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Survival of hepatitis C-infected haemophilia patients is predicted by presence of cirrhosis but not by anti-viral treatment
Yaakov Maor
,
Corresponding author
halishy@netvision.net.il

Correspondence and reprint request:
, Jonathan M. Schapiro**, Dalia Bashari**, Uri Martinowitz**
* Department of Gastroenteroloy and Hepatology, Sheba Medical Center, Tel-Hashomer, Israel
** The Israeli National Hemophilia Center (INHC), Sheba Medical Center, Tel-Hashomer, Israel
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between 10 and 20&#37; will spontaneously clear the virus with the generation of measurable anti-HCV antibodies and with persistently negative HCV RNA levels&#46;</p><p id="p0010" class="elsevierStylePara elsevierViewall">Within the HCV-infected group&#44; a significant number of haemophilia patients became co-infected with both HCV and HIV where many of these patients previously succumbed to AIDS prior to the era of effective antiretroviral therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> With the wider use of highly active antiretroviral therapy &#40;HAART&#41;&#44; the prognosis of HIV infection has substantially improved so that HCV infection has assumed a much greater clinical importance&#44; where liver disease has become the major cause of morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Furthermore&#44; co-infection with HIV virus is recognized as an independent predictor of liver disease progression&#46; Amongst those with HCV&#47;HIV co-infection&#44; there is some evidence that HAART slows the progression to end stage liver disease &#40;ESLD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> although this remains controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">We have estimated that patients with haemophila and other congenital coagulation disorders followed at the Israeli National Hemophilia Center &#40;INHC&#41; are now infected for about 25 years&#59; therefore&#44; about 20 to 30&#37; of these patients have so far developed progressive fibrosis or cirrhosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">In those HCV-infected patients&#44; the principal aim of anti-HCV treatment is to eradicate the virus and prevent disease progression&#44; with assessment of the sustained virological response &#40;SVR&#41; which is defined as absence of viremia 24 weeks after cessation of all antiviral medication&#46; Several studies demonstrated that SVR is associated with a reduced occurrence of liver failure and liver-related deaths in patients with chronic HCV and advanced hepatic fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; data regarding the most substantial clinical end point i&#46;e&#46;&#44; improved survival and its relationship of SVR is scarce&#46; Recently&#44; it has been shown that the beneficial effects of SVR also result in reduced all-cause mortality in the high risk population of patients with chronic HCV infection and severe hepatic fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The strongest evidence on the association between virologic and overall survival is a large Veterans Affairs cohort study that found SVR to be associated with a 30 to 50&#37; reduction in mortality risk&#44; after adjustment for many confounders&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">Essentially all HCV&#47;HIV co-infected patients at the INHC are treated with HAART regimens&#46; Since 2000 all HCV-infected patient with haemophilia and other hereditary bleeding disorders were systematically evaluated for pegylated interferon alfa and ribavirin &#40;PEG-IFN&#47;RBV&#41; combination therapy&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">The aim of this study was to examine the overall and liver-related survival in a cohort of HCV-infected patients at our institution over a 10-year period&#46; We also sought to investigate whether anti-HCV treatment and attaining an SVR would improve survival rates in these patients&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Material and Methods</span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Selection of patients</span><p id="p0035" class="elsevierStylePara elsevierViewall">About 215 patients with haemophilia and other disorders of coagulation in Israel were born prior to 1986&#44; so that they potentially were exposed to non-virucidally treated concentrated clotting factors for at least one year&#46; All of these patients were managed at the INHC&#46; Of this cohort&#44; 195 &#40;90&#46;7&#37;&#41; tested positive for anti-HCV antibodies with a viral status being known in 180 &#40;83&#46;7&#37;&#41; patients&#46; These patients were separated into 3 main groups&#58; HCV mono-infected patients &#40;N &#61; 127&#41;&#44; HCV&#47;HIV co-infected patients &#40;N &#61; 28&#41; and patients who tested positive for HCV-serology but who were persistently HCV RNA negative &#40;N &#61; 25&#41; and who were considered to have spontaneously cleared their HCV infection &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46; Patients with genotype 1 &#40;and all genotypes in the HCV&#47;HIV co-infected group&#41; were treated with PEG-IFN&#47;RBV for 48 weeks&#46; Those patients with genotypes 2 and 3 were treated in the same way&#44; although only for a 24 week period&#46; Only patients who received at least 80&#37; of the recommended PEG-IFN&#47;RBV dose were considered evaluable for their response to treatment&#46; Before commencing the PEG-IFN&#47;RBV combination&#44; the HAART regimen was individually modified in order to avoid adverse side-effects and undesirable drug interactions with Ribavirin&#44; where Zidovudine and Didanosine were generally replaced with other antiretroviral medications&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0040" class="elsevierStylePara elsevierViewall">For the purpose of determining non-responders&#44; those patients were divided into 3 groups&#46; Null-responders were defined as those who received at least 80&#37; of the recommended PEG-IFN&#47;RBV dose for at least 12 weeks but who achieved a &#60; 2 log<span class="elsevierStyleInf">10</span> IU&#47;mL reduction in HCV RNA serum levels when compared with their baseline&#46; Partial responders were those who exhibited a &#8805; 2 log<span class="elsevierStyleInf">10</span> IU&#47;mL reduction of their viral load but who did not reach undetectable levels at any measurement time-point&#46; Relapsers were defined as those who achieved undetectable HCV RNA serum levels at the end of the scheduled 24 or 48 weeks of PEG-IFN&#47;RBV treatment but who had detectable HCV RNA levels within 24 weeks of follow-up&#46; Sustained viral response &#40;SVR&#41; was defined as an undetectable HCV RNA level in the serum 24 weeks after treatment termination&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">Clinical suspected cirrhosis was defined as the development of one of the following characteristics&#59; including decompensated liver disease &#40;ascites&#44; hepatic encephalopathy&#44; jaundice or bleeding varices&#41;&#44; signs of hypersplenism &#40;both an enlarged spleen and thrombocytopenia&#41;&#44; ultrasonography suggestive of the presence of cirrhosis or any of its complications&#44; or signs of portal hypertension &#40;varices on upper gastrointestinal endoscopy or diagnostic <span class="elsevierStyleSup">99</span>Tc liver&#47; spleen scan&#41;&#46; All patients who were diagnosed with clinical features consistent with cirrhosis were also staged as F4 on the Fibro-Test &#40;FT&#41;&#46; Calculation of the FT score was derived from serum samples measuring &#945;2-macroglobulin&#44; total bilirubin&#44; &#947;-glutamyl trans-peptidase &#40;GGT&#41;&#44; apolipoprotein A1 and haptoglobin with adjustment according to the prescribed formula for age and gender&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Total bilirubin&#44; GGT and AST levels were measured by an Hitachi 917 Analyzer using Roche Diagnostics reagents &#40;Mannheim&#44; Germany&#41; whereas &#945;2-macroglobulin&#44; apolipoprotein A1&#44; haptoglobin and total cholesterol levels were measured using a Modular analyzer &#40;BNII&#59; Dade Behring&#44; Marburg&#44; Germany&#41;&#46; All biochemical analyses were performed on serum samples shipped to the New Rambam Laboratory &#40;Jerusalem&#44; Israel&#41; within a 2 h period&#46; The FT score was calculated using the Biopredictive websiste according to the manufacturer&#8217;s instructions&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> FT determination was deferred during episodes of active haematoma&#44; infection or inflammation in order to avoid misleading measurements of bilirubin&#44; haptoglobin&#44; and a2-macroglobulin&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Overall and liver-related survival</span><p id="p0050" class="elsevierStylePara elsevierViewall">Overall and liver-related survival of HCV-infected and non-infected haemophilia patients and those with other congenital coagulation disorders all managed at a single center were recorded between 2000 and 2010&#46; The cause of death was obtained from hospital records&#46; Death was classified as liver related if the patient had cirrhosis and died from typical complications of terminal liver disease &#40;variceal bleeding&#44; failure of hepatic biosynthetic function&#44; cholestasis&#44; portal hypertension with ascites&#44; hepatorenal syndrome&#44; hepatic encephalopathy with coma&#41;&#44; or had liver cancer&#46; Liver transplantation was considered in the liver-related mortality category&#46; The outcome of patients with haemophilia was compared in 3 main sub-groups&#58; HCV mono-infected patients &#40;N &#61; 127&#41;&#44; HCV&#47;HIV co-infected patients &#40;N &#61; 28&#41; and a third group which combined those patients who tested HCV-antibody negative &#40;N &#61; 20&#41; with those who were persistently HCV RNA-negative &#40;N &#61; 25&#41;&#46; This latter combined group of 45 patients was classified as non-infected&#46; Haemophilia patients who tested positive for HCV-antibodies but where data concerning virological status was lacking &#40;N &#61; 15&#41;&#44; were excluded from analysis&#46; All patients belonging to this last group survived during the follow-up period &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Variables potentially influencing overall survival were analyzed including basic demographic data&#44; characteristics of the underlying coagulation disorder&#44; the presence of HCV&#47;HIV co-infection&#44; clinical features consistent with cirrhosis&#44; the viral load &#40;where a high viral load was defined as an HCV RNA level &#8805; 800&#44;000 lU&#47;mL&#41;&#44; the viral genotype and the stage of liver fibrosis as determined at baseline by the FT&#46; The influence of anti-HCV treatment with the PEG-IFN&#47;RBV combination on the SVR and the effect of SVR on survival were determined&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Statistical analysis</span><p id="p0060" class="elsevierStylePara elsevierViewall">Quantitative variables were expressed as means &#177; SD unless otherwise specified&#46; Continuous variables were compared using the Student t-test with frequencies being compared utilizing the two-tailed Fisher&#8217;s exact test&#46; For the purposes of analysis&#44; null responders&#44; partial responders and relapsers were all considered as one group&#46; For the calculation of the age-at-infection and its duration&#44; we applied a method of estimation based upon the haemophilia type&#44; the severity of the disorder and the history of clotting factor replacement as previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Survival was analyzed with the Kaplan-Meier method with comparison between subgroups and those receiving anti-HCV treatment or having an SVR being performed with the log-rank test&#46; Variables on study entry were assessed by univariate analysis &#40;ANOVA&#41; and were entered step-wise into a Cox proportional hazard regression model if a difference with a p-value of &#60; 0&#46;1 was detected&#46; P-values of &#60; 0&#46;05 were considered significant&#46; Statistical analysis was conducted using Statistical Analysis Software version 8&#46;2 &#40;SAS Institute Inc&#46;&#44; Cary&#44; NC&#41;&#46;</p></span></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Results</span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Patients characteristics</span><p id="p0065" class="elsevierStylePara elsevierViewall">Baseline demographic&#44; clinical and virological data are shown in <a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#46; Both HCV&#47;HIV co-infected and HCV mono-infected patients had a higher incidence of underlying severe haemophilia when compared with non-infected patients &#40;93&#44; 78 and 64&#37;&#44; respectively&#41;&#44; with significance shown between HCV&#47;HIV co-infected when compared with HCV-negative patients &#40;p &#61; 0&#46;005&#41;&#46; The estimated duration of HCV infection was about 25 years for both groups&#46; Infection with the HCV genotype 1 was more prevalent in HCV mono-infected patients than in the HCV&#47;HIV co-infected group &#40;82 <span class="elsevierStyleItalic">vs&#46;</span> 59&#37;&#59; p &#61; 0&#46;013&#41;&#46; There was no statistically significant difference in the frequency of high viral load &#40;i&#46;e&#46;&#44; HCV RNA &#8805; 800&#44;000 IU&#47;mL&#41; between HCV&#47;HIV co-infected and HCV mono-infected patients &#40;58 <span class="elsevierStyleItalic">vs&#46;</span> 46&#37;&#41;&#46; Liver disease was more advanced in the HCV&#47;HIV co-infected patients when compared with the HCV mono-infected patients as indicated by the presence of clinically suspected cirrhosis &#40;14 <span class="elsevierStyleItalic">vs&#46;</span> 4&#37;&#59; p &#61; 0&#46;03&#41; and by an FT staging of F3 or F4&#44; although this difference did not reach statistical significance &#40;50 <span class="elsevierStyleItalic">vs&#46;</span> 33&#37;&#44; respectively&#59; p &#61; 0&#46;1&#41;&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><p id="p0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#t0005">Table 1</a> depicts the characteristics of the HIV infection in those haemophilia patients with HCV&#47;HIV co-infection&#46; All except one patient were treated with HAART combinations&#44; where most of them attained satisfactory immunological control &#40;mean CD4 &#43; count 382 &#177; 207 cells&#47;mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#41;&#44; and low or undetectable &#40;62&#37; of co-infected patients&#41; HIV viral load&#46;</p><p id="p0075" class="elsevierStylePara elsevierViewall">Overall&#44; 62 patients &#40;40&#37;&#41; received anti-HCV treatment during the study period&#44; including 51&#47;127 &#40;40&#46;2&#37;&#41; of the HCV mono-infected patients and 11&#47; 28 &#40;39&#46;3&#37;&#41; of the HCV&#47;HIV co-infected group&#46; All these patients were treated between 2001 and 2003&#46; An SVR &#40;as defined&#41; was observed overall in 25&#47;62 &#40;40&#46;3&#37;&#41; of the treated patients&#59; with an SVR in 22&#47; 51 &#40;43&#46;1&#37;&#41; of the HCV mono-infected and in 3&#47;11 &#40;27&#46;3&#37;&#41; of the HCV&#47;HIV co-infected patients&#46; A fibrosis stage of F3 or F4 determined by the FT was present in 49&#46;1&#37; of the treated patients vs&#46; 25&#46;8&#37; of those not treated &#40;p &#61; 0&#46;009&#41;&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Overall and liver-related survival</span><p id="p0080" class="elsevierStylePara elsevierViewall">Comparative cumulative overall and liver-related survival over a 10 year follow-up are shown in <a class="elsevierStyleCrossRef" href="#f0010">figure 2</a>&#46; The overall survival of the HCV&#47;HIV co-infected patients was inferior to that of both the HCV mono-infected and the non-infected patients &#40;81&#46;2&#44; 95&#46;3 and 100&#37;&#44; respectively&#41;&#44; showing significance for HCV&#47;HIV <span class="elsevierStyleItalic">vs&#46;</span> HCV mono-infected patients &#40;p &#61; 0&#46;015&#41; and in comparison of HCV&#47;HIV co-infected <span class="elsevierStyleItalic">vs&#46;</span> non-infected patients &#40;p &#61; 0&#46;003&#41;&#46; The overall survival rate of the HCV mono-infected patients did not significantly differ from the non-infected group &#40;p &#61; 0&#46;14&#41;&#46; The liver-related survival of the HCV&#47;HIV co-infected patients was lower when compared with HCV mono-infected patients &#40;89&#46;2 <span class="elsevierStyleItalic">vs&#46;</span> 99&#46;8&#37;&#59; p &#61; 0&#46;023&#41; and when compared with non-infected patients &#40;89&#46;2 <span class="elsevierStyleItalic">vs&#46;</span> 100&#37;&#59; p &#61; 0&#46;003&#41;&#44; where no significant difference was noted in overall survival between the HCV mono-infected and the non-infected patients &#40;p &#61; 0&#46;55&#41;&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0085" class="elsevierStylePara elsevierViewall">The causes of mortality in 11 patients who died between 2000 and 2010 are shown in <a class="elsevierStyleCrossRef" href="#t0010">table 2</a> with the major cause of death in the HCV&#47;HIV co-infected patients being liver-related&#46; One patient underwent combined liver-kidney transplantation and is still alive&#46; Amongst the HCV mono-infected patients&#44; a further patient underwent liver transplantation for ESLD but died in the immediate postoperative period&#46; Of the 62 patients who received anti-HCV treatment 59 &#40;95&#46;2&#37;&#41; survived&#44; while of the 93 untreated patients 85 &#40;91&#46;4&#37;&#41; survived &#40;p &#61; 0&#46;37&#41;&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Predictors of mortality</span><p id="p0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#t0015">Table 3</a> shows the results of the univariate and multivariate analyses&#44; respectively incorporating factors which predicted for overall survival&#46; On univariate analysis&#44; advanced age&#44; HCV&#47;HIV co-infection&#44; coincident clinically suspected cirrhosis and a non-1 genotype infection acted as predictive factors for mortality&#44; however&#44; neither anti-HCV treatment with the PEG-IFN&#47;RBV combination nor the development of an SVR &#40;which occurred in 25 patients&#41;&#44; influenced survival&#46; On multivariate analysis&#44; only clinically suspected cirrhosis remained as an independent predictor of overall mortality &#40;OR &#61; 15&#46;119&#59; 95&#37; CI&#44; 2&#46;388-95&#46;735&#59; p &#61; 0&#46;004&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 3</a>&#41;&#46; The effects of anti-HCV treatment and the presence of an SVR on cumulative overall survival are shown in <a class="elsevierStyleCrossRef" href="#f0015">figure 3</a>&#44; respectively&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia></span></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Discussion</span><p id="p0095" class="elsevierStylePara elsevierViewall">Our study found a higher overall and liver-related mortality in an Israeli cohort of haemophilia patients born prior to 1986 who contracted combined HCV and HIV infection when compared with HCV mono-infected and non-infected patients&#46; The main cause of death in HCV&#47;HIV co-infected patients was ESLD&#46; Although HIV infection was fairly well controlled with the HAART regimens in essentially all patients&#44; their unfavorable outcome persisted&#46; There was no effect either of the use of anti-HCV therapy &#40;combined PEG-IFN&#47;RBV&#41; or if an SVR has been attained with treatment&#46; Only the presence of clinically suspected cirrhosis remained as an independent negative prognostic variable of survival&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">Our report has several limitations&#46; First&#44; this is a retrospective analysis&#44; nevertheless&#44; the collection of data was based on regular follow-up of patients with haemophilia and other disorders of coagulation all managed at one center &#8212; the INHC&#46; Given this very special population&#44; our cohort is conceivably relatively small&#46; Nonetheless&#44; the prevalence of HCV infection is very high among haemophilia patients compared with other populations at risk to contract such infection&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">Combination therapy with HAART regimens can be limited in some cases by hepatotoxicity&#44; increase in HCV viral load and enhanced fibrosis progression rate&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; control of HIV replication has been associated with a delay in the progression of hepatic fibrosis&#44; a longer time to initial hepatic decompensation and a prolonged overall survival&#46; In this respect&#44; long-term follow-up from a German haemophilia cohort<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> has shown that effective antiretroviral treatment lowers the mortality in patients with HCV-related chronic liver disease&#44; where the peak of liver-related mortality was found between 1991 and 1996&#44; after approximately 10 years of recorded co-infection and prior to the introduction of effective antiretroviral therapy&#46; In this study&#44; the mortality rate then declined from 1997 until 2002&#44; suggesting a selective survival benefit in co-infected patients being treated with HAART&#46; Another study from several US haemophilia centers&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported that the median ESLD-free survival was significantly shorter in HIV-positive than HIV-negative men with haemophilia&#46; In contrast&#44; ESLD-free survival among HAART-treated HIV-infected men was significantly longer than in non-HAART-treated HIV-infected men 30 <span class="elsevierStyleItalic">vs&#46;</span> 20 year&#44; but was similar to that in HIV-negative men&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">In our study&#44; essentially all HCV&#47;HIV co-infected haemophilia patients were treated with HAART that induced an acceptable immunological and virological control&#46; Over a 10-year follow-up period we found 19 and 11&#37; overall and liver-related mortality rates&#44; respectively&#46; In contrast to the aforementioned reports&#44; mortality rates were still significantly higher in HCV&#47;HIV co-infected patients when compared with HCV mono-infected &#40;5 and 1&#37;&#44; respectively&#41; or non-infected patients &#40;none&#41;&#46; Nevertheless&#44; even though mortality is greater&#44; the mortality in HIV&#47; HCV is still relatively low over 10 years&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">Prior studies in patients with HCV and severe hepatic fibrosis have reported reduction in complications of advanced liver disease and improved liver-related mortality associated with SVR&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Most studies however&#44; did not investigate all-cause mortality as a single outcome&#44; and reduction in liver-related death may not directly translate into an overall survival benefit&#46; In a recent international&#44; multicenter&#44; long-term follow-up study&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> SVR was associated with prolonged overall survival&#46; This study with a long follow-up duration demonstrated a lower risk for all-cause mortality in patients with chronic HCV infection and advanced hepatic fibrosis who achieved SVR&#46; The risk of all-cause mortality was almost 4-fold lower in patients with SVR compared with patients without SVR&#46; In another study in patients with advanced fibrosis or cirrhosis&#44; the association of SVR with all cause death and liver transplantation as a combined end point was analyzed&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The adjusted cumulative proportion of patients who died or underwent liver transplantation after 7&#46;5 years of follow-up was higher in patients not responding to PEG-IFN&#47;RBV therapy &#40;27&#46;2&#37;&#41; compared with patients with virological relapse &#40;4&#46;4&#37;&#41; or who achieved an SVR &#40;2&#46;2&#37;&#41;&#46; In the largest study&#44; predominantly male population of US veterans was followed up for a median of 3&#46;8 years&#46; In this cohort with all stages of liver fibrosis&#44; 5-year mortality rates of 6&#46;7 to 8&#46;0&#37; in patients with SVR <span class="elsevierStyleItalic">vs&#46;</span> rates of 14&#46;4 to 24&#46;4&#37; in patients without SVR were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="p0120" class="elsevierStylePara elsevierViewall">Regression of fibrosis as assessed by paired liver biopsies was reported in non-haemophilic HCV patients who achieved an SVR&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> A study from a Dutch haemophilia cohort<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> demonstrated that even after a long HCV infection duration&#44; successful antiviral treatment led to a significant improvement of fibrosis&#44; evaluated by liver stiffness measurement&#46; It is anticipated that the objective attenuation of fibrosis may select for survival in those patients who develop an SVR&#46;</p><p id="p0125" class="elsevierStylePara elsevierViewall">To our knowledge&#44; the present report is the first attempt to correlate anti-HCV treatment and SVR with survival in a cohort of haemophilia patients&#46; A principal question remains as to why in our cohort&#44; overall or liver-related survival benefit was not observed following anti-HCV treatment and why there was no clinical effect even in those who achieved an SVR&#46; The relatively small number of patients may not allow for a sufficient statistical power to show such a relationship&#46; Furthermore&#44; in previous reports survival advantage was demonstarated only in those patients achieving an SVR&#46; The SVR rate in our cohort was lower than the SVR rates reported in other HCV-infected haemophiliacs or non-haemophilic populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22</span></a><span class="elsevierStyleSup">&#8211;</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> We also acknowledge some bias caused by inadvertent selection of patients with more advanced stage of fibrosis to undergo anti-HCV treatment&#46; Indeed&#44; advanced fibrosis as assessed by the FT was observed in about a half of the treated patients&#44; whereas it was found in only a quarter of the untreated group&#46; Finally&#44; most studies have shown both an overall and liver-related survival advantage in patients with advanced fibrosis or cirrhosis capable of generating an SVR&#44; although there are confounding variables which also limit the interpretation of comparative data&#46; Only one study including over 16&#44;000 patients showed such advantage in a population representing all stages of liver fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In this particular study only 9 to 16&#37; of the included patients were registered as having cirrhosis&#44; nevertheless&#44; the relatively high death rate in the study of the US veterans may be due to other co-morbidities in this particular patient population&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">In summary&#44; in our population of HCV-infected patients with haemophilia and other congenital bleeding disorders&#44; we found an unfavorable outcome in HCV&#47;HIV co-infected patients mainly due to complications of advanced liver disease&#46; This outcome was not improved by anti-HCV treatment even when it resulted in an SVR&#46; As treatment failure remains the main challenge for HCV mono-infected and HCV&#47;HIV co-infected patients&#44; there may be future promise in the use of novel directly acting drugs &#40;DDI&#41; that may also benefit those who fail previous standard of care or who display specific predictors of poor treatment outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Addendum</span><p id="p0135" class="elsevierStylePara elsevierViewall">Y&#46; Maor-Conceived and designed the study&#44; interpreted and analyzed the data&#44; wrote the manuscript and gave final approval of the version to be published&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">J&#46;M&#46; Schapiro-Designed the study&#44; interpreted the data&#44; critically revised the intellectual content and gave final approval of the version to be published&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">D&#46; Bashari-Designed and generated the study database&#44; critically revised the intellectual content and gave final approval of the version to be published&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">U&#46; Martinowitz-Conceived and designed the study&#44; interpreted the data&#44; critically revised the intellectual content and gave final approval of the version to be published&#46;</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Disclosures of Conflict of Interest</span><p id="p0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest during the conduct of this trial&#46;</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Compliance with Ethical Requirements</span><p id="p0160" class="elsevierStylePara elsevierViewall">All the authors hereby state that they do not have any conflict of interest&#47;financial disclosure&#46; The study was approved by the local IRB committee&#46; According to national regulations retrospective studies do not require signed informed consent from patients&#46; The study does not involve animals&#46;</p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Acknowledgements</span><p id="p0165" class="elsevierStylePara elsevierViewall">Medical writing support was commissioned from A&#46; Zbar CEO surgical-steps&#46;com</p></span></span>"
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          "titulo" => "Material and Methods"
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            0 => array:2 [
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              "titulo" => "Selection of patients"
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              "titulo" => "Overall and liver-related survival"
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            2 => array:2 [
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          "titulo" => "Results"
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              "titulo" => "Patients characteristics"
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              "titulo" => "Overall and liver-related survival"
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            2 => array:2 [
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              "titulo" => "Predictors of mortality"
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          "titulo" => "Discussion"
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          "titulo" => "Addendum"
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          "titulo" => "Disclosures of Conflict of Interest"
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          "titulo" => "Compliance with Ethical Requirements"
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          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "fechaRecibido" => "2014-03-21"
    "fechaAceptado" => "2014-06-03"
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            0 => "Hepatitis C"
            1 => "Coinfection"
            2 => "Haemophilia"
            3 => "Natural history"
            4 => "Pegylated interferon alfa"
            5 => "Ribavirin"
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    "resumen" => array:1 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Background&#47;Purpose&#46;</span> Hepatitis C &#40;HCV&#41; is a major cause of morbidity and mortality in haemophilia patients who received clotting factor concentrates before the availability of virus-inactivated factors in the mid-1980s&#46; Recently&#44; it has been suggested that anti-HCV treated patients&#44; particularly those achieving a sustained virological response &#40;SVR&#41; have an improved outcome&#46; We sought to examine the survival of treated and untreated HCV-infected haemophilia patients&#46;</p><p id="sp1020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Material and methods&#46;</span> We studied overall and liver-related survival of patients with haemophilia and other congenital bleeding disorders between 2000 and 2010&#46; The outcome was compared in 3 sub-groups&#58; HCV mono-infected &#40;N &#61; 127&#41;&#44; HCV&#47;HIV co-infected &#40;N &#61; 28&#41;&#44; and patients with either HCV-antibodies negative or persistent HCV RNA-negative &#40;referred to as non-infected&#41; &#40;N &#61; 45&#41;&#46; Sixty-two &#40;40&#37;&#41; &#40;HCV and HCV&#47;HIV&#41; patients underwent anti-HCV treatment with an SVR rate of 40&#46;3&#37;&#46;</p><p id="sp1035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Results&#46;</span> Overall and liver-related 10-year survival were&#58; 82&#46;1 and 89&#46;3&#37;&#44; 95&#46;3 and 99&#46;2 and 100&#37; for HCV&#47;HIV co-infected&#44; HCV mono-infected and non-infected haemophilia patients&#44; respectively &#40;p &#61; 0&#46;015 and 0&#46;023 for comparisons of HCV&#47;HIV <span class="elsevierStyleItalic">vs&#46;</span> HCV&#59; p &#61; 0&#46;003 for comparison of HCV&#47;HIV and non-infected&#41;&#46; One HCV mono-infected and 3 co-infected patients died of end-stage liver disease &#40;2 underwent liver transplantation&#41;&#46; There was no survival benefit from anti-HCV treatment or from attaining of an SVR&#46; Only clinically suspected cirrhosis remained as an independent predictor of survival&#46;</p><p id="sp3035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Conclusion&#46;</span> The prognosis of haemophilia patients who acquired HCV&#47;HIV co-infection is worse than that of HCV mono-infected or non-infected or haemophiliacs&#46; This is mainly due to liver-related mortality&#46; Anti-HCV treatment or SVR had no observable impact on survival rate&#46;</p></span>"
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          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Overall &#40;<span class="elsevierStyleBold">A</span>&#41; and liver-related &#40;<span class="elsevierStyleBold">B</span>&#41; cumulative survival of hepatitis C-infected haemophilia patients &#40;Overall survival&#58; HCV&#47;HIV</span> vs&#46; <span class="elsevierStyleItalic">HCV&#59; p &#61; 0&#46;015&#59; HCV&#47;HIV</span> vs&#46; <span class="elsevierStyleItalic">non-HCV&#59; p &#61; 0&#46;003&#59; HCV</span> vs&#46; <span class="elsevierStyleItalic">non-HCV&#59; p &#61; 0&#46;14&#41; &#40;Liver-related Survival&#58; HCV&#47;HIV</span> vs&#46; <span class="elsevierStyleItalic">HCV&#59; p &#61; 0&#46;023&#59; HCV&#47;HIV</span> vs&#46; <span class="elsevierStyleItalic">non-HCV&#59; p &#61; 0&#46;003&#59; HCV</span> vs&#46; <span class="elsevierStyleItalic">non-HCV&#59; p &#61; 0&#46;55&#41;&#46;</span></p>"
        ]
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        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          0 => array:4 [
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          "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Cumulative survival according to treatment &#40;<span class="elsevierStyleBold">A</span>&#41; and viral response &#40;<span class="elsevierStyleBold">B</span>&#41;&#46;</p>"
        ]
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        "identificador" => "t0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">HCV &#40;N &#61; 127&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">HCV&#47;HIV &#40;N &#61; 28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">HCV-Neg&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a> &#40;N &#61; 45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#177; 14 &#40;16-71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#177; 10 &#40;26-64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#177; 15 &#40;16-58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coagulation disorder Haemophilia &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005 for HCV&#47;HIV vs&#46; HCV-Neg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;08 for HCV vs&#46; HCV-Neg&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of infection &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#177; 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#177; 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Genotype 1 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High viral load &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical cirrhosis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis stage F3-F4 by FT &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treated &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SVR &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2060566.png"
              ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Combination of HCV-antibody negative and persistent HCV RNA-negative&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">95&#37; haemophilia A&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "&#42;&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">von Willebrand disease&#44; Glanzmann&#8217;s thrombasthenia&#46; NA&#58; not applicable&#46; NS&#58; non significant&#46; FT&#58; FibroTest&#46; SVR&#58; sustained virological response&#46;</p>"
            ]
          ]
        ]
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          "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Demographic&#44; clinical&#44; and virological data of haemophilia patients born before 1986&#46;</p>"
        ]
      ]
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        "identificador" => "t0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">HCV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">HCV&#47;HIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">End-stage liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Septic arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2<a class="elsevierStyleCrossRef" href="#tblfn0020">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Major bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suicide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV-related&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dementia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2060567.png"
              ]
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            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">One patient with clinical cirrhosis&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Cause of death in hepatitis C-infected haemophilia patients&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "t0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Survived N &#61; 189&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Dead N &#61; 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">RR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;1 &#177; 13&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;5 &#177; 12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HCV &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;066&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;674 - 15&#46;651&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe hemophilia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical cirrhosis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;685&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;633 - 47&#46;150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information
ISSN: 16652681
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos