and survival. RESULTS: A total of 110 articles were identified and 63 were selected. Most of the studies evaluated recurrence and survival after LT. Survival reached 90-100% in 1 year and 52-100% in 5 years. Recurrence of NAFLD (steatosis) was described in 15-100% and NASH, in 4-71%. NAFLD and de novo NASH were observed in 18-67% and 3-17%, respectively. Metabolic syndrome, diabetes mellitus, dyslipidemia and hypertension were seen in 45-58%, 18-59%, 25-66% and 52-82%, respectively. CONCLUSION: After liver transplants, patients present a high prevalence of recurrent and de novo NASH. They also show a high frequence of metabolic disorders. Nevertheless, these alterations seem not to influence patient survival.

Intensive care management of patients with liver disease: proceedings of a single-topic conference sponsored by the Brazilian Society of Hepatology.

Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.

Nonalcoholic steatohepatitis in posttransplantation liver: Review article / Esteato-hepatite não alcoólica no pós-transplante de fígado: artigo de revisão

Summary Introduction: Nonalcoholic steatohepatitis (NASH) associated or not with cirrhosis is the third leading indication for liver transplantation (LT) around the world. After transplants, NASH has a high prevalence and occurs as both recurrent and de novo manifestations. De novo NASH can also occur in allografts of patients transplanted for non-NASH liver disease. Objective: To evaluate recurrent or de novo NASH in post-LT patients. Method: A literature review was performed using search engines of indexed scientific material, including Medline (by PubMed), Scielo and Lilacs, to identify articles published in Portuguese and English until August 2016. Eligible studies included: place and year of publication, prevalence, clinical characteristics, risk factors and survival. Results: A total of 110 articles were identified and 63 were selected. Most of the studies evaluated recurrence and survival after LT. Survival reached 90-100% in 1 year and 52-100% in 5 years. Recurrence of NAFLD (steatosis) was described in 15-100% and NASH, in 4-71%. NAFLD and de novo NASH were observed in 18-67% and 3-17%, respectively. Metabolic syndrome, diabetes mellitus, dyslipidemia and hypertension were seen in 45-58%, 18-59%, 25-66% and 52-82%, respectively. Conclusion: After liver transplants, patients present a high prevalence of recurrent and de novo NASH. They also show a high frequence of metabolic disorders. Nevertheless, these alterations seem not to influence patient survival.

Resumo Introdução: A doença hepática gordurosa não alcoólica (DHGNA) é a terceira causa de transplante hepático no mundo. Tem elevada prevalência após transplante hepático (TH) e é representada pela recorrência da esteato-hepatite (NASH), ou por NASH de novo, que ocorre em pacientes transplantados por outra etiologia. Objetivo: Realizar uma revisão da literatura para avaliar a relevância da recorrência ou do NASH de novo em pacientes transplantados de fígado. Método: Realizada revisão da literatura através de artigos indexados no Medline, Scielo e Lilacs até 2016 publicados em inglês e português. Foram considerados elegíveis estudos que incluíram local e ano de publicação, prevalência e características clínicas dos pacientes. Resultados: Foram identificados 110 artigos e selecionados 63, que avaliaram a recorrência de NASH, NASH de novo e sobrevida após o TH. A sobrevida foi de 90% a 100% em um ano e de 52-100% em 5 anos. A recorrência de esteatose variou de 15-100% e a de NASH de 4-71%, enquanto esteatose e NASH de novo variaram de 18-67% e 3-17%, respectivamente. A frequência de síndrome metabólica, diabetes, dislipidemia e hipertensão variaram de 45-58%, 18-59%, 25-66% e 52-82%, respectivamente. Conclusão: No pós-transplante de fígado, os pacientes apresentam elevada prevalência de recorrência, de NASH de novo e de distúrbios metabólicos. Entretanto, essas alterações parecem não influenciar a sobrevida dos pacientes.

[Risk factors for maternal mortality in an urban area of Northeast Brazil]. / Fatores de risco para mortalidade materna em área urbana do Nordeste do Brasil.

A case-control study was conducted to investigate risk factors for maternal mortality in Recife, Pernambuco State, Brazil, in 2001-2005. Cases were 75 maternal obstetric deaths in Recife, identified from the Mortality Information System, investigated and analyzed by an expert committee on maternal mortality. Controls, selected from the Information System on Live Births using systematic sampling, were 300 women living in Recife whose last pregnancy occurred during the same period and ended in live births. Increased risk of maternal death was associated with use of the public health system (OR = 4.47; 95%CI: 1.87-10.29), age > 35 years (OR = 3.06; 95%CI: 1.59-5.92), < 4 years of schooling (OR = 4.95; 95%CI: 2.43-10.08), cesarean section (OR = 3.06; 95%CI: 1.77-5.29), and lack of prenatal care or fewer than four prenatal visits (OR = 9.78; 95%CI: 5.52-17.34). The results confirm social inequalities in maternal mortality in Recife and indicate the need to improve healthcare for women during the prenatal period, delivery, and postpartum.

Intensive care management of patients with liver disease: proceedings of a single-topic conference sponsored by the Brazilian Society of Hepatology

ABSTRACT Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.

RESUMO A sobrevida de pacientes cirróticos críticos aumentou significantemente nos últimos anos devido a inúmeros avanços obtidos no manejo do paciente com cirrose descompensada e com insuficiência hepática aguda grave, particularmente após a incorporação na prática clínica de uma série de estratégias baseadas em evidencias com impacto reconhecido na redução de mortalidade. Com o intuito de discutir as principais evidencias disponíveis na literatura médica sobre o assunto, a Sociedade Brasileira de Hepatologia, em conjunto com a Associação de Medicina Intensiva Brasileira e a Associação Brasileira de Transplantes de Órgãos promoveu uma reunião monotemática sobre o manejo do paciente hepatopata crítico, que ocorreu em 21 de maio de 2014 na cidade do Rio de Janeiro. O relatório da reunião foi resumido no presente manuscrito com o objetivo de nortear a prática clínica de intensivistas, gastroenterologistas e hepatologistas no manejo do paciente hepatopata em ambiente de terapia intensiva.

Fatores de risco para mortalidade materna em área urbana do Nordeste do Brasil / Risk factors for maternal mortality in an urban area of Northeast Brazil

Este estudo de caso-controle analisou fatores de risco para mortalidade materna no Recife, Pernambuco, Brasil, no período de 2001-2005. Os casos foram 75 óbitos maternos obstétricos, identificados no Sistema de Informações sobre Mortalidade, investigados e analisados pelo Comitê de Mortalidade Materna. Os controles, selecionados no Sistema de Informações sobre Nascidos Vivos, pela amostra sistemática, foram 300 mulheres residentes no Recife cuja última gravidez ocorreu no mesmo período e não resultou em óbito. O risco de morte foi mais elevado para as usuárias do SUS (OR = 4,47; IC95 por cento: 1,87-10,29), com idade > 35 anos (OR = 3,06; IC95 por cento: 1,59-5,92), < 4 anos de estudo (OR = 4,95; IC95 por cento: 2,43-10,08), que tiveram parto cesáreo (OR = 3,06; IC95 por cento: 1,77-5,29) e para aquelas que não realizaram pré-natal ou tiveram menos de 4 consultas (OR = 9,78; IC95 por cento: 5,52-17,34). Os resultados reafirmam as desigualdades sociais na determinação de mortalidade materna no Recife. Além disso, indicam a necessidade de aprimorar a assistência à saúde da gestante durante o pré-natal, parto e puerpério.

A case-control study was conducted to investigate risk factors for maternal mortality in Recife, Pernambuco State, Brazil, in 2001-2005. Cases were 75 maternal obstetric deaths in Recife, identified from the Mortality Information System, investigated and analyzed by an expert committee on maternal mortality. Controls, selected from the Information System on Live Births using systematic sampling, were 300 women living in Recife whose last pregnancy occurred during the same period and ended in live births. Increased risk of maternal death was associated with use of the public health system (OR = 4.47; 95 percentCI: 1.87-10.29), age > 35 years (OR = 3.06; 95 percentCI: 1.59-5.92), < 4 years of schooling (OR = 4.95; 95 percentCI: 2.43-10.08), cesarean section (OR = 3.06; 95 percentCI: 1.77-5.29), and lack of prenatal care or fewer than four prenatal visits (OR = 9.78; 95 percentCI: 5.52-17.34). The results confirm social inequalities in maternal mortality in Recife and indicate the need to improve healthcare for women during the prenatal period, delivery, and postpartum.