- 題目： Short duration of direct-acting antivirals for acute HCV infection
- 作者：Yu, Ming-Lung(附院 肝膽胰內科 余明隆) LANCET INFECTIOUS DISEASES v.17 n.5 p.481-482
I read with interest the report on the HepNet Acute HCV IV study.1 Katja Deterding and colleagues1 reported that a short duration of direct-acting antiviral agents, a ledipasvir plus sofosbuvir fixed-dose combination for 6 weeks, achieved a sustained virological response 12 weeks after the end of treatment in 100% of patients (n=20) with acute hepatitis C virus (HCV) genotype 1 monoinfection. However, only two patients in the study had high baseline viral loads (>1 000 000 IU/mL) and most patients (n=15) had baseline viral loads lower than 100 000 IU/mL.1 Universal recommendation of short-duration treatment for acute HCV infection in patients with high baseline viral loads remains difficult.
Previous studies have shown that 6-week sofosbuvir-based regimens are suboptimal for patients with acute HCV infection with or without HIV co-infection, especially among those with high baseline HCV viral loads. Martinello and colleagues2 observed that, with 6 weeks of sofosbuvir plus ribavirin for acute HCV infection, none of eight patients with baseline HCV RNA greater than 1 000 000 IU/mL achieved a sustained virological response 12 weeks after the end of treatment, compared with 55% (six of 11) of those with baseline HCV RNA 1 000 000 log10 IU/mL or lower (p=0•018). After exclusion of patients with reinfection during the follow-up period, occurrence of virological failure was found to be significantly higher among patients with baseline HCV RNA greater than 1 000 000 IU/mL than among those with baseline HCV RNA 1 000 000 log10 IU/mL or lower (100% [eight of eight] vs 33% [three of nine], p=0•009).2 Nine of the 12 patients who had virological failure had relapsed.2 Rockstroh and colleagues3 reported similar results with 6 weeks of ledipasvir-sofosbuvir for treatment of acute HCV infection in patients with HIV co-infection. Treatment failure rate was higher in patients with a baseline viral load 800 000 IU/mL or higher (33% [four of 12]; three relapses and one reinfection) than in those with a baseline viral load lower than 800 000 IU/mL (14% [two of 14]; both patients achieved a sustained virological response 4 weeks after the end of treatment but were lost to follow-up).3 The three patients who relapsed had baseline viral loads greater than 6•96 log10 IU/mL.3
The effect of high baseline HCV RNA viral loads on treatment efficacy, in terms of increased relapse rate, with a short duration of antiviral therapy was also noticed among patients with chronic HCV infection treated with both interferon-based4 and interferon-free5 direct-acting antiviral regimens. In the C-SWIFT study,5 which assessed the efficacy of 6 weeks of grazoprevir/elbasvir plus sofosbuvir in patients with non-cirrhotic HCV genotype 1 infection, the sustained virological response rate 12 weeks after the end of treatment was 69% (nine of 13) in patients with baseline HCV RNA greater than 2 000 000 IU/mL, and 100% (17 of 17) in those with baseline HCV RNA 2 000 000 IU/mL or lower.
Further large-scale studies are therefore needed to establish the effectiveness of 6-week direct-acting antiviral regimens for treatment of HCV infection in patients with high viral loads.
I have received research support from AbbVie, Abbott, Bristol-Myers Squibb, Gilead, Merck, and Roche; was a consultant for AbbVie, Abbott, Ascletis, Bristol-Myers Squibb, Gilead, Johnson & Johnson, Merck, Novartis, Pharmaessential, and Roche; and received speaking fees from AbbVie, Abbott, Ascletis, Bristol-Myers Squibb, Gilead, Merck, Pharmaessential, and Roche.
- 題目：Percutaneous Nephrolithotomy: Update, Trends, and Future Directions for Simultaneous Supine Percutaneous Nephrolithotomy and Retrograde Ureterolithotripsy in the Galdakao-modified Supine Valdivia Position for Large Proximal Ureteral Calculi
- 作者：Huang, Tsung-Yi(附院 泌尿部 黃琮懿); Feng, Kathy Ming(附院 泌尿部); Lo, Ing-Shiang(附院 泌尿部 羅英襄) EUROPEAN UROLOGY v.71 n.5 p.837-838
We analyzed several population-based studies reporting outcomes and innovations in the practice of percutaneous nephrolithotomy (PCNL) since 2000. Current treatments for removal of renal calculi include extracorporeal shock wave lithotripsy (ESWL), ureterolithotripsy, PCNL, and laparoscopic and open surgery . According to the European Association of Urology (EAU) guidelines on urolithiasis, PCNL is recommended for large renal calculi. However, the treatment for large, proximal ureteral calculi (located between the ureteropelvic junction and the lower border of the fourth lumbar vertebra) remains controversial.
Retrograde ureterolithotripsy for large proximal ureteral stones requires several passages with the ureteroscope to remove all the stone fragments after intracorporeal lithotripsy. This not only increases ureteral trauma; the continuous high-pressure irrigation may also result in stone migration back to the renal pelvis or calices. The stone may become unreachable and require further use of a rigid or semi-rigid ureteroscope . Laparoscopic or open ureterolithotomy is not recommended because of longer hospitalization and greater postoperative morbidity such as postoperative ileus, urinary leakage, and peritonitis .
Endoscopic combined intrarenal surgery in the Galdakao-modified supine Valdivia (GMSV) position is considered a single-step treatment for a simultaneous antero-retrograde approach using retrograde flexible ureteroscopy (fURS) and PCNL . However fURS is expensive, skill-dependent, and time consuming. Therefore, we prefer semi-rigid ureteroscopes because of their durability and affordable price range for hospitals. Hence, we propose a technique that uses simultaneous supine PCNL and retrograde semi-rigid ureterolithotripsy in the GMSV position for large proximal ureteric calculi.
Between September 2014 and May 2015, our group collected data for 13 patients with large proximal ureteral stones (>15 mm in length) who underwent simultaneous supine PCNL and retrograde ureterolithotripsy in the GMSV position at Kaohsiung Medical University Hospital. The mean operation time was 40 min (range 25–55) and ureteral stents were introduced without a nephrostomy tube (tubeless method) in all patients. The average postoperative hospital stay was 3.4 d (range 2–5). All patients were stone-free at 3-mo follow-up.
We believe that simultaneous PCNL and ureterolithotripsy is a new strategy to explore for the treatment of upper tract urolithiasis. This approach creates an open, low-pressure system that reduces the absorption of irrigation fluid into the circulation. The proximal ureteral stone can be pushed back and retrieved via forceps with a nephroscope through an Amplatz sheath in a single procedure without the need for baskets, reducing the risk of ureteral injury. An Amplatz sheath allows removal of fragments of up to 1 cm. In addition, during withdrawal of the ureteroscope, the ureter and bladder can be evaluated for any residual stone fragments, bleeding, or blood clots.
In conclusion, simultaneous supine PCNL and retrograde ureterolithotripsy in the GMSV position represents significant progress in the treatment of large proximal ureteral stones. It is likely that as experience using the modified supine lithotomy position increases, this approach will gain increasing acceptance among urologists in the coming years.