ABSTRACT BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

ABSTRACT Objective: To evaluate the degree of satisfaction and the socioeconomic profile of patients attending Gastroenterology Outpatient Clinics at a University institution linked to the Brazilian Unified Health System. Method: A researcher-administered questionnaire was applied during a structured interview in outpatient clinics. Results: Two hundred and forty (240) patients were included in the study (mean age of 53 years, 55% women). About 30% of the patients had incomplete elementary education, 25% had complete secondary education, and 53% were active workers. Approximately 87% attending the outpatient clinics were from the B2, C1 and C2 socioeconomic classes with an estimated family income of USD$275.00 to USD$825.00/month. Ninety-two percent (92%) of patients were satisfied with the care received; the items associated with a lower degree of satisfaction were facilities/comfort, cleanliness, and waiting time for consultation. No relationship was observed between socioeconomic profile and degree of satisfaction. Conclusion: Satisfaction surveys are important to identify opportunities for improving healthcare services, and it is incumbent upon managers, health professionals and even users to promote compliance with laws and decrees that seek to improve healthcare.

RESUMEN Objetivo: Evaluar el grado de satisfacción y el perfil socioeconómico de pacientes atendidos en Clínicas Externas de Gastroenterología de un centro universitario vinculado al Sistema Único de Salud brasileño. Método: Un cuestionario administrado por investigador fue aplicado durante entrevista estructura en clínicas externas. Resultados: Doscientos cuarenta (240) pacientes fueron incluidos en el estudio (edad media de 53 años, el 55% mujeres). Un 30% de los pacientes tenían educación básica incompleta, el 25% tenían el bachillerato/secundaria incompleto/a y el 53% eran trabajadores activos. Cerca del 87% de los que eran atendidos en la clínicas externas se hallaban en las clases económicas B2, C1 y C2 con ingresos familiares estimados entre 275,00 y 825,00 dólares estadounidenses por mes. El noventa y dos por ciento (92%) de los pacientes estaban satisfechos con la atención recibida; los puntos asociados con bajo grado de satisfacción fueron las instalaciones/comodidad, limpieza y tiempo de espera para consulta. Ninguna relación fue observada entre perfil socioeconómico y grado de satisfacción. Conclusión: Encuestas de satisfacción son importantes para identificar oportunidades de mejorar los servicios sanitarios y para que sus gerentes responsables, profesionales sanitarios e incluso los mismos usuarios puedan promocionar el cumplimiento a la leyes y decretos a fin de mejorar la atención sanitaria.

RESUMO Objetivo: Avaliar o grau de satisfação e o perfil socioeconômico de pacientes que são atendidos em Clínicas Externas de Gastrenterologia de uma instituição universitária vinculada ao Sistema Único de Saúde brasileiro. Método: Um questionário administrado por pesquisador foi aplicado durante uma entrevista estruturada em clínicas externas. Resultados: Duzentos e quarenta (240) pacientes foram incluídos no estudo (idade média de 53 anos, 55% mulheres). Aproximadamente 30% dos pacientes tinham ensino fundamental incompleto, 25% tinham ensino médio incompleto e 53% eram trabalhadores na ativa. Cerca de 87% dos que eram atendidos nas clínicas externas se encontravam nas classes econômicas B2, C1 e C2 com renda familiar estimada entre 275,00 e 825,00 dólares americanos por mês. Noventa e dois por cento (92%) dos pacientes estavam satisfeitos com o atendimento recebido; os itens associados a baixo grau de satisfação foram as instalações/conforto, limpeza e tempo de espera para consulta. Nenhuma relação foi observada entre perfil socioeconômico e grau de satisfação. Conclusão: Pesquisas de satisfação são importantes para identificar oportunidades para melhorar os serviços de saúde e para que seus gerentes responsáveis, profissionais da saúde e até mesmo usuários possam promover o cumprimento às leis e decretos que visam melhorar o atendimento em saúde.

RESUMO Objetivo: Avaliar o grau de satisfação e o perfil socioeconômico de pacientes que são atendidos em Clínicas Externas de Gastrenterologia de uma instituição universitária vinculada ao Sistema Único de Saúde brasileiro. Método: Um questionário administrado por pesquisador foi aplicado durante uma entrevista estruturada em clínicas externas. Resultados: Duzentos e quarenta (240) pacientes foram incluídos no estudo (idade média de 53 anos, 55% mulheres). Aproximadamente 30% dos pacientes tinham ensino fundamental incompleto, 25% tinham ensino médio incompleto e 53% eram trabalhadores na ativa. Cerca de 87% dos que eram atendidos nas clínicas externas se encontravam nas classes econômicas B2, C1 e C2 com renda familiar estimada entre 275,00 e 825,00 dólares americanos por mês. Noventa e dois por cento (92%) dos pacientes estavam satisfeitos com o atendimento recebido; os itens associados a baixo grau de satisfação foram as instalações/conforto, limpeza e tempo de espera para consulta. Nenhuma relação foi observada entre perfil socioeconômico e grau de satisfação. Conclusão: Pesquisas de satisfação são importantes para identificar oportunidades para melhorar os serviços de saúde e para que seus gerentes responsáveis, profissionais da saúde e até mesmo usuários possam promover o cumprimento às leis e decretos que visam melhorar o atendimento em saúde.

ABSTRACT Objective: To evaluate the degree of satisfaction and the socioeconomic profile of patients attending Gastroenterology Outpatient Clinics at a University institution linked to the Brazilian Unified Health System. Method: A researcher-administered questionnaire was applied during a structured interview in outpatient clinics. Results: Two hundred and forty (240) patients were included in the study (mean age of 53 years, 55% women). About 30% of the patients had incomplete elementary education, 25% had complete secondary education, and 53% were active workers. Approximately 87% attending the outpatient clinics were from the B2, C1 and C2 socioeconomic classes with an estimated family income of USD$275.00 to USD$825.00/month. Ninety-two percent (92%) of patients were satisfied with the care received; the items associated with a lower degree of satisfaction were facilities/comfort, cleanliness, and waiting time for consultation. No relationship was observed between socioeconomic profile and degree of satisfaction. Conclusion: Satisfaction surveys are important to identify opportunities for improving healthcare services, and it is incumbent upon managers, health professionals and even users to promote compliance with laws and decrees that seek to improve healthcare.

RESUMEN Objetivo: Evaluar el grado de satisfacción y el perfil socioeconómico de pacientes atendidos en Clínicas Externas de Gastroenterología de un centro universitario vinculado al Sistema Único de Salud brasileño. Método: Un cuestionario administrado por investigador fue aplicado durante entrevista estructura en clínicas externas. Resultados: Doscientos cuarenta (240) pacientes fueron incluidos en el estudio (edad media de 53 años, el 55% mujeres). Un 30% de los pacientes tenían educación básica incompleta, el 25% tenían el bachillerato/secundaria incompleto/a y el 53% eran trabajadores activos. Cerca del 87% de los que eran atendidos en la clínicas externas se hallaban en las clases económicas B2, C1 y C2 con ingresos familiares estimados entre 275,00 y 825,00 dólares estadounidenses por mes. El noventa y dos por ciento (92%) de los pacientes estaban satisfechos con la atención recibida; los puntos asociados con bajo grado de satisfacción fueron las instalaciones/comodidad, limpieza y tiempo de espera para consulta. Ninguna relación fue observada entre perfil socioeconómico y grado de satisfacción. Conclusión: Encuestas de satisfacción son importantes para identificar oportunidades de mejorar los servicios sanitarios y para que sus gerentes responsables, profesionales sanitarios e incluso los mismos usuarios puedan promocionar el cumplimiento a la leyes y decretos a fin de mejorar la atención sanitaria.

OBJECTIVE: To evaluate the effectiveness and safety of first-generation protease inhibitors for the treatment of genotype 1 hepatitis C virus-infected patients at Brazilian reference centers. METHODS: This multicenter cross-sectional study included hepatitis C virus genotype 1 monoinfected patients treated with Peg-interferon, ribavirin, and either boceprevir (n=158) or telaprevir (n=557) between July 2013 and April 2014 at 15 reference centers in Brazil. Demographic, clinical, virological, and adverse events data were collected during treatment and follow-up. RESULTS: Of the 715 patients, 59% had cirrhosis and 67.1% were treatment-experienced. Based on intention-to-treat analysis, the overall sustained viral response was 56.6%, with similar effectiveness in both groups (51.9% for boceprevir and 58% for telaprevir, p=0.190). Serious adverse events occurred in 44.2% of patients, and six deaths (0.8%) were recorded. Cirrhotic patients had lower sustained viral response rates than non-cirrhotic patients (46.9% vs. 70.6%, p<0.001) and a higher incidence of serious adverse events (50.7% vs. 34.8%, p<0.001). Multivariate analysis revealed that sustained viral response was associated with the absence of cirrhosis, viral recurrence after previous treatment, pretreatment platelet count greater than 100,000/mm3, and achievement of a rapid viral response. Female gender, age>65 years, diagnosis of cirrhosis, and abnormal hemoglobin levels/platelet counts prior to treatment were associated with serious adverse events. CONCLUSION: Although serious adverse events rates were higher in this infected population, sustained viral response rates were similar to those reported for other patient cohorts.

Abstract Brazil is one of the 22 countries that concentrates 80% of global tuberculosis cases concomitantly to a large number of hepatitis C carriers and some epidemiological risk scenarios are coincident for both diseases. We analyzed tuberculosis cases that occurred during α-interferon-based therapy for hepatitis C in reference centers in Brazil between 2001 and 2012 and reviewed their medical records. Eighteen tuberculosis cases were observed in patients submitted to hepatitis C α-interferon-based therapy. All patients were human immunodeficiency virus-negative. Nine patients (50%) had extra-pulmonary tuberculosis; 15 (83%) showed significant liver fibrosis. Hepatitis C treatment was discontinued in 12 patients (67%) due to tuberculosis reactivation and six (33%) had sustained virological response. The majority of patients had a favorable outcome but one died. Considering the evidences of α-IFN interference over the containment of Mycobacterium tuberculosis, the immune impairment of cirrhotic patients, the increase of tuberculosis case reports during hepatitis C treatment with atypical and severe presentations and the negative impact on sustained virological response, we think these are strong arguments for latent tuberculosis infection screening before starting α-interferon-based therapy for any indication and even to consider IFN-free regimens against hepatitis C when a patient tests positive for latent tuberculosis infection.

Approximately 170 million people are infected with hepatitis C, and the sustained virological response rate to treatment with pegylated interferon and ribavirin is 30-50%. In an attempt to improve the chances of cure, boceprevir is being added to therapy, but it is associated with an increased incidence of adverse events. We herein report a case of acute pancreatitis developed during treatment with pegylated interferon, ribavirin and boceprevir. Boceprevir was the most likely cause of drug-associated pancreatitis after the most common causes were ruled out, since this adverse event had not occurred when the patient had previously been exposed to pegylated interferon and ribavirin and there was no recurrence of the episode of pancreatitis when these two drugs were reintroduced. Acute pancreatitis is a rare adverse event associated with boceprevir therapy, but a potentially fatal event. Sequential determination of pancreatic enzymes should be considered during hepatitis C treatment with boceprevir.