Economic evaluation of long-term albumin use in cirrhosis patients from the Mexican healthcare system perspective

Introduction and objectivesLiver cirrhosis is a major public health issue associated with high morbidity and mortality. The ANSWER trial showed that long-term human albumin (LTA) infusions led to significant reduction of complications and mortality in patients with uncomplicated ascites. The present study aimed to assess the incremental cost of cirrhosis patients treated with LTA plus standard medical treatment (SMT) versus those treated with SMT from the perspective of the Mexican Social Security Institute (IMSS).Material and methodsCost of illness for patients with cirrhosis and grade 2-3 ascites treated with SMT or with SMT and LTA (following the treatment regimen from ANSWER) over a one-year period was estimated according to the IMSS perspective. Rates of treatments, complications and hospitalizations were based on results from the ANSWER trial. Unit costs from IMSS were gathered from public sources and transformed to 2020 Mexican $ (Mex$).ResultsThe use of LTA is estimated to require additional annual expenditure derived from the pharmacological cost of human albumin and by the follow up visits required for LTA administration (Mex$28,128). However, this cost may potentially be counterbalanced by the reduction in paracentesis, cirrhosis-related complications and hospitalizations which would lead to cost savings of Mex$33,417 per patient/year.ConclusionsBased on the ANSWER trial results, our study suggests that LTA may result in improved clinical outcomes and reduced costs for the IMSS when administered to cirrhosis patients with uncomplicated ascites.     

误诊为嗜酸粒细胞增多症1例分析

回顾性分析我院收治的1例误诊为嗜酸粒细胞增多症的腹水型嗜酸粒细胞性胃肠炎(EG)患者的临床资料,并复习相关文献,探讨EG的临床特征、误诊原因及防范措施。患者以“腹胀半个月”入院,入院前腹部CT提示腹腔及盆腔积液,入院后查血常规示嗜酸性粒细胞计数及比例异常增多,腹水有核细胞涂片镜检可见大量嗜酸粒细胞。骨髓穿刺提示嗜酸粒细胞增多症;直肠黏膜组织活检镜下见黏膜内散在淋巴细胞、嗜酸粒细胞及中性粒细胞浸润。临床诊断嗜酸粒细胞增多症。患者转上级医院继续诊疗,上级医院修正诊断为腹水型EG。EG发病率低,外周血及骨髓检查类似嗜酸粒细胞增多症,临床医师应注意鉴别;临床对不明原因的腹水患者,应警惕浆膜型EG存在的可能性,以免误诊。     

Approach to persistent ascites after liver transplantation

Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.     

腹水/血清肿瘤标志物对良恶性腹水的鉴别价值

目的:评价同时测定腹水和血清中5种肿瘤标志物AFP,CEA,CA19-9,CA50,CA125水平及其腹水／血清(F／S)比值对良恶性腹水鉴别诊断的价值．方法:对明确诊断的腹水患者105例(良性57 例,恶性48例)同时采血和抽取腹水,采用化学发光法测定AFP和CEA,免疫放射分析法测定 CA19-9,CA50和CA125．结果:腹水中肿瘤标志物的水平高于血清正常上限值(AFP>25 μg／L,CEA>5 μg／L, CA19-9>37 kU／L和CA50>20 mg／L)时,良性腹水的F／S比值都小于1．2,而恶性腹水的绝大多数F／S比值大于1．2．腹水AFP,CEA, CA19-9．CA50的上述上限值结合F／S比值大于1．2,诊断敏感性分别为18．8％,62．5％,58．3％和72．9％,除AFP外,皆显著高于单纯的腹水浓度和F/S比值的敏感性(16．7％,37．5％,29．2％和47．9％)(P<0．01)．四项联合诊断敏感性达 91．7％,特异性100％．结论:与单纯血清或腹水中浓度测定相比,同时测定肿瘤标志物AFP,CEA,CA19-9和CAS0 的腹水浓度和F/S比值能显著提高诊断的敏感性和特异性,对良恶性腹水的鉴别诊断具有较大的价值．     

Association between proton pump inhibitor use and spontaneous bacterial peritonitis in cirrhotic patients with ascites

BACKGROUND:

There are data suggesting a link between proton pump inhibitor (PPI) use and the development of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites; however, these data are controversial.

OBJECTIVE:

To assess whether the use of PPIs in cirrhotic patients with ascites is associated with an increased risk for SBP.

METHODS:

A retrospective case-control study (June 2004 to June 2010) was conducted at the Centre Hospitalier de l’Université de Montréal in Montreal, Quebec. Fifty-one cirrhotic patients admitted with paracentesis-proven SBP (≥250 neutrophils/mm³), occurring within seven days of hospital admission, met the inclusion criteria. These patients were matched 1:2 (for age, Child-Pugh class and year of admission) with 102 comparable cirrhotic patients with ascites who were admitted for conditions other than SBP.

RESULTS:

Patients with SBP had a significantly higher rate of pre-hospital PPI use (60.8%) compared with cirrhotic patients without SBP (42.2%; P=0.03). On multivariate analysis, PPI use was the only factor independently associated with SBP (OR 2.09 [95% CI 1.04 to 4.23]; P=0.04). Thirty-five (35%) patients in both groups had no documented indication for PPI use in their charts. Forty-five percent of the remaining cirrhotic patients with SBP had an inappropriate indication, as defined in the protocol, for PPI use compared with 25% of controls.

CONCLUSIONS:

Cirrhotic patients with SBP were twice as likely to have taken PPIs than patients without SBP. These findings reinforce the association between PPI use and SBP observed in other studies. A high percentage of cirrhotic patients were taking a PPI without any documented indication.     

腹腔热灌注化疗治疗癌性腹水的系统评价

目的：评价腹腔热灌注化疗治疗癌性腹水的疗效及安全性。 方法：计算机检索国内外数据库,同时辅以其他检索,收集所有比较热灌注化疗与常温灌注化疗的随机对照试验。评价员2名按照研究计划书进行文献筛选和资料提取,并对纳入文献进行质量评价后,使用RevMan 5.2软件进行Meta分析。 结果：最终纳入15篇RCT,共998例患者,其中腹腔热灌注化疗506例（热灌注组）,腹腔常温灌注化疗492例（常温灌注组）。Meta分析显示,热灌注组的1年生存率、有效率、完全缓解率、生活质量改善率均优于常温灌注组,差异均有统计学意义（均P<0.05）;热灌注组的恶心呕吐、骨髓抑制以及肝肾功能损害的发生率均低于常温灌注组,但其差异无统计学意义（均P>0.05）;而热灌注组腹痛的发生率明显高于常温灌注组,差异有统计学意义（P<0.05）。 结论：腹腔热灌注化疗治疗癌性腹水安全、有效,并能提高患者的生存,但其长期安全性评价尚需大样本高质量的RCT进一步验证。     

血清CA125检测在肝癌腹水中的诊断价值

目的探讨定量检测血清肿瘤标志物CA125在原发性肝细胞肝癌患者早期腹水中临床意义,评价CA125作为肝癌腹水诊断的实验室指标价值。方法采用回顾性分析研究,对云南省肿瘤医院介入科2013年7月到2014年1月共计111例原发性肝细胞肝癌患者,对照组为我院健康体检者23例,采用全自动化学发光检测血清CA125,并同时采用腹部CT及B超诊断患者腹水。对32例肝癌患者进行2次以上跟踪检测血清CA125。对血清CA125与肝储备功能child-pugh分级进行比较两者的相关性。数据统计处理采用spss17.0版统计分析软件。各组间CA125值差异性比较采用MannWhitney U检验;阳性率用χ2检验比较;各组间CA125值与child分级的相关性用Spearman等级相关性分析。结果肝癌腹水组CA125结果为287.33U/mL,肝癌无腹水组CA125结果 37.15 U/mL,健康对照组为15.96U/mL,各组之间CA125水平比较P〈0.01,提示有显著性差异;肝癌腹水组CA125阳性率为88.6%,肝癌无腹水CA125阳性率37.31%,健康对照组阳性率7.69%,各组之间CA125阳性率比较χ2=49.685,P〈0.01,有显著性差异;32例跟踪检查患者中,无腹水稳定组有12例,CA125为29.56 U/mL;无腹水进展组有15例,CA125为168.35 U/mL;腹水组有5例,CA125结果为187.00U/mL,进展组血清CA125与稳定组比较P〈0.01,差异具有统计学意义,进展组与腹水组比较P〈0.05,差异具有统计学意义;CA125与child-pugh-分级相关性研究,其中child-A有83例,CA125结果为57.17 U/mL;child-B有18例,CA125结果为268.14 U/mL;child-C有10例,CA125为581.05 U/mL,血清CA125与child-pugh分级的相关性系数r=0.665,P〈0.01,提示2者之间有显著性相关。结论血清CA125可作为诊断肝癌并发腹水的实验室检查方法;血清CA125与child-pugh分级密切相关。     

正交试验法优化胸腹腔积液细胞学检查条件

目的优选胸腹腔积液细胞学检查的条件。方法在单因素试验结果的分析基础上，考察送检标本量、送检次数、原发部位是否确诊对胸腹腔积液细胞学检查阳性检出率的影响。结果最佳检查条件为在有临床诊断依据的情况下，送检40ml，送检4次。结论胸腹腔积液细胞学检查的优化结果满意、确实可行。     

腹腔置管腹水引流联合腹腔内灌注化疗治疗恶性腹水（附10例报告）

目的分析腹腔置管腹水引流联合腹腔内灌注化疗治疗恶性腹水的疗效。方法采用14G深静脉导管腹腔置入，腹水引流后，腹腔内灌注地塞米松10mg、顺铂60mg。结果患者近期自觉症状均得到改善。结论对于晚期癌症合并大量腹水患者，腹腔置管引流、腔内灌注化疗，能够减轻患者痛苦，提高生活质量，延长存活期。     

血清CA125检测在腹水性质分析中的诊断价值

目的 探讨血清CA125检测在腹水性质分析中的诊断价值.方法 对14例结核性腹膜炎、10例自发性细菌性腹膜炎、29例肝硬化腹水和44例腹膜转移癌患者血清CA125进行检测,并对59例不伴有腹水的腹腔脏器恶性肿瘤患者和20例健康人进行对照.结果 腹水患者血清CA125明显高于正常对照组(P＜0.01);不同性质腹水患者之间血清CA125无明显差异(P＞0.05);不伴有腹水的腹腔脏器恶性肿瘤(包括卵巢癌)患者血清CA125与正常对照组无明显差异(P＞0.05);卵巢癌伴腹膜转移者血清CA125高于其他腹膜转移癌(P＜0.05).结论 血清CA125检测,对腹水性质无鉴别诊断价值.血清CA125不是卵巢癌特异性标志物,但可作为卵巢癌腹膜转移的标志.