Transarterial chemoembolization in combination with percutaneous ablation therapy in unresectable hepatocellular carcinoma: a meta‐analysis

Background: Recent evidence suggests that transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or a percutaneous ethanol injection (PEI) may have a synergistic effect in treating hepatocellular carcinoma (HCC). The aim of the current meta‐analysis was to identify the survival benefits of TACE combined with percutaneous ablation (PA) therapy (RFA or PEI) for unresectable HCC compared with those of TACE or PA alone. Methods: Randomized‐controlled trials (RCTs) published as full papers or abstracts were searched to assess the survival benefit or tumour recurrence for patients with unresectable HCC on electronic databases. The primary outcome was survival. The secondary outcomes were response to therapy and tumour recurrence. Results: Ten RCTs met the criteria to perform a meta‐analysis including 595 participants. TACE combined with PA therapy, respectively improved, 1‐, 2‐, and 3‐year overall survival compared with that of monotherapy [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.14–4.57; P=0.020], (OR=4.53, 95% CI 2.62–7.82, P<0.00001) and (OR=3.50, 95% CI 1.75–7.02, P=0.0004). Sensitivity analysis demonstrated a significant benefit in 1‐, 2‐ and 3‐year overall survival of TACE plus PEI compared with that of TACE alone for patients with large HCC lesions, but not in TACE plus RFA vs RFA for patients with small HCCs. The pooled result of five RCTs showed that combination therapy decreased tumour recurrence compared with that of monotherapy (OR=0.45, 95% CI 0.26–0.78, P=0.004). Conclusion: TACE combined with PA therapy especially PEI improved the overall survival status for large HCCs.     

Conventional transarterial chemoembolization vs microsphere embolization in hepatocellular carcinoma: A meta-analysis

AIM:To compare conventional transarterial chemoembolization(c-TACE)with microsphere embolization in hepatocellular carcinoma(HCC).METHODS:We searched Pub Med,Medline,Embase and the Cochrane Library for trials assessing the efficacy and safety of c-TACE in comparison with those of yttrium-90 microsphere or drug-eluting bead embolization from January 2004 to December 2013.Overall survival rate(OSR),tumor response[complete response,partial response(PR),stable disease(SD),progressive disease(PD)],α-fetoprotein(AFP)response,progression rate and complications were compared and analyzed.Pooled ORs with 95%CI were calculated using either the fixed-effects model or random-effects model.All statistical analyses were conducted using the Review Manager(version 5.1.)from the Cochrane collaboration.RESULTS:Thirteen trials were identified,including a total of 1834 patients;1233 were treated with c-TACE,377 underwent yttrium-90 microsphere embolization and 224 underwent drug-eluting bead embolization.The meta-analysis with either the random-effects model or fixed-effects model indicated that microsphere embolization was associated with significantly higher OSRs compared with those of c-TACE(OR1-year=1.38,95%CI1-year:1.05-1.82;OR2-year=2.88,95%CI2-year:1.18-7.05;OR3-year=2.15,95%CI3-year:1.18-3.91).The complete tumor response rates of patients who underwent microspheres embolization were significantly higher than those of patients treated with c-TACE(OR=2.19,95%CI:1.31-3.64).The tumor progression rate after microsphere embolization was markedly lower than that after c-TACE(OR=0.56,95%CI:0.39-0.81).There was no significant difference between microsphere embolization and c-TACE in PR(OR=0.73,95%CI:0.47-1.15),SD(OR=1.07,95%CI:0.79-1.44),PD(OR=0.75,95%CI:0.33-1.68),AFP response(OR=1.38,95%CI:0.64-2.94)and complications(OR=0.68,95%CI:0.46-1.00).CONCLUSION:Our analysis indicated that microsphere embolization was associated with superior survival and treatment response in comparison with c-TACE in the treatment of patients with HCC.     

Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma

This randomized, controlled trial assessed the efficacy of transarterial Lipiodol (Lipiodol Ultrafluide, Laboratoire Guerbet, Aulnay-Sous-Bois, France) chemoembolization in patients with unresectable hepatocellular carcinoma. From March 1996 to October 1997, 80 out of 279 Asian patients with newly diagnosed unresectable hepatocellular carcinoma fulfilled the entry criteria and randomly were assigned to treatment with chemoembolization using a variable dose of an emulsion of cisplatin in Lipiodol and gelatin-sponge particles injected through the hepatic artery (chemoembolization group, 40 patients) or symptomatic treatment (control group, 40 patients). One patient assigned to the control group secondarily was excluded because of unrecognized systemic metastasis. Chemoembolization was repeated every 2 to 3 months unless there was evidence of contraindications or progressive disease. Survival was the main end point. The chemoembolization group received a total of 192 courses of chemoembolization with a median of 4.5 (range, 1-15) courses per patient. Chemoembolization resulted in a marked tumor response, and the actuarial survival was significantly better in the chemoembolization group (1 year, 57%; 2 years, 31%; 3 years, 26%) than in the control group (1 year, 32%; 2 years, 11%; 3 years, 3%; P =.002). When adjustments for baseline variables that were prognostic on univariate analysis were made with a multivariate Cox model, the survival benefit of chemoembolization remained significant (relative risk of death, 0.49; 95% CI, 0.29-0.81; P =.006). Although death from liver failure was more frequent in patients who received chemoembolization, the liver functions of the survivors were not significantly different. In conclusion, in Asian patients with unresectable hepatocellular carcinoma, transarterial Lipiodol chemoembolization significantly improves survival and is an effective form of treatment.     

Combination therapy with transarterial chemoembolization and interferon-α compared with transarterial chemoembolization alone for hepatitis B virus related unresectable hepatocellular carcinoma

Background and Aims:  The present study was carried out to test the hypothesis that interferon-α (IFN-α) treatment would reduce or postpone the recurrence rate and improve the overall survival rate in patients after transarterial chemoembolization (TACE) treatment of hepatitis B virus (HBV) related unresectable hepatocellular carcinoma (HCC).
Methods:  216 patients with unresectable HBV-related HCC were randomized into a TACE group and a TACE-IFN group, each group had 108 patients. In the TACE-IFN group, patients received IFN-α1b at a dose of 3 million units (mu) three times a week by intramuscular injection one week after/before TACE treatment, for 48 weeks.
Results:  The median disease-free survival in the TACE-IFN treatment group was 23.6 months (95% CI: 21.4–25.8) and 20.3 months (95% CI: 15.8–24.8) in the TACE group ( P  = 0.027). The disease free rate at 24 months in the TACE group was lower than in the TACE-IFN group (39.8% vs 59.3%, P  = 0.004). The median overall survival was 29 months (95% CI: 27.5–32.1) in the TACE-IFN group and 26 months (95% CI: 20.1–31.9) in the TACE group ( P  = 0.003). The 2-year overall survival in the TACE-IFN group was higher than in the TACE group (72.2% vs 52.8%, P  = 0.003).
Conclusions:  IFN-α treatment reduced recurrence and improved the survival of patients after TACE treatment of HBV-related HCC, with acceptable toxicities.     

Valacyclovir provides optimum acyclovir exposure for prevention of cytomegalovirus and related outcomes after organ transplantation

A meta-analysis of 12 randomized trials (1574 patients) examined herpesvirus and related outcomes following organ transplantation over a range of acyclovir exposures (including valacyclovir). Overall, cytomegalovirus (CMV) infection (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.34-0.57; P<.001), CMV disease (OR, 0.41; 95% CI, 0.31-0.54; P<.001), death (OR, 0.60; 95% CI, 0.40-0.90; P=.01), opportunistic infection (OR, 0.70; 95% CI, 0.53-0.91; P=.009), acute graft rejection (OR, 0.67; 95% CI, 0.52-0.86; P<.001), herpes simplex virus disease (OR, 0.17; 95% CI, 0.12-0.24; P<.001), and varicella-zoster virus disease (OR, 0.06; 95% CI, 0.01-0.25; P<.001) were significantly reduced. Increased acyclovir exposure influenced more end points: Maximum efficacy resulted from valacyclovir (8 g/day). Increasing acyclovir exposure to that achieved with valacyclovir extends benefits of prophylaxis to include impact on graft rejection and opportunistic infections.     

射频消融治疗早期肝癌的荟萃分析

目的 根据现有的临床研究资料评价射频消融(RFA)治疗早期肝癌的疗效与安全性.方法 检索Cochrane图书馆、EMBASE、PubMed、OVID等数据库和中国期刊网中的随机对照试验(RCT)文献,将Jadad评分≥3分的高质量论文纳入研究,并提取纳入研究的特征信息.采用STATA9.0软件进行数据分析,首先进行异质性检验,根据异质性检验结果选择相应的效应模型.然后进行敏感性分析,并以漏斗图和Egger回归方程评定有无发表偏倚.结果 共6篇RCT文献纳入本研究,共包含862例早期肝癌患者.研究表明与其他治疗方法相比,RFA治疗可明显增加早期肝癌患者的3年生存率,并减少了肝内局部复发率,OR值分别为2.06(95%CI为1.54～2.77,P=0.000)和0.40(95%CI为0.28～0.57,P=0.000);而在肝内转移、远处转移、严重副作用等方面差异无统计学意义.漏斗图基本呈现下宽上窄左右对称的图形,Egger线性回归显示3年生存率、肝内局部复发率、肝内转移、远处转移、严重副作用等方面的P值分别为0.670、0.160、0.884、0.087、0.317,提示无发表偏倚.结论 早期肝癌经RFA治疗可获得优于其他疗法的局部疗效和3年生存率.RFA具有微创、简便和经济的优点,有可能作为早期肝癌的首选治疗手段之一.     

Racial differences in survival of hepatocellular carcinoma in the United States: a population-based study.

BACKGROUND & AIMS: Survival after hepatocellular carcinoma (HCC) diagnosis is generally dismal, but there are patients with more favorable outcomes. Racial variation in survival of patients with HCC could be associated with observed differences in survival; however this has not been previously examined. METHODS: During 1987-2001, HCC patients were identified from 9 Surveillance, Epidemiology, and End-Results registries. One- and 3-year survival rates were calculated and compared by race. Models were constructed to examine the effects of race on the mortality risk. RESULTS: Asians had the highest 1- and 3-year observed and relative survival, followed by whites, Hispanics, and blacks. Compared with whites, Asians (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.11-1.69) were more likely to receive local or surgical therapy, whereas blacks (OR, 0.62; 95% CI, 0.49-0.78) and Hispanics (OR, 0.81; 95% CI, 0.60-1.09) were less likely to receive therapy. Adjusting for differences in receipt of therapy, stage of HCC, year of diagnosis, and other demographics, Asians (hazard rate [HR], 0.84; 95% CI, 0.78-0.91) maintained a lower mortality risk compared with whites. In adjusted models, Hispanics (HR, 1.13; 95% CI, 1.03-1.24) maintained a higher mortality risk, whereas the mortality risk for blacks became nonsignificant different from whites (HR, 1.06; 95% CI, 0.99-1.14). Last, a 22% improvement in survival was observed between 1987-1991 and 1997-2001, which was mostly explained by increased receipt of local or surgical therapy. CONCLUSIONS: We observed significant racial variation in survival. These variations in survival are partly explained by a lower likelihood of receipt of therapy and more advanced HCC at diagnosis among blacks and Hispanics.     

Delay in surgical treatment of patients with hilar cholangiocarcinoma: does time impact outcomes?

BackgroundSubstantial time elapses before patients with hilar cholangiocarcinoma (HCC) receive surgical treatment because of time-consuming preoperative staging and other interventions, including biliary drainage and portal vein embolization. Prolonged times potentially lead to unresectability and the formation of metastases, yet these issues have not been investigated previously in HCC. This study aimed to evaluate the time between onset of symptoms and the provision of ultimate treatment in patients with HCC and the impact of the length of time on outcomes.MethodsDelays in the treatment of consecutive patients with HCC were evaluated by contacting general practitioners (GPs) and extracting data from hospital files. Time periods were correlated with resectability, occurrence of metastasis, tumour stage and survival using logistic and Cox regression analyses.ResultsTreatment times in 209 consecutive HCC patients were evaluated. The median time from first GP visit until presentation at the tertiary centre was 35 days. Time until treatment was longer when initial symptoms did not include jaundice (non-specific symptoms, P < 0.001). Duration of workup and preoperative biliary drainage at the tertiary centre prior to final surgical treatment resulted in an additional median time of 74 days. No correlation was found between treatment time in weeks and resectability [odds ratio (OR) 1.010, 95% confidence interval (CI) 0.985–1.036], metastasis (OR = 0.947, 95% CI 0.897–1.000), tumour stage (OR = 1.006, 95% CI 0.981–1.031) or survival in resected patients (hazard ratio = 0.996, 95% CI 0.975–1.018).ConclusionsThe time that elapses between the presentation of symptoms and final treatment in patients with HCC is substantial, especially in patients with non-specific symptoms. This time, however, does not affect resectability, metastasis, tumour stage or survival, which suggests that preoperative optimization should not be omitted because of potential delays in treatment.     

Community-acquired pneumonia due to gram-negative bacteria and pseudomonas aeruginosa: incidence,risk, and prognosis

BACKGROUND: Initial empirical antimicrobial treatment of patients with community-acquired pneumonia (CAP) is based on expected microbial patterns. We determined the incidence of, prognosis of, and risk factors for CAP due to gram-negative bacteria (GNB), including Pseudomonas aeruginosa. METHODS: Consecutive patients with CAP hospitalized in our 1000-bed tertiary care university teaching hospital were studied prospectively. Independent risk factors for CAP due to GNB and for death were identified by means of stepwise logistic regression analysis. RESULTS: From January 1, 1997, until December 31, 1998, 559 hospitalized patients with CAP were included. Sixty patients (11%) had CAP due to GNB, including P aeruginosa in 39 (65%). Probable aspiration (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.02-5.2; P =.04), previous hospital admission (OR, 3.5; 95% CI, 1.7-7.1; P<.001), previous antimicrobial treatment (OR, 1.9; 95% CI, 1.01-3.7; P =.049), and the presence of pulmonary comorbidity (OR, 2.8; 95% CI, 1.5-5.5; P =.02) were independent predictors of GNB. In a subgroup analysis of P aeruginosa pneumonia, pulmonary comorbidity (OR, 5.8; 95% CI, 2.2-15.3; P<.001) and previous hospital admission (OR, 3.8; 95% CI, 1.8-8.3; P =.02) were predictive. Infection with GNB was independently associated with death (relative risk, 3.4; 95% CI, 1.6-7.4; P =.002). CONCLUSIONS: In our setting, in every tenth patient with CAP, an etiology due to GNB has to be considered. Patients with probable aspiration, previous hospitalization or antimicrobial treatment, and pulmonary comorbidity are especially prone to GNB. These pathogens are also an independent risk factor for death in patients with CAP.     

Overexpression of Yes‐associated protein and its association with clinicopathological features of hepatocellular carcinoma: A meta‐analysis

Background

Yes‐associated protein (YAP) overexpression is reported to be associated with risk of hepatocellular carcinoma (HCC) but current studies have not explored the relationship between YAP expression with HCC clinicopathological features.

Methods

To assess these associations, a meta‐analysis was performed which included four eligible studies including 391 HCC cases and 334 controls. There were eight eligible studies to investigate the association between YAP expression in HCC and clinicopathological features of liver cancer patients. Literature was obtained from PubMed, Embase, Wangfang and China National Knowledge Infrastructure.

Results

Analysis indicated that YAP expression in HCC was greater than in adjacent non‐tumour tissue (odds ratio [OR], 15.80, 95% confidence interval [CI], 10.53‐23.70, P<.00001; heterogeneity=.30). YAP overexpression in HCC was significantly associated with vascular invasion (OR, 2.21, 95% CI, 11.64‐2.97, P<.00001, heterogeneity=.10), less cellular differentiation (OR, 2.38, 95% CI, 1.61‐3.51, P<.00001, heterogeneity=.333), tumours larger than 5 cm (OR, 2.52, 95% CI, 1.75‐3.62, P<.00001; heterogeneity=.17) and TNM tumour stage I + II (OR, 0.44, 95% CI, 0.28‐0.75, P=.00003, heterogeneity=.12).

Conclusions

Overexpression of YAP contributes to HCC formation, and its overexpression is associated with vascular invasion, low cellular differentiation tumours larger than 5 cm and TNM tumour stage III + IV.     

Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis.

Endoscopic treatment (ET) is frequently used to prevent variceal rebleeding but this still occurs in about 50% of patients. Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been compared with ET in several trials. Using a meta-analysis, we evaluated randomized trials comparing TIPS to ET assessing prevention of rebleeding, survival, and the effects on resource use and the quality of patients' lives. Medical databases were searched between January 1988 and January 1999 as well as published citations and conference proceedings. Sensitivity analyses for type of publication, methodological quality score, mean duration of follow-up, type of ET, etiology, and severity of liver disease were performed. Eleven randomized trials involving 811 patients fulfilled the selection criteria. The median follow-up ranged from 10 to 32 months. Variceal rebleeding was significantly more frequent with ET (47%) compared with TIPS (19%) (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.8-5.2; P <.001), but there was no difference in mortality (OR, 0.97; 95% CI, 0.71-1.34). Post-treatment encephalopathy occurred significantly less often after ET (19%) than after TIPS (34%) (OR, 0.43; 95% CI, 0.30-0.60; P <.001). In the studies showing resource use this was more extensive for TIPS. The sensitivity analyses did not alter the main conclusion, and sole comparison with endoscopic ligation did not alter these results. In conclusion, in patients with variceal bleeding, TIPS compared with ET reduces the rebleeding rate, but does not improve survival, and increases the incidence of encephalopathy in a period of 1 to 2.5 years. Thus, TIPS cannot be recommended as the first choice treatment for prevention of variceal rebleeding.     

The addition of camrelizumab is effective and safe among unresectable hepatocellular carcinoma patients who progress after drug-eluting bead transarterial chemoembolization plus apatinib therapy

ObjectiveCamrelizumab synergizes with apatinib or transarterial chemoembolization via tumor immunity and chemosensitivity. This study aimed to investigate the efficacy and safety of camrelizumab plus apatinib with or without drug-eluting bead transarterial chemoembolization (DEB-TACE) in unresectable hepatocellular carcinoma (HCC) patients after progression to DEB-TACE plus apatinib.MethodsEighty-nine unresectable HCC patients accepted previous DEB-TACE plus apatinib therapy, then further received second-line camrelizumab plus apatinib with or without DEB-TACE treatment. Treatment responses were calculated at 3 months (M3) and 6 months (M6). Survival and treatment-related adverse events were documented.ResultsObjective response rate and disease control rate were 39.3% and 80.9% at M3; meanwhile, they were 22.4% and 54.1% at M6. Furthermore, the median progression-free survival (PFS) (95% confidence interval (CI)) was 7.0 (6.2-7.8) months with a 1-year PFS rate of 18.4%; the median overall survival (OS) (95% CI) was 17.0 (15.3-18.7) months with a 1-year OS rate of 73.9%. Multivariable Cox's proportional hazards regression analysis presented that 3-4 times (vs. 0 time) of DEB-TACE, apatinib dose duration> 4 months, and camrelizumab dose duration> 5 months independently predicted longer PFS (all P<0.05); meanwhile, declined ECOG PS score, new lesions as progression pattern, 1-2 and 3-4 times (vs. 0 time) of DEB-TACE, apatinib dose duration> 4 months independently predicted prolonged OS (all P<0.05). Moreover, treatment-related adverse events mainly included grade 1-2 fever, gastrointestinal reaction, fatigue, hand-foot skin reaction, and hypertension.ConclusionAfter progression to DEB-TACE plus apatinib treatment, the addition of camrelizumab is effective and safe among unresectable HCC patients.     

The impact of the use of statins on the prevalence of dementia and the progression of cognitive impairment

BACKGROUND: Previous evidence suggests that treatment with 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitors (statins) has a positive impact on dementia. We decided to investigate the association between the use of statins and the prevalence of dementia and statins' impact on the progression of cognitive impairment. METHODS: This is a case-control and a retrospective cohort study of a community-based ambulatory primary care geriatric practice. We included a convenience sample of all patients (N = 655, mean age 78.7 +/- 0.3 years, 85% Caucasian, 74% women) with hypercholesterolemia or dementia, or using statins. We compared those using statins with those who do not with respect to the clinical diagnosis of dementia and its subtypes and the progression of cognitive impairment. RESULTS: At the initial visit, 35% had dementia, and 17% were using statins. After covariate adjustments, patients on statins were less likely to have dementia (odds ratio [OR] for dementia based on composite definition = 0.23; 95% confidence interval [CI] [0.1-0.56], p =.001, OR Alzheimer's disease = 0.37; 95% CI [0.19-0.74], p =.005, OR vascular dementia = 0.25; 95% CI [0.08-0.85], p =.027). At follow-up, patients on statins showed an improvement on their Mini-Mental Status Examination score by 0.7 +/- 0.4 compared to a decline by 0.5 +/- 0.3 in controls, p =.025 (OR for no change or improvement on statins = 2.81; 95% CI [1.02-8.43], p =.045) and scored higher on the Clock Drawing Test (difference of 1.5 +/- 0.1, p =.036). CONCLUSIONS: The use of statins is associated with a lower prevalence of dementia and has a positive impact on the progression of cognitive impairment.     

Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality.

Forty-two consecutive patients with leptospirosis and acute lung injury who were mechanically ventilated were analyzed in a prospective cohort study. Nineteen patients (45%) survived, and 23 (55%) died. Multivariate analysis revealed that 3 variables were independently associated with mortality: hemodynamic disturbance (odds ratio [OR], 6.0; 95% confidence interval [CI], 0.9-38.8; P=. 047), serum creatinine level >265.2 micromol/L (OR, 10.6; 95% CI, 0. 9-123.7; P =.026), and serum potassium level >4.0 mmol/L (OR, 19.9; 95% CI, 1.2-342.8; P=.009). These observations can be used to identify factors associated with mortality early in the course of severe respiratory failure in leptospirosis.     

Transarterial chemoembolization combined with percutaneous radiofrequency ablation versus TACE and PRFA monotherapy in the treatment for hepatocellular carcinoma: a meta-analysis

Purpose

This meta-analysis was designed to compare the effectiveness of the combination of transarterial chemoembolization (TACE) and percutaneous radiofrequency ablation (PRFA) with that of TACE and PRFA monotherapy in hepatocellular carcinoma (HCC).

Methods

Randomized controlled trials were searched using various databases, and six studies were revealed on comparing TACE plus PRFA with TACE and/or PRFA alone for the treatment for HCC. Overall survival rate and recurrence-free survival rate were analyzed and compared. All statistic analyses were conducted using Review Manager (version 4.2.2.) from the Cochrane collaboration.

Results

Meta-analysis data revealed that TACE plus PRFA had significantly better effectiveness on 1- and 3-year overall survival rate(odds ratio [OR] 1-year = 4.61, 95 % confidence interval [95 % CI] 2.26–9.42, P < 0.0001; OR 3-year = 2.79, 95 % CI 1.69–4.61, P < 0.0001) and 3-year recurrence-free survival rate ([OR] 3-year = 3.00, [95 % CI] 1.75–5.13, P < 0.0001) than that of TACE and/or PRFA alone treatment. There was no significant difference between the combined therapy and monotherapy on 1-year recurrence-free survival rate ([OR] 1-year = 1.55, [95 % CI] 0.91–2.65, P = 0.11).

Conclusions

The data of our study indicate that the combination of TACE and PRFA has better effectiveness than that of TACE and PRFA monotherapy in the treatment for patients with HCC.     

Further evidence for an association between non-insulin-dependent diabetes mellitus and chronic hepatitis C virus infection.

Non-insulin-dependent diabetes mellitus (NIDDM) may be associated with chronic hepatitis C virus (HCV) infection. This was studied further in two parts. First, 1,151 patients with HCV-related cirrhosis and 181 patients with hepatitis B virus (HBV)-related cirrhosis, well matched for age, sex, and severity of cirrhosis, were reviewed retrospectively. The prevalence of diabetes mellitus was higher in HCV-related cirrhosis (23.6%) than in HBV-related cirrhosis (9.4%; odds ratio [OR], 2.78; 95% confidence interval [CI], 1.6-4.79; P =.0002). The prevalence of diabetes mellitus was associated closely with the Child-Pugh score (OR, 3.83; 95% CI, 2. 38-6.17; P <.0001) and increasing age (OR, 1.02; 95% CI, 1.00-1.03; P =.0117). Second, 235 patients with biopsy confirmed chronic HBV or HCV underwent an oral glucose tolerance test. Only 1 of 70 patients with chronic viral hepatitis without cirrhosis was diabetic. However, 31 of 127 patients with HCV-related cirrhosis (24.4%) were diabetic compared with 3 of 38 patients with HBV-related cirrhosis (7.9%, P =.0477). The major variables associated with NIDDM were cirrhosis (OR, 14.39; 95% CI, 1.91-108; P =.0096) and male sex (OR, 4.64; 95% CI, 1. 32-16.18; P =.0161). Fasting insulin levels in 30 patients with HCV-related cirrhosis and diabetes mellitus were elevated significantly, which was consistent with insulin resistance. However, acute insulin responsiveness was reduced in all patients with HCV infection and diabetes suggesting concomitant B-cell dysfunction. This study confirms an association between HCV and NIDDM.     

Habitual betel quid chewing and risk for hepatocellular carcinoma complicating cirrhosis

This case-control study aimed to assess the independent and interactive role of habitual betel quid chewing and known risk factors for hepatocellular carcinoma (HCC). Subjects enrolled included 210 pairs of sex- and age-matched cirrhotic patients with HCC, patients with cirrhosis alone, and healthy controls. Information on risk factors was obtained through serologic examination of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti-HCV), and a standardized personal interview with a structured questionnaire. Multivariate analysis indicated that betel quid chewing (odds ratio [OR], 5.81; 95% confidence interval [CI], 2.26-14.94); HBsAg (OR, 37.98; 95% CI, 19.65-73.42); and anti-HCV (OR, 47.23; 95% CI, 18.86-118.25) were independent risk factors for HCC when HCC patients were compared with healthy controls. Using patients with cirrhosis alone as a reference group, multivariate analysis indicated that only betel quid chewing (OR, 1.69; 95% CI, 1.04-2.76) and HBsAg (OR, 1.54; 95% CI, l.01-2.37) were independent risk factors for HCC. There was an additive interaction between betel quid chewing and the presence of either HBsAg (synergy index, 5.22) or anti-HCV (synergy index, 1.35). Moreover, a higher risk of HCC was associated with a longer duration of betel quid chewing and a larger amount of betel quid consumed (each p(for trend) < 0.0001). In conclusion, betel quid chewing is an independent risk factor for cirrhotic HCC. There is an additive interaction between betel quid chewing and chronic hepatitis B and/or hepatitis C virus infection.     

Clinical outcomes in statin treatment trials: a meta-analysis.

OBJECTIVE: To determine the risk of cardiovascular events and death in patients receiving statin treatment for cholesterol regulation. METHODS: Systematic review and meta-analysis of all randomized controlled trials that were published as of April 15, 1997. Primary or secondary prevention trials or regression trials were eligible. MAIN OUTCOME MEASURES: All-cause mortality, fatal myocardial infarction (MI) or stroke, nonfatal MI or stroke, angina, and withdrawal from the studies. Both random- and fixed-effects models were run for the outcomes of interests, and results are expressed as odds ratios (ORs). Sensitivity analyses tested the impact of the study type and duration, statin treatment type, and control arm event rates. Intent-to-treat denominators were used whenever they were available, and the number needed to treat was calculated when appropriate. RESULTS: Seventeen studies (21 303 patients) were included (2 secondary prevention studies, 5 mixed primary-secondary prevention population studies, and 10 regression trials). Treatment groups included lovastatin (t = 5), pravastatin (t = 10), and simvastatin (t = 3). For all-cause mortality, the OR was 0.76 (95% confidence interval [CI], 0.67-0.86) in favor of receiving statin treatment; for fatal MI, the OR was 0.61 (95% CI, 0.48-0.78); for nonfatal MI, the OR was 0.69 (0.54-0.88); for fatal stroke, the OR was 0.77 (95% CI, 0.57-1.04); for nonfatal stroke, the OR was 0.69 (95% CI, 0.54-0.88); and for angina, the OR was 0.70 (95% CI, 0.65-0.76). CONCLUSIONS: Patients who received statin treatment demonstrated a 20% to 30% reduction in death and major cardiovascular events compared with patients who received placebo. This advantage was generally present across study types and statin treatment types and for patients with less severe dyslipidemias. The benefit in clinical outcomes was noticeable as early as 1 year.     

Insurance status impacts treatment for hepatocellular carcinoma

Introduction and aimPrevious studies have identified treatment disparities in the treatment of hepatocellular carcinoma (HCC) based on insurance status and provider. Recent studies have shown more Americans have healthcare insurance; therefore we aim to determine if treatment disparities based on insurance providers continue to exist.Materials and methodsA retrospective database analysis using the NIS was performed between 2010 and 2013 including adult patients with a primary diagnosis of HCC determined by ICD-9 codes. Multivariable logistic regressions were performed to analyze differences in treatment, mortality, features of decompensation, and metastatic disease based on the patient's primary payer.ResultsThis study included 62,368 patients. Medicare represented 44% of the total patients followed by private insurance (27%), Medicaid (19%), and other payers (10%). Patients with Medicare, Medicaid, and other payer were less likely to undergo liver transplantation [(OR 0.63, 95% CI 0.47–0.84), (OR 0.23, 95% CI 0.15–0.33), (OR 0.26, 95% CI 0.15–0.45)] and surgical resection [(OR 0.74, 95% CI 0.63–0.87), (OR 0.40, 95% CI 0.32–0.51), (OR 0.42, 95% CI 0.32–0.54)] than patients with private insurance. Medicaid patients were less likely to undergo ablation then patients with private insurance (OR 0.52, 95% CI 0.40–0.68). Patients with other forms of insurance were less likely to undergo transarterial chemoembolization (TACE) compared to private insurance (OR 0.64, 95% CI 0.43–0.96).ConclusionInsurance status impacts treatment for HCC. Patients with private insurance are more likely to undergo curative therapies of liver transplantation and surgical resection compared to patients with government funded insurance.