metricas
covid
Buscar en
Annals of Hepatology
Toda la web
Inicio Annals of Hepatology Efficacy of maintenance subcutaneous hepatitis B immune globulin (HBIG) post-tra...
Journal Information

Statistics

Follow this link to access the full text of the article

Efficacy of maintenance subcutaneous hepatitis B immune globulin (HBIG) post-transplant for prophylaxis against hepatitis B recurrence
Janakie Singham*, Erica D. Greanya**, Kirby Lau***, Siegfried R. Erb*, Nilu Partovi**, Eric M. Yoshida
,
Corresponding author
eric.yoshida@vch.ca

Correspondence and reprint request:
* From the Division of Gastroenterology, the University of British Columbia
** The Department of Pharmacy, the Vancouver General Hospital
*** The BC Hepatitis Program and the BC Transplant Society, Vancouver BC, Canada
Read
2387
Times
was read the article
568
Total PDF
1819
Total HTML
Share statistics
 array:24 [
  "pii" => "S1665268119316564"
  "issn" => "16652681"
  "doi" => "10.1016/S1665-2681(19)31656-4"
  "estado" => "S300"
  "fechaPublicacion" => "2010-04-01"
  "aid" => "71342"
  "copyright" => "Fundación Clínica Médica Sur, A.C."
  "copyrightAnyo" => "2010"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "fla"
  "cita" => "Ann Hepatol. 2010;9:166-71"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 72
    "formatos" => array:3 [
      "EPUB" => 11
      "HTML" => 18
      "PDF" => 43
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1665268119316576"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31657-6"
    "estado" => "S300"
    "fechaPublicacion" => "2010-04-01"
    "aid" => "71343"
    "copyright" => "Fundación Clínica Médica Sur, A.C."
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "fla"
    "cita" => "Ann Hepatol. 2010;9:172-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 50
      "formatos" => array:3 [
        "EPUB" => 9
        "HTML" => 20
        "PDF" => 21
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Genotype f prevails in Venezuelan urban patients with chronic hepatitis B<a class="elsevierStyleCrossRef" href="#fn1"><span class="elsevierStyleSup">&#40;a&#41;</span></a>"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "172"
          "paginaFinal" => "176"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "f0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 711
              "Ancho" => 999
              "Tamanyo" => 49412
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">HBV DNA viral loads shown by the group of urban patients with CHB&#44; genotype F&#44; e-antigen positive and e-antigen negative&#46; HBV DNA levels expressed as log<span class="elsevierStyleInf">10</span> IU&#47;mL&#44; were significantly higher &#40;P &#61; 0&#46;0001&#41; in 74 patients with CHB e-antigen positive compared to 16 patients with CHB e-antigen negative&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Irma V&#46; Machado, Mar&#237;a del Pilar Fortes, Berta Vargas-Lovelle, Aleidy C&#46; Tr&#243;mpiz, Danerys A&#46; L&#243;pez, Roberto V&#46; Le&#243;n, Merita Senior, Lucy Dagher, Carmen E&#46; L&#243;pez, Elena Pesta&#241;a, Rom&#225;n Bacalao, Miguel E&#46; Garassini"
          "autores" => array:12 [
            0 => array:2 [
              "nombre" => "Irma"
              "apellidos" => "V&#46; Machado"
            ]
            1 => array:2 [
              "nombre" => "Mar&#237;a"
              "apellidos" => "del Pilar Fortes"
            ]
            2 => array:2 [
              "nombre" => "Berta"
              "apellidos" => "Vargas-Lovelle"
            ]
            3 => array:2 [
              "nombre" => "Aleidy C&#46;"
              "apellidos" => "Tr&#243;mpiz"
            ]
            4 => array:2 [
              "nombre" => "Danerys A&#46;"
              "apellidos" => "L&#243;pez"
            ]
            5 => array:2 [
              "nombre" => "Roberto V&#46;"
              "apellidos" => "Le&#243;n"
            ]
            6 => array:2 [
              "nombre" => "Merita"
              "apellidos" => "Senior"
            ]
            7 => array:2 [
              "nombre" => "Lucy"
              "apellidos" => "Dagher"
            ]
            8 => array:2 [
              "nombre" => "Carmen E&#46;"
              "apellidos" => "L&#243;pez"
            ]
            9 => array:2 [
              "nombre" => "Elena"
              "apellidos" => "Pesta&#241;a"
            ]
            10 => array:2 [
              "nombre" => "Rom&#225;n"
              "apellidos" => "Bacalao"
            ]
            11 => array:2 [
              "nombre" => "Miguel E&#46;"
              "apellidos" => "Garassini"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119316576?idApp=UINPBA00004N"
    "url" => "/16652681/0000000900000002/v1_201907070740/S1665268119316576/v1_201907070740/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1665268119316552"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31655-2"
    "estado" => "S300"
    "fechaPublicacion" => "2010-04-01"
    "aid" => "71341"
    "copyright" => "Fundaci&#243;n Cl&#237;nica M&#233;dica Sur&#44; A&#46;C&#46;"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "fla"
    "cita" => "Ann Hepatol. 2010;9:161-5"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 56
      "formatos" => array:3 [
        "EPUB" => 14
        "HTML" => 16
        "PDF" => 26
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Association between elevated aminotransferase levels and the metabolic syndrome in Northern Turkey"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "161"
          "paginaFinal" => "165"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "f0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 825
              "Ancho" => 987
              "Tamanyo" => 47422
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">ALT levels according to risk factors for metabolic syndrome in men with elevated aminotransferase levels&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Beytullah Yildirim, Fikret Ozugurlu, Semsettin Sahin, Huseyin Ozyurt, Omer Atis, Ali Akbas, Yeliz Akturk, Metin Ozdemir, Idris Sahin, Yunus Bulut, Ilker Etikan, M&#46;Murat Firat"
          "autores" => array:12 [
            0 => array:3 [
              "preGrado" => "MD"
              "nombre" => "Beytullah"
              "apellidos" => "Yildirim"
            ]
            1 => array:2 [
              "nombre" => "Fikret"
              "apellidos" => "Ozugurlu"
            ]
            2 => array:2 [
              "nombre" => "Semsettin"
              "apellidos" => "Sahin"
            ]
            3 => array:2 [
              "nombre" => "Huseyin"
              "apellidos" => "Ozyurt"
            ]
            4 => array:2 [
              "nombre" => "Omer"
              "apellidos" => "Atis"
            ]
            5 => array:2 [
              "nombre" => "Ali"
              "apellidos" => "Akbas"
            ]
            6 => array:2 [
              "nombre" => "Yeliz"
              "apellidos" => "Akturk"
            ]
            7 => array:2 [
              "nombre" => "Metin"
              "apellidos" => "Ozdemir"
            ]
            8 => array:2 [
              "nombre" => "Idris"
              "apellidos" => "Sahin"
            ]
            9 => array:2 [
              "nombre" => "Yunus"
              "apellidos" => "Bulut"
            ]
            10 => array:2 [
              "nombre" => "Ilker"
              "apellidos" => "Etikan"
            ]
            11 => array:2 [
              "nombre" => "M&#46;Murat"
              "apellidos" => "Firat"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119316552?idApp=UINPBA00004N"
    "url" => "/16652681/0000000900000002/v1_201907070740/S1665268119316552/v1_201907070740/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "titulo" => "Efficacy of maintenance subcutaneous hepatitis B immune globulin &#40;HBIG&#41; post-transplant for prophylaxis against hepatitis B recurrence<span class="elsevierStyleSup">&#8224;</span>"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "166"
        "paginaFinal" => "171"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Janakie Singham, Erica D&#46; Greanya, Kirby Lau, Siegfried R&#46; Erb, Nilu Partovi, Eric M&#46; Yoshida"
        "autores" => array:6 [
          0 => array:3 [
            "nombre" => "Janakie"
            "apellidos" => "Singham"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Erica D&#46;"
            "apellidos" => "Greanya"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;&#42;</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Kirby"
            "apellidos" => "Lau"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;&#42;&#42;</span>"
                "identificador" => "aff3"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Siegfried R&#46;"
            "apellidos" => "Erb"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Nilu"
            "apellidos" => "Partovi"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;&#42;</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          5 => array:4 [
            "nombre" => "Eric M&#46;"
            "apellidos" => "Yoshida"
            "email" => array:1 [
              0 => "eric.yoshida@vch.ca"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor1"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "From the Division of Gastroenterology&#44; the University of British Columbia"
            "etiqueta" => "&#42;"
            "identificador" => "aff1"
          ]
          1 => array:3 [
            "entidad" => "The Department of Pharmacy&#44; the Vancouver General Hospital"
            "etiqueta" => "&#42;&#42;"
            "identificador" => "aff2"
          ]
          2 => array:3 [
            "entidad" => "The BC Hepatitis Program and the BC Transplant Society&#44; Vancouver BC&#44; Canada"
            "etiqueta" => "&#42;&#42;&#42;"
            "identificador" => "aff3"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#42;"
            "correspondencia" => "Correspondence and reprint request&#58;"
          ]
        ]
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "f0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 661
            "Ancho" => 1003
            "Tamanyo" => 58716
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Mean anti-HBs titres post first injection over time&#46; The number of patients at each time value changes based on patient compliance with bloodwork each week&#44; and with those that need to be removed from this figure as they required a repeat injection&#44; such that n values are shown at each week&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">For much of its history&#44; liver transplantation has not been feasible for patients with end-stage disease secondary to hepatitis B virus &#40;HBV&#41; because of post-transplant viral graft re-infection rates as high as 70-100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Chronic hepatitis B ceased being a contraindication to liver transplantation when the use of post-operative passive immunization via Hepatitis B immunoglobulin &#40;HBIG&#41; reduced the re-infection rate to 20-40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Subsequent use of antiviral agents like lamivudine in combination with HBIG has further reduced the re-infection rate to 010&#37;&#44; and is now considered the standard of care&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Traditionally&#44; HBIG was administered in high doses via an intravenous &#40;IV&#41; route&#44; but later studies showed that low dose intramuscular &#40;IM&#41; administration is of equal efficacy and more cost effective when compared with the IV route &#40;3&#44;4&#41;&#46; Thus a long-term or indefinite course of low dose IM HBIG&#44; in concert with lamivudine or another comparable antiviral medication&#44; to maintain anti-HBs titres greater than 100 IU&#44; is the post liver transplantation strategy currently used by transplant centers to prevent graft reinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">IM administration of HBIG is not ideal in all situations however&#44; and many patients experience significant pain associated with IM injections&#46; Furthermore&#44; IM injections are contraindicated in patients with coagulopathies&#44; as well as patients who are pharmaceutically anticoagulated secondary to other comorbidities such as thromboembolism or atrial fibrillation&#44; as IM injections in these patients are associated with an increased risk of intramuscular hematomas&#46; We recently reported a case of a liver transplant patient who developed recurrent portal vein thrombosis post-operatively such that he required anticoagulation&#44; and thus IM injections were contraindicated&#46; Therefore subcutaneous &#40;SC&#41; HBIG was successfully used instead to maintain anti-HBs titres above the required range to stave off graft re-infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This case report posed the question as to whether SC HBIG can be used as a potentially safer and less painful alternative to IM HBIG to prevent viral graft re-infection in liver transplant patients&#44; which we attempted to answer in this pilot study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Study design and patients</span><p id="p0015" class="elsevierStylePara elsevierViewall">In this single centre&#44; prospective observational study&#44; consecutive patients were enrolled during their regularly scheduled clinic visits&#46; Patients enrolled were orthotopic liver transplantation recipients for hepatitis B infection at the Vancouver General Hospital at least one year prior to enrollment&#44; who had stable graft function &#40;ALT&#44; AST&#44; ALP&#44; GGT&#44; total and direct bilirubin&#41;&#44; and were on our centre&#8217;s standard IM HBIG protocol &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46; Patients were excluded if they had an episode of acute rejection within the past 6 months&#44; were non-compliant with bloodwork or injections&#44; changes had been made to their antiviral &#40;lamivudine or alternate agent&#41; or im-munosuppressive medication in the previous 6 months&#46; This study was approved by our institution&#8217;s ethics review board and all patients provided written informed consent prior to study entry&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">Our centre&#8217;s standard regimen in the stable post liver transplant patients with hepatitis B consists of 10 mL &#40;2170 IU&#41; HyperHEP B<span class="elsevierStyleSup">&#174;</span> &#40;Talecris Biothe-rapeutics Inc&#44; Research Triangle Park NC&#41; by IM injection as 2 x 5 mL injections into each gluteal muscle&#46; The dosing frequency is approximately once a month&#44; based on maintaining anti-HBs ti-tres &#62; 100 IU&#47;L according to a standard protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Intervention</span><p id="p0025" class="elsevierStylePara elsevierViewall">Patients meeting the inclusion and exclusion criteria were switched to the study SC injection protocol on their next scheduled IM injection date&#46; Each SC dose consisted of 10 ml &#40;3120 IU&#41; HBIG &#40;Hepa-Gam B&#174;&#44; Cangene Corp&#44; Winnipg MB&#44; Canada&#41; as 4 x 2&#46;5 mL injections&#44; administered as 2 injections into each arm&#46; As SC administration decreases absorption by 20&#37;&#44; it was deemed appropriate to use a higher total dose of HBIG for this initial study&#46; The use of 4 x 2&#46;5 mL injections was required as the maximum SC injection volume according to our institute&#8217;s patient care manual is 2&#46;5 mL&#46; Anti-HBs titres were measured at twice weekly intervals on Mondays and Thursdays after the first sc injection was given for a study period of 12 weeks&#46; Subsequent injections were given to maintain anti-HBs titres greater than 100 IU&#47;L&#44; and once titres were 100-150 IU&#47;L the next SC injection was given on the next scheduled bloodwork day&#46; All patients were continued on their baseline antiviral therapy for hepatitis B virus &#40;100 mg of lamivudine orally&#41; as per our center&#8217;s standard practice&#46; No changes were made to the antiviral therapy or immunosuppressive therapy during the study period&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">For safety purposes&#44; in addition to anti-HBs titres at study entry and then twice weekly&#44; assessment of graft function &#40;via AST&#44; ALT&#46; ALP&#44; GGT&#44; direct and total bilirubin&#41; was also done&#46; Routine monthly bloodwork including complete blood cell count&#44; electrolytes&#44; creatinine&#44; and immunosuppressive medication trough levels &#40;tacrolimus or cyclosporine&#41; continued as part of our centre&#8217;s standard of care&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">A questionnaire was given at the beginning and at the end of the study period to assess the pain intensity &#40;from a scale of 0-10&#44; 0 being no pain and 10 being very painful&#41; of each mode of administration &#40;IM versus SC&#41;&#44; and which mode the patients subjectively preferred&#46; The questionnaire further determined whether they experienced any local or systemic side effects from either or both medications in order to subjectively compare side effect profiles&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">Efficacy was objectively evaluated by recording the frequency of IM injections the patients required to maintain anti-HBs levels greater than 100 IU&#47;L prior to study enrollment&#44; the frequency of SC injections the patients required within the 12 week observation period&#44; as well as serial anti-HBS titres&#44; and liver function during the study period&#46; Patient satisfaction and adverse effects were subjectively measured via the aforementioned surveys&#46; All statistical analysis was descriptive&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="p0045" class="elsevierStylePara elsevierViewall">Seventeen patients were initially enrolled in the study&#46; Three patients subsequently withdrew consent secondary to the personal inconvenience of increased frequency of phleobotomy required for the study&#44; and two more patients were excluded due to non-adherence with the required bloodwork during the study period&#46; Therefore 12 patients were included in the data analysis &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>&#41;&#46; Of these patients 11 were male and 1 was female&#44; and the average age was 57&#46; All of the patients were adequately immuno-suppressed on 1 or 2 immunosuppressive medications&#44; and all patients had concomitant antiviral therapy with lamivudine 100 mg once daily&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0050" class="elsevierStylePara elsevierViewall">The maximum anti HBs titre post first injection &#40;Cmax&#41; was 465&#46;8 &#177; 94&#46;2 &#40;range 304&#46;8-631&#46;1&#41; The mean time to measured &#40;Tmax&#41; was 12 &#177; 4&#46;8 days&#44; &#40;range 7-21&#41;&#46; <a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a> outlines the mean anti-HBs titres over time following the first injection until the next dose was administered&#46; Individual patient anti HBs titres over the entire 12 week study period is depicted in <a class="elsevierStyleCrossRef" href="#f0010">Figure 2</a>&#46; Only one patient deviated from protocol and fell below an anti HBs titre of 100 IU&#47;L during the study period due to injection scheduling problems&#46; As the IM injections were administered according to the standard protocol with anti HBs ti-tres measured at 4 weeks post injection&#44; and SC injections were administered whenever the measured anti HBs titre was less than 150 IU&#47;L&#44; it was determined a priori that direct comparison between the two medications could not be made in this study&#46; Injections were required on average every 48&#46;4 days while the patients were receiving HBIG intramuscularly&#44; and every 56&#46;5 days when receiving the drug subcutaneously&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0055" class="elsevierStylePara elsevierViewall">All except one patient had normal liver biochemical levels for the 6 month period prior to study enrollment&#44; while maintained on IM HBIG for anti-reinfection prophylaxis&#46; These values remained stable throughout the study period&#46; The one patient who did have elevated liver enzymes prior to enrollment had a long standing history of idiopathic post-transplant hepatitis and steatosis&#44; with multiple biopsies since 2005 suggestive of this&#46; A liver biopsy performed on this patient during the study period suggested histopathological improvement when compared with previous biopsies&#44; and liver biochemistry was at its lowest level in the past 4 years and did not change during the study period&#46; Although routine HBV DNA levels were not done on these patients&#44; there was no clinical or bloodwork abnormalities that raised suspicion of graft re-infection&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Pre and Post study questionnaires were completed by 9 of 12 patients&#46; The patients mean rating of pain associated with the injections&#44; based on the previously mentioned pain scale of 0-10&#44; was 5 for the IM route and 1&#46;6 for the SC route&#46; Based on subjective responses to the question &#8220;have you experienced any adverse reaction at the site of the intramuscular &#40;into the muscle&#41; injection&#8221;&#44; 6 of 9 &#40;667&#41; patients specifically reported significant pain that lasted for over a day after the IM injections&#46; 7 patients &#40;787&#41; described the SC injections as &#8220;much less painful&#8221;&#44; 5 patients described less bruising&#44; and all nine patients reported less burning&#47;stinging with the SC injections as compared to IM&#46; All 9 patients did not find the 4 SC injections as a disadvantage when compared to the 2 IM injections&#44; and over half found the 4 injections easier&#46; All 9 patients preferred the SC injections to the IM&#46; No local or systemic adverse effects were reported with either injection method&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="p0065" class="elsevierStylePara elsevierViewall">Patients with end stage liver disease secondary to HBV infection represent 10-20&#37; of all recipients of orthotopic liver transplants in America&#44; and this number is higher in regions such as China where the prevalence of HBV is higher&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> These patients are at significant risk of graft re-infection if appropriate prophylaxis is not employed<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> HBV re-infection leads to graft dysfunction and may lead to chronic hepatitis&#44; cholestatic fibrosing hepatitis and progressive cirrhosis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The risk of graft re-infection has been shown to be associated with pre-transplant viral replicavity&#44; represented by the presence of Hepatitis B e antigen &#40;HBeAg&#41; in the serum&#44; and with a detectable HBV DNA load&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Additionally&#44; the presence of an extra-hepatic reservoir of latent HBV in sites such as blood&#44; mononuclear cells and the spleen provide an ongoing source of infection even after liver transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">Passive immunization with HBIG has been used since the 1980&#8217;s to prophylax against post-transplant re-infection&#44; and recurrence rates dropped to 20-40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> HBIG works by binding to and neutralizing circulating HBV and hepatitis B surface antigen &#40;HBsAg&#41;&#44; and by entering hepatocytes via endocytosis and interacting with and decreasing release of HBsAg&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> HBIG effectively prophylaxes against re-infection when used in doses sufficient to maintain anti HBs titres greater than 100 IU&#47;L&#46; It is believed that passive immunization alone cannot reduce re-infection rates further because of the development of a mutation in the S region of the genome&#44; which encodes the HBsAg&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Moreover&#44; passive immunization does not affect the presence of HBe-Ag&#44; which as mentioned above is associated with reinfection&#46; Therefore the addition of antiviral agents such as lamivudine was introduced to the regimen in the late 1990&#8217;s&#44; and re-infection rates were successfully reduced to 0-10&#37;&#44; such that these patients have a similar or better prognosis than those patients receiving a liver transplant for other reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Effective protection against graft re-infection is sustained when the regimen of paren-teral HBIG and oral antiviral agents are continued long-term&#44; as HBV DNA becomes detectable again when HBIG is discontinued&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Although initially administered IV&#44; low dose intramuscular HBIG has been shown to effectively prophylax against graft reinfection and be more cost effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="p0075" class="elsevierStylePara elsevierViewall">Ultimately&#44; this means that patients who receive liver transplantation for HBV must be subjected to many years&#44; if not a lifetime&#44; of painful IM injections&#46; As demonstrated by our pre-study questionnaires&#44; patients do report substantial pain and discomfort from the IM injections&#44; and would prefer an alternative route that would be more comfortable yet as efficacious in preventing graft re-infection&#46; Given that IM administration is titrated to anti HBs levels greater than 100&#44; and that maintenance of anti HBs above this level is thought to be adequate protection against re-infection&#44; it stands to reason that another&#44; less painful route to administer HBIG and maintain such therapeutic levels would be more attractive to the patients&#46; Furthermore&#44; IM injections are contraindicated in patients with coagulopa-thies or those pharmaceutically anticoagulated for other comorbidities&#46; IM injections have also been associated with such complications as skin necrosis&#44; nerve injury&#44; nicolau syndrome &#40;severe pain&#44; skin discolouration&#44; and tissue necrosis requiring amputation after IM injections&#41; infection and sepsis&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Protecting patients from such complications by employing a safer route of administration is also an attractive strategy&#46; This study&#44; as well as our previously published case report&#44; shows that SC HBIG adequately maintains anti HBs levels greater than 100 IU&#47;L without significantly altering the frequency of injections required in stable liver transplant recipients maintained on an IM protocol&#46; Throughout the 12-week study period&#44; the liver enzymes did not change while the patients received the HBIG SC&#44; nor was there any clinical changes that raised suspicion of graft re-infection&#44; thus showing that the alternative route did not increase the risk of rejection&#44; graft dysfunction or re-infection&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">The main disadvantage to subcutaneous administration is the lower volume injection which requires increased needle pokes for each dose&#46; Interestingly&#44; the patients did not object to the 2 extra injections required for SC administration according to the survey results&#44; and some even felt that the 4 total SC injections took less time than the 2 IM injections&#46; This affords patients the safety and comfort of SC injections without making their clinic visits to receive the drug any more frequent or time consuming&#46; It would be an appropriate next step to determine if a lower dosage of SC HBIG could mimic these effects and allow for a lower total volume and less injections while maximizing efficacy&#46; Moreover&#44; diabetic patients have for decades been self sufficient in administering their own subcutaneous insulin&#44; and the advent of pre-filled insulin pens further increased patient safety and satisfaction&#46; <span class="elsevierStyleSup">27-29</span> Therefore the results of this study may result in a system by which patients do not need to attend clinic to receive their HBIG&#44; but rather administer it themselves via vials or prefilled pens&#46; The patients could have standard bloodwork measuring anti HBs levels&#44; which can be monitored by transplant clinic staff&#44; and the patient contacted when their next HBIG dose is required&#46; This will provide the patient with substantial autonomy&#44; and be very convenient to those patients residing in remote regions afar from tertiary transplantation centres&#46; A further area of study may be for standard dosing frequency given that in the individual pharmacokinetic curves of SC HBIG for each patient in this study&#44; the rate of decline of anti HBs between injections was also slow and predictable&#46; This may allow for an initial individualiza-tion of dosing frequency and a reduction in the total bloodwork required for the regimen&#46; Larger studies will be invaluable to determine pharmacokinetics of this medication which will allow evolution of new protocols for SC HBIG incorporating these proposed lower doses and self-administration&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">Very striking in this study was the result that 100&#37; of patients who returned the survey subjectively preferred SC HBIG when compared with IM&#44; and reported less pain with the former&#46; Furthermore&#44; they also reported less bruising&#44; burning and stinging&#44; thus alleviating many of the patient concerns associated with IM injections&#46; Such marked patient preference and satisfaction is difficult to ignore&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="p0090" class="elsevierStylePara elsevierViewall">Patients who receive liver transplantation for end stage liver disease secondary to HBV infection require long-term prophyllaxis against graft re-infection with HBIG and antiviral therapy&#46; This study shows that SC administration of HBIG can effectively maintain anti HBs levels above the requisite 100 IU&#47;L while substantially decreasing patient discomfort and improving patient satisfaction&#44; and therefore becomes a very attractive alternative to IM HBIG injections&#46; This study also shows that SC HBIG can be used as a safe alternative to IM HBIG when intramuscular injections are contraindicated&#46; Further studies and wider use of SC HBIG based on this study may alter the standard practice of transplantation centres&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Disclosure</span><p id="p0095" class="elsevierStylePara elsevierViewall">This study was supported by an unrestricted research grant by Cangene Corporation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Acknowledgements</span><p id="p0100" class="elsevierStylePara elsevierViewall">The investigators sincerely thank the Solid Organ Transplant Clinic staff especially Ms&#46; Irene Tse RN and Ms&#46; Jo-Anne Harrigan RN&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:3 [
          "identificador" => "xres1217530"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abs0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1132911"
          "titulo" => "Key words"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        3 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study design and patients"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Intervention"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Results"
        ]
        5 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
        ]
        6 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusion"
        ]
        7 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Disclosure"
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Acknowledgements"
        ]
        9 => array:1 [
          "titulo" => "Reference"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec1132911"
          "palabras" => array:6 [
            0 => "Hepatitis B"
            1 => "Immune globulin"
            2 => "Liver transplantation"
            3 => "Subcutaneus"
            4 => "Prophylaxis"
            5 => "HBIG"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Background&#46;</span> Patients who receive liver transplantation for chronic hepatitis B infection require long-term combination therapy with hepatitis B immunoglobulin &#40;HBIG&#41; and oral antiviral medication to prophylax against graft re-infection&#46; This study examines the efficacy and patient preference of subcutaneous &#40;SC&#41; administration of HBIG in maintaining anti HBs titres &#62; 100 IU7L&#46;</p><p id="sp1025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Materials and methods&#46;</span> 12 patients who were stable while receiving our standard IM HBIG protocol received an alternate formulation by SC injection&#44; consisting of 10 mL &#40;3120 IU&#41; HBIG as 4 x 2&#46;5 mL SC injections&#46; SC injection were repeated as soon as titres reached 100-150 IU&#47;mL during the 3 month study period&#46; A questionnaire was administered upon study entry and exit to subjectively assess patient preference&#46;</p><p id="sp2025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Results&#46;</span> Anti-HBs Cmax after first injection was 441&#46;6 IU&#47;L &#177; 81&#46;5&#44; and Tmax was 7&#46;1 &#177; 3&#46;2 days&#46; SC injections were required every 56 days&#44; which compared well to the frequency of required IM injections prior to study enrollment of 45 days&#46; The patients mean ratings of pain on a 0-10 scale were 5 for the IM route and 1&#46;6 for the SC route&#46; All patients preferred the SC injections to the IM&#46;</p><p id="sp3025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Conclusion&#46;</span> SC administration of HBIG can effectively maintain anti HBs levels above the requisite 100 IU&#47;L while substantially decreasing patient discomfort and improving patient satisfaction&#44; and therefore becomes a very attractive alternative to IM HBIG injections&#46; Further studies and wider use of SC HBIG based on this study may alter the standard practice of transplantation centers&#46;</p></span>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "f0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 661
            "Ancho" => 1003
            "Tamanyo" => 58716
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Mean anti-HBs titres post first injection over time&#46; The number of patients at each time value changes based on patient compliance with bloodwork each week&#44; and with those that need to be removed from this figure as they required a repeat injection&#44; such that n values are shown at each week&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "f0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1515
            "Ancho" => 2074
            "Tamanyo" => 238186
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Anti-HBs titres for each patient over time throughout the study period&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "t0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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="center" valign="middle" scope="col">Anti HBs Titre &#40;IU&#47;L&#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="center" valign="middle" scope="col">Action&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="center" valign="middle">&#62; 300&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="center" valign="middle">Recheck level in 2 weeks&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="center" valign="middle">200-300&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="center" valign="middle">Injection in 3 weeks&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="center" valign="middle">150-200&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="center" valign="middle">Injection in 2 week&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="center" valign="middle">100-150&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
                  \t\t\t\t  " align="center" valign="middle">Injection in 1 week&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="center" valign="middle">&#60; 100&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="center" valign="middle">Injection now&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2078584.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Standard protocol to determine frequency of IM HBIG injections based on Anti HBs titres&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "t0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="npara0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">TAC&#58;</span> Tacrolimus&#46; <span class="elsevierStyleBold">MMF&#58;</span> Mycophenolate mofetil&#46; <span class="elsevierStyleBold">CSA&#58;</span> Cyclosporine&#46; <span class="elsevierStyleBold">AZA&#58;</span> Azathioprine&#46;</p>"
          "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="center" valign="middle" scope="col">Characteristic&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="center" valign="middle" scope="col">Variable&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="center" valign="middle" scope="col">Patients &#40;&#37;&#41;&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="center" valign="middle">Gender&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="center" valign="middle">Male&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="center" valign="middle">11 &#40;91&#46;7&#41;&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="center" valign="middle">&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="center" valign="middle">Female&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="center" valign="middle">1&#40;8&#46;3&#41;&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="center" valign="middle">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="center" valign="middle">Mean &#40;SD&#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="center" valign="middle">56&#46;7 &#40;9&#46;38&#41;&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="center" valign="middle">&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="center" valign="middle">Range&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="center" valign="middle">30-66&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="center" valign="middle">Antiviral Therapy&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="center" valign="middle">Lamivudine&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="center" valign="middle">12 &#40;100&#37;&#41;&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="center" valign="middle">Immunosuppressive Therapy&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="center" valign="middle">TAC&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="center" valign="middle">3 &#40;25&#41;&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="center" valign="middle">&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="center" valign="middle">MMF&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="center" valign="middle">1 &#40;8&#46;3&#41;&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="center" valign="middle">&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="center" valign="middle">TAC &#43; CSA&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="center" valign="middle">1 &#40;8&#46;3&#41;&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="center" valign="middle">&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="center" valign="middle">TAC &#43; AZA&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="center" valign="middle">2 &#40;16&#46;7&#41;&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="center" valign="middle">&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="center" valign="middle">CSA &#43; AZA&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="center" valign="middle">4 &#40;33&#46;3&#41;&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="center" valign="middle">&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="center" valign="middle">TAC &#43; MMF&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="center" valign="middle">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2078585.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Demographics&#44; antiviral therapy and immunosuppressive regimens of study patients&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Reference"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0005"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recurrent Viral Liver Disease &#40;Hepatitis B and C&#41; After Liver Transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Olivera-Martinez A&#46;M&#46;"
                            1 => "Gallegos-Orezco J&#46;F&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arcmed.2006.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Archives of Medical Research"
                        "fecha" => "2007"
                        "volumen" => "38"
                        "paginaInicial" => "691"
                        "paginaFinal" => "701"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17613360"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of hepatitis B virus recurrence after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Eisenbach C&#46;"
                            1 => "Sahuer P&#46;"
                            2 => "Mehrabi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1399-0012.2006.00609.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clinical Transplantation"
                        "fecha" => "2006"
                        "volumen" => "20"
                        "paginaInicial" => "111"
                        "paginaFinal" => "116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17100710"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review&#58; Hepatitis B Immune Globulin for Prevention of Hepatitis B Infection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Zuckerman J&#46;N&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jmv.20816"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Med Virol"
                        "fecha" => "2007"
                        "volumen" => "79"
                        "paginaInicial" => "919"
                        "paginaFinal" => "921"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17516515"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Liver transplantation for chronic hepatitis B infection with the use of combination lamivudine and low-dose hepatitis B immune globulin"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:5 [
                            0 => "Yoshida E&#46;M&#46;"
                            1 => "Erb S&#46;R&#46;"
                            2 => "Partovi N&#46;"
                            3 => "Scudamore C&#46;H&#46;"
                            4 => "Chung S&#46;W&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl Surg"
                        "fecha" => "1999"
                        "volumen" => "5"
                        "paginaInicial" => "520"
                        "paginaFinal" => "525"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10545541"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of Hepatitis B Recurrence after Liver Transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Seehofer D&#46;"
                            1 => "Berg T&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Transplantation"
                        "fecha" => "2005"
                        "volumen" => "80"
                        "paginaInicial" => "S120"
                        "paginaFinal" => "S124"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16286888"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prophylaxis and Treatment of Recurrent Hepatitis B After Liver Transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Lo C&#46;M&#46;"
                            1 => "Fan S&#46;T&#46;"
                            2 => "Liu C&#46;L&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Trans-plantation"
                        "fecha" => "2003"
                        "volumen" => "75"
                        "numero" => "3"
                        "paginaInicial" => "S41"
                        "paginaFinal" => "S44"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subcutaneous administration of hepatitis B immune globulin in combination with lamivudine following orthotopic liver transplantation&#58; effective prophylaxis against recurrence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Powell J&#46;J&#46;"
                            1 => "Apiratpracha W&#46;"
                            2 => "Partovi N&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1399-0012.2006.00517.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clinical Transplantation"
                        "fecha" => "2006"
                        "volumen" => "20"
                        "paginaInicial" => "524"
                        "paginaFinal" => "525"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16842532"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A study of the pharmacokinetic profile of low-dose hepatitis B immune globulin in long-term liver transplant recipients for chronic hepatitis B"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Partovi N&#46;"
                            1 => "Guy M&#46;W&#46;"
                            2 => "Ensom M&#46;H&#46;H&#46;"
                            3 => "Noble M&#46;A&#46;"
                            4 => "Yoshida E&#46;M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Transpl"
                        "fecha" => "2001"
                        "volumen" => "1"
                        "paginaInicial" => "51"
                        "paginaFinal" => "54"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hepatitis B immune globulin to prevent hepatitis B virus graft re-infection following liver transplantation&#58; a concise review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Shouval D&#46;"
                            1 => "Samuel D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jhep.2000.19789"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2000"
                        "volumen" => "32"
                        "paginaInicial" => "1189"
                        "paginaFinal" => "1195"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11093723"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of hepatitis B infection in liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Vierling J&#46;M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7150/ijms.2.41"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Med Sci"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "41"
                        "paginaFinal" => "49"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15968339"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Liver transplantation in European patients with the hepatitis B surface antigen"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Samuel D&#46;"
                            1 => "Muller R&#46;"
                            2 => "Alexander G&#46;"
                            3 => "Fassati L&#46;"
                            4 => "Ducot B&#46;"
                            5 => "Benhamou J&#46;P&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199312163292503"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1993"
                        "volumen" => "329"
                        "paginaInicial" => "1842"
                        "paginaFinal" => "1847"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8247035"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized study comparing lamivudine monotherapy after a short course of hepatitis B immune globulin &#40;HBIg&#41; and lamivudine with long-term lamivudine plus HBIg in the prevention of hepatitis B virus recurrence after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Buti M&#46;"
                            1 => "Mas A&#46;"
                            2 => "Prieto M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2003"
                        "volumen" => "38"
                        "paginaInicial" => "811"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12763375"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endocytosis of hepatitis B immune globulin into hepatocytes inhibits the secretion of hepatitis B virus surface antigen and virions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Schilling R&#46;"
                            1 => "Ijaz S&#46;"
                            2 => "Davidoff M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/jvi.77.16.8882-8892.2003"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Virol"
                        "fecha" => "2003"
                        "volumen" => "77"
                        "paginaInicial" => "8882"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12885906"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome of liver transplantation for hepatitis B in the United States"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Kim W&#46;R&#46;"
                            1 => "Poterucha J&#46;J&#46;"
                            2 => "Kreimers W&#46;K&#46;"
                            3 => "Ishitani M&#46;B&#46;"
                            4 => "Dickson E&#46;R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/lt.20217"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2004"
                        "volumen" => "10"
                        "paginaInicial" => "968"
                        "paginaFinal" => "974"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15390321"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combination low-dose hepatitis B immune globulin and lamivudine therapy provides effective prophylaxis against post-transplantation hepatitis B"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Angus P&#46;W&#46;"
                            1 => "McCaughan G&#46;W&#46;"
                            2 => "Gane E&#46;J&#46;"
                            3 => "Crawford D&#46;H&#46;"
                            4 => "Harley M&#46;H&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jlts.2000.8310"
                      "Revista" => array:6 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2000"
                        "volumen" => "6"
                        "paginaInicial" => "429"
                        "paginaFinal" => "433"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10915163"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Passive immunopro-phylaxis after liver transplantation in HBsAgpositive patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Samuel D&#46;"
                            1 => "Bismuth A&#46;"
                            2 => "Mathieu D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/0140-6736(91)92515-4"
                      "Revista" => array:5 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1991"
                        "volumen" => "337"
                        "paginaInicial" => "813"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1672913"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improved clinical outcomes with liver transplantation for hepatitis Binduced chronic liver failure using passive immunization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Sawyer R&#46;G&#46;"
                            1 => "McGory R&#46;W&#46;"
                            2 => "Gaffey M&#46;J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/00000658-199806000-00007"
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "1998"
                        "volumen" => "227"
                        "paginaInicial" => "841"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9637547"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention and treatment of hepatitis B virus reinfection after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Cai C&#46;J&#46;"
                            1 => "Zhao H&#46;"
                            2 => "Yang Y&#46;"
                            3 => "Chen G&#46;H&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Zhonghua Wai Ke Za Zhi"
                        "fecha" => "2006"
                        "volumen" => "44"
                        "paginaInicial" => "742"
                        "paginaFinal" => "744"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16836920"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Conversion from intravenous to intramuscular hepatitis B immune globulin in combination with lamivudine is safe and cost-effective in patients receiving long-term prophylaxis to prevent hepatitis B recurrence after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Han S&#46;H&#46;"
                            1 => "Martin P&#46;"
                            2 => "Edelstein M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jlts.2003.50002"
                      "Revista" => array:5 [
                        "tituloSerie" => "Liver Transpl"
                        "fecha" => "2003"
                        "volumen" => "9"
                        "paginaInicial" => "182"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12548512"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intramuscular hepatitis B immune globulin combined with lamivudine for prophylaxis against hepatitis B recurrence after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Yao F&#46;Y&#46;"
                            1 => "Osorio R&#46;W&#46;"
                            2 => "Roberts J&#46;P&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Liver Transpl Surg"
                        "fecha" => "1999"
                        "volumen" => "5"
                        "paginaInicial" => "491"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10545536"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Costeffective and safe ambulatory long-term immunoprophylaxis with intramuscular instead of intravenous hepatitis B immunoglobulin to prevent reinfection after orthotopic liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Faust D&#46;"
                            1 => "Rabenau H&#46;F&#46;"
                            2 => "Allwinn R&#46;"
                            3 => "Caspary W&#46;F&#46;"
                            4 => "Zeuzem S&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Transplant"
                        "fecha" => "2003"
                        "volumen" => "17"
                        "paginaInicial" => "254"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12780677"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized study of adefovir dipivoxil in place of HBIG in combination with lamivudine as post-liver transplantation hepatitis B prophylaxis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Angus P&#46;W&#46;"
                            1 => "Patterson S&#46;J&#46;"
                            2 => "Strasser S&#46;I&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.22524"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2008"
                        "volumen" => "48"
                        "paginaInicial" => "1460"
                        "paginaFinal" => "1466"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18925641"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin necrosis after self-administered intramuscular diclofenac"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Uri O&#46;"
                            1 => "Arad E&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bjps.2014.08.054"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Plast Reconstr Aesthet Surg"
                        "fecha" => "2009"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25216566"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nicolau Syndrome&#58; three cases and review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:4 [
                            0 => "Luton K&#46;"
                            1 => "Garcia C&#46;"
                            2 => "Poletti E&#46;"
                            3 => "Koester A&#46;D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-4632.2006.02674.x"
                      "Revista" => array:7 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "2006"
                        "volumen" => "45"
                        "numero" => "11"
                        "paginaInicial" => "1326"
                        "paginaFinal" => "1328"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17076716"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Quality of life and treatment satisfaction in patients being treated with long-acting insulin analogues&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Hagenmeyer E&#46;G&#46;"
                            1 => "Shadlich P&#46;K&#46;"
                            2 => "Koster A&#46;D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-0029-1208087"
                      "Revista" => array:7 [
                        "tituloSerie" => "Dtsch Med Wochenschr"
                        "fecha" => "2009"
                        "volumen" => "134"
                        "numero" => "12"
                        "paginaInicial" => "565"
                        "paginaFinal" => "570"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19277932"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Insulin delivery with Flex-Pen&#58; dose accuracy&#44; patient preference and adherence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:8 [
                            0 => "Pf&#252;tzner A&#46;"
                            1 => "Asakura T&#46;"
                            2 => "Sommavilla B&#46;"
                            3 => "Lee W&#46;"
                            4 => "Pf&#252;tzner A&#46;"
                            5 => "Asakura T&#46;"
                            6 => "Sommavilla B&#46;"
                            7 => "Lee W&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1517/17425247.5.8.915\t"
                      "Revista" => array:7 [
                        "tituloSerie" => "Expert Opin Drug Deliv"
                        "fecha" => "2008"
                        "volumen" => "5"
                        "numero" => "8"
                        "paginaInicial" => "915"
                        "paginaFinal" => "925"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18713000"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety&#44; simplicity and convenience of a modified prefilled insulin pen"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Sommavilla B&#46;"
                            1 => "J&#248;rgensen C&#46;"
                            2 => "Jensen K&#46;H&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1517/14656566.9.13.2223\t"
                      "Revista" => array:7 [
                        "tituloSerie" => "Expert Opin Pharmacother"
                        "fecha" => "2008"
                        "volumen" => "9"
                        "numero" => "13"
                        "paginaInicial" => "2223"
                        "paginaFinal" => "2232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18710348"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/16652681/0000000900000002/v1_201907070740/S1665268119316564/v1_201907070740/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "77721"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Original Article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/16652681/0000000900000002/v1_201907070740/S1665268119316564/v1_201907070740/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119316564?idApp=UINPBA00004N"
]
Article information
ISSN: 16652681
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 1 0 1
2024 October 39 14 53
2024 September 36 17 53
2024 August 25 20 45
2024 July 42 9 51
2024 June 28 7 35
2024 May 25 2 27
2024 April 17 4 21
2024 March 25 7 32
2024 February 29 7 36
2024 January 26 3 29
2023 December 26 14 40
2023 November 23 7 30
2023 October 47 12 59
2023 September 32 9 41
2023 August 35 5 40
2023 July 32 8 40
2023 June 41 4 45
2023 May 66 9 75
2023 April 50 4 54
2023 March 74 1 75
2023 February 42 12 54
2023 January 30 20 50
2022 December 46 5 51
2022 November 33 11 44
2022 October 35 14 49
2022 September 41 5 46
2022 August 73 9 82
2022 July 55 12 67
2022 June 57 9 66
2022 May 42 16 58
2022 April 42 11 53
2022 March 43 8 51
2022 February 34 6 40
2022 January 42 8 50
2021 December 20 6 26
2021 November 43 10 53
2021 October 48 23 71
2021 September 40 18 58
2021 August 41 3 44
2021 July 10 8 18
2021 June 13 8 21
2021 May 27 10 37
2021 April 78 13 91
2021 March 48 20 68
2021 February 29 15 44
2021 January 14 12 26
2020 December 7 6 13
2020 November 5 12 17
2020 October 5 8 13
2020 September 11 4 15
2020 August 8 8 16
2020 July 5 2 7
2020 June 6 10 16
2020 May 2 5 7
2020 April 0 4 4
2020 March 6 8 14
2020 February 2 4 6
2020 January 3 9 12
2019 December 3 12 15
2019 November 5 6 11
2019 October 1 3 4
2019 September 2 6 8
2019 August 1 1 2
2019 July 2 5 7
Show all

Follow this link to access the full text of the article

es en pt

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

Are you a health professional able to prescribe or dispense drugs?

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