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Multaq Attorney : Chronic Hepatitis B—HBeAg positive

People with HBeAg positive chronic hepatitis B have only an 8 to 15 percent probability each year of becoming negative for HBeAg and HBV DNA. This is known as a spontaneous remission. When this happens, temporary gross eleva­tion in transaminases (AST and ALT) is observed, followed by a rapid return to normal levels. Antibodies to HBeAg (known as HBeAb) are formed. This is known as seroconversion. These people are no longer contagious to others and they experience minimal, if any. liver damage going forward. In fact, any past liver damage often resolves within the next few years. This resolution confirms the transition from chronic hepatitis B into the inactive HBsAg carrier state, as discussed above. Women, older people, and those individuals with genotype B are likeliest to seroconvert. Unfortunately, reactivation to the infectious state can occur in some of these people. Thus, these people must be observed carefully, ft is not clear which factors play a role in causing some people to relapse into an in­fectious state. Certainly excessive alcohol intake may have a harmful effect on people with chronic hepatitis B. And it has been demonstrated that excessive iron intake may promote persistent HBV replication in some people. (Excessive iron in itself can damage the liver and may lead to cirrhosis and liver cancer. This is dis­cussed in more detail in chapters 18 and 23.) Therefore, people with chronic hep­atitis B are advised to refrain from alcohol intake and should avoid excess iron supplementation. Seroconverters whose immune systems subsequently become compromised are at risk for a relapse. Immune-system function can become im­paired by a number of factors, including infection with the human immunodefi­ciency virus (HIV), treatment with chemotherapeutic agents for cancer, or use of corticosteroids such as prednisone.

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Chronic Hepatitis B—HBeAg negative

People with chronic hepatitis B who are negative for HBeAg have a mutant strain of chronic hepatitis B. A mutation is a permanent alteration of the hepatitis B virus’s genetic makeup. There are many different types of hepatitis B mutations. In this case, the genetic mutation is characterized by the failure of the virus to make the hepatitis B “e” antigen (HBeAg). This is known as a precore mutation. This mutation does not affect the virus’s ability to replicate. Therefore, on blood tests, these people are negative for HBeAg, but positive for HBV DNA. Men are more likely than women to have this mutation, and HBeAg negative chronic hep­atitis B does not occur with genotype A. Precore mutant hepatitis B has been responsible for several cases of surprised transmission of hepatitis B to others, as these people were unaware that they were infectious. This strain of hepatitis B may be genetically superior to HBeAg positive chronic hepatitis B. Thus, liver disease is usually more active and liver scarring more advanced. These individu­als are more likely to develop cirrhosis compared with HBeAg positive people. Furthermore, this strain is usually more resistant to treatment.

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In some instances, a person who is HBsAg positive can become HBsAg negative, which is the last category of chronic hepatitis B, known as resolved chronic hep­atitis B. However, it is very uncommon and occurs only at a rate of approxi­mately 0.5 to 2 percent of hepatitis patients each year. Loss of HBsAg is more likely to occur in women than men and is rare in people with the mutant strain.

Most, but not all, people who do resolve will develop the hepatitis B anti­body (HbsAb). Liver enzymes (ALT and AST) normalize. Clearance of hepatitis B antigen decreases the risk of progression to liver failure and liver cancer. Most people who have resolved have a benign course of disease. However, approxi­mately half of these people continue to have very low levels of HBV DNA and are considered to be noninfectious to others.

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Multaq Attorneys : A low level, also considered a noninfectious level of HBV DNA, is defined as less than 10,000 copies/ml. These low HBV DNA levels are only detectable if a very sensitive laboratory assay known as the polymerase chain reaction (PCR) is used. The PCR assay has the ability to detect levels as low 200 copies/ml. (These test results are often reported in picograms per milliliters (pg/ml) lpg/ml =

280,0 copies/ml.) In situations where people with resolved hepatitis B experi­ence severe immune suppression, such as cancer chemotherapy or organ trans­plantation, chronic hepatitis B can be reactivated. This means that HBsAg will become positive again.

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More than 1 million people worldwide die each year from hepatitis B. So, why is it that some people can live a long healthy life with hepatitis B and others experience serious complications? Well, it has been demonstrated that there are many factors that influence the progression from a mild, innocuous illness to a grave outcome. These factors include advanced age, general poor health—tor ex­ample, depressed immune status such as additionally infection with HIV; the presence of advanced damage found on a liver biopsy sample; and the presence of markers of chronicity and active infectiousness, especially HBV DNA. Simi­larly, people who do not clear HBeAg (spontaneous remission) tend to have a more aggressive course than those who clear HBeAg. In fact, in some studies it has been shown that people who clear HBeAg rarely progress to cirrhosis. Fur­thermore, people who clear HBeAg. whether spontaneously or from treatment, have a decreased incidence of liver failure and an improved long-term survival rate. People who are additionally infected with the hepatitis delta virus (HDV) (see page 106) or the hepatitis C virus (see chapter 10) also have poorer prog­noses. In addition, it has been shown that the outcome of a person infected with HBV is highly dependent upon the stage at which she first obtained medical at­tention. Those people who have more advanced disease on liver biopsy samples when initially seen by a specialist have a shorter survival time. It has also been found that people with genotype C have a worse prognosis than those with other genotypes. Lastly, it has been demonstrated that people infected with HBV are more susceptible to the toxic effects of alcohol on the liver than are those with­out HBV. Therefore, it is important for people with chronic hepatitis B to avoid all intake of alcohol, as alcohol may worsen the course and accelerate the pro­gression of the disease. See chapter 17 for more information on

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The Long-term Prognosis for Those with Chronic Hepatitis B

The probability each year that a person with chronic hepatitis B will develop cir­rhosis is about 2 percent. However, different studies have reported rates varying from 0.1 to 10 percent per year. The cumulative probability of progression to cir­rhosis over five years is approximately 15 to 20 percent. After the development of cirrhosis, the probability of developing serious complications, such as decom­pensated cirrhosis, is about 2 to 10 percent each year. The five-year survival rate after cirrhosis has developed varies from 52 to 80 percent. However, if a person has decompensated cirrhosis, the five-year survival rate decreases to between 14 and 35 percent.

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Multaq Lawsuit : Chronic Hepatitis B and Long-term Liver Cancer Risk

People with chronic hepatitis B are at increased risk for developing liver cancer. The exact risk is unknown, but in some studies, people with chronic hepatitis B were two hundred times more likely to develop liver cancer compared with people without this disease. Cancer usually occurs in those who have developed cirrhosis. However, cancer can also occur in chronic HBV carriers without cir­rhosis. In fact, in some parts of the world where hepatitis B is endemic, such as in Africa, up to 30 percent of people with chronic hepatitis B develop liver can­cer without underlying cirrhosis.

Prom the time a person becomes infected with HBV, liver cancer generally takes about twenty to thirty years to develop. Thus, people who were infected at birth can develop liver cancer as early as the age of twenty. It appears that infec­tion with both HBV and HCV or infection with both HBV and HDV, drinking ex­cessive alcohol, and having a family history of HCC can increase the likelihood that a person will develop liver cancer. It has been noted that men appear to have an increased risk ot developing HCC compared to women. Whether this is due to hormonal differences is unclear. See chapter 19 for more information on HBV and liver cancer.

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THE HEPATITIS DELTA VIRUS (HDV)

Hepatitis D is inflammation of the liver due to a virus called the hepatitis delta virus (HDV). HDV is a virus that can live only in people with hepatitis B. Ap­proximately 70,000 people in the United States are infected with HDV. Although HDV only accounts for a small percentage of cases of chronic viral hepatitis, it tends to be particularly severe and to have significant long-term consequences. In fact, chronic hepatitis D causes more than one thousand deaths each year in the United States. In the 1970s, hepatitis delta virus infection was endemic through­out Southern Europe. However, by the 1990s the incidence of HDV infection had significantly decreased. In fact, one study done in Italy estimated that the num­ber of cases of HDV within that country decreased by 1.5 percent each year from 1987 to 1997. And, it is anticipated that this trend will continue. Currently, new HDV infections are rare.

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HDV infection may be silent or may cause the same kind of fatigue and other symptoms associated with other forms of hepatitis. However, up to 20 percent of hepatitis D patients develop fulminant hepatitis, a particularly serious condition that requires hospitalization. See chapter 7 for a discussion on fulminant hepatitis.

HDV is transmitted through the same blood, sexual, and perinatal routes as HBV, which were discussed on page 92. There are two ways in which a person infected with HBV may become infected with HDV: coinfection and superinfection. When HBV and HDV are acquired at the same time, it is known as coinfection. In 90 to 95 percent of cases, such people will be able to completely eliminate both viruses from their bodies. This means that only approximately 5 to 10 percent of coinfected individuals go on to develop chronic hepatitis B and D. HDV can also be acquired by someone who already has chronic hepatitis B. This is known as superinfection. In contrast to people infected with both viruses simultaneously, approximately 70 to 95 percent of people who become infected in this two-step fashion progress to chronic hepatitis D.

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LONG-TERM PROGNOSIS FOR THOSE WITH CHRONIC HEPATITIS B AND D

Compared with people who have chronic hepatitis B alone, those with chronic infections of both HBV and HDV are more likely to have a poor outcome. These people tend to develop cirrhosis more frequently and more rapidly than those with chronic hepatitis B alone. Approximately 60 to 70 percent ot all people with chronic hepatitis D develop cirrhosis, and 15 percent of them develop cirrhosis in two years or less from the time of initial infection. This is much more frequent and rapid than for any other form of chronic viral hepatitis. People with both chronic hepatitis B and chronic hepatitis D are also more likely to develop com­plications, such as liver failure and liver cancer, and are more likely to require a liver transplant as compared with people suffering from other forms of chronic viral hepatitis.

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WHAT IS HEPATITIS C?

Hepatitis C is inflammation of the liver due to a virus called the hepatitis C virus (HCV). After the discovery of the hepatitis A virus in 1973 and the hepatitis B virus in 1963, the remaining hepatitis viruses were lumped into the category of non-A non-B (NANB) hepatitis. Any cases of acute or chronic hepatitis or cirrhosis with­out identifiable causes were suspected to be a result of the NANB hepatitis viruses. In 1989, a major breakthrough regarding this mysterious and intriguing disease occurred—the hepatitis C virus was identified. Now, HCV is believed to be the virus responsible for more than 90 percent of all cases of NANB hepatitis.

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HCV is the most common cause of cirrhosis and liver cancer in the United States. More than 4 million Americans (approximately 2 percent of the United States population) and more than 170 million people worldwide (ap­proximately 3 percent of the world’s population) are infected with HCV. (HCV is more prevalent in Africa, the eastern Mediterranean, Southeast Asia, and the western Pacific than in the United States.) The Centers for Disease Control (CDC) estimates that only a small percentage (probably around 5 percent) of in­fected individuals are even aware that they harbor this virus in their bodies.

People between the ages of forty and fifty-nine are most likely to be diag­nosed with HCV. And it is estimated that there will be a fourfold increase in the number of adults diagnosed with HCV by the year 2015. While HCV can infect anyone with risk factors, it has been found to be more common among certain subgroups of people. For example, the prevalence of HCV among prison inmates is between 39 and 54 percent, among intravenous drug users between 70 and 90 percent, and among those attending Veterans Administration outpatient clinics between 18 and 40 percent.

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Vaginal Lawsuit: Withdrawal of endogenous oestrogen at the menopause results in well-documented climacteric symptoms, such as hot flushes and night sweats, in addition to the less commonly reported symptoms of urogenital atrophy. Symptoms do not usually develop until several years after the menopause when levels of endogenous oestrogens fall below the level.

Vaginal dryness is commonly the first reported symptom of urogenital atrophy and is caused by a reduction in mucus production within the vaginal glands. Atrophy within the vaginal epithelium leads to thinning and an increased susceptibility to infection and mechanical trauma. Following the menopause, glycogen depletion within the vaginaL mucosa leads to a decrease in lactic acid formation by Doderlein’s lactobacillus and a consequent rise in vaginal pH. The pH increases from around 4, to between 6 and 7. This allows bacterial overgrowth and colonization with Gram­negative bacilli, thus compounding the effects of vaginal atrophy and leading to symptoms of vaginitis,

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Symptoms of urogenital atrophy do not occur until the levels of endogenous oestrogen are lower than that required to promote endometrial proliferation.¹⁶ Consequently, it is possible to use a low dose of oestrogen replacement therapy in order to alleviate urogenital symptoms while also avoiding the risk of endometrial proliferation and removing the need to provide endometrial protection with progestogens.

However, studies investigating the use of oestrogens in the management of urogenital symptoms have shown that 8-10 pg of vaginal oestradiol is effective.¹⁸ Thus, only 10-30% of the dose used to treat vasomotor symptoms may be effective in the management of urogenital symptoms. Since 10-25% of women receiving systemic hormone replacement therapy still experience the symptoms of urogenital atrophy,¹³ Low-dose local preparations may have an additional beneficial effect.

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A recent review of oestrogen therapy in the management of urogenital atrophy has been performed by the Hormones and Urogenital Therapy (HUT) Committee.²⁰ Meta-analysis of 10 placebo-controlled trials confirmed the significant effect of oestrogens in the management of urogenital atrophy. Oestrogen is efficacious in the treatment of urogenital atrophy and low-dose vaginal preparations are as effective as systemic therapy. In addition, exogenous oestrogens have been shown to increase the number of intermediate and superficial cells in the vagina of postmenopausal women.²⁵ These changes have also been demonstrated in the bladder and urethra.

Oestrogen receptors, although absent in the transitional epithelium of the bladder, are present in the areas of the trigone that have undergone squamous metaplasia.²⁴ Oestrogen is known to have a direct effect on detrusor function – oestradiol has been shown to reduce the amplitude and frequency of spontaneous rhythmic detrusor contractions.²⁷ There is also evidence that it may increase the sensory threshold of the bladder in some women.

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Trans Vaginal Mesh Lawsuit : Your doctor will perforin the first examination for incontinence or prolapse in the same way as all gynecologic exams are done. The doctor will have you lie on your back on the examining table with your feet in stirrups. The uterus, fallopian tubes, and ovaries will be examined to make sure they feel normal. Even if you have had a hysterectomy, the doctor will perform an internal exam to make sure nothing else is pushing down on the vagina or rectum. The vagina will then be examined a bit more carefully to see if the blad­der or rectum is pushing against a weakened vaginal wall, causing a visible bulge. You will be asked to cough or bear down so that any weakness in the muscles supporting the bladder or rectum is made more apparent. The extra pressure will make weakened areas bulge further. Childbirth, gravity, menopause, aging, and heredity may all contribute to the problem of sagging or dropping of these organs.

The areas around the vagina and rectum will be touched with a Q-tip, and the doctor will record your ability to feel that touch. If you are unable to feel the Q-tip touching you, there may be a prob­lem with die nerves in the area of the bladder or rectum. In that case, you may be referred to a neurologist for further evaluation. Some neurological conditions, such as back injuries, strokes, dia­betes, and multiple sclerosis, can affect the muscles that aid blad­der function.

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After the pelvic examination, other tests may be employed to help determine which type of incontinence you have. We routinely per­form two simple tests called the cough stress test and the Q-tip test. The cough stress test is performed with you lying on the exam table with your feet in stirrups. You are asked to cough with a full bladder to see if that causes leakage of urine. The Q-tip test is per­formed in the same position. A cotton-tipped swab covered with anesthetic gel is painlessly inserted into the urethra, the bladder opening. You are asked to cough and strain, and the doctor or nurse measures the movement of the end of the Q-tip (Figure 3-1). Excessive movement of the Q-tip or loss of urine with coughing usually indicates a weakening of the tissues supporting the urethra that is associated with stress incontinence.

Next, you will be asked to empty your bladder completely. A small tube, called a catheter, is painlessly passed through the ure­thra into the bladder, and any remaining urine is collected and measured. The amount of urine left in the bladder after urination is called the postvoid residual. Some doctors now use ultrasound to measure tire postvoid residual and the amount of movement of the urethra upon a laugh or a cough. The only part of the instrument that touches you is a small wand placed in the vagina, just beneath the bladder.

Almost everyone has some urine remaining in the bladder after a trip to the bathroom, even if you feel you have entirely emp­tied it. It is normal to have up to two ounces left over. More indi­cates that your bladder is not able to empty properly. This is often associated with a type of incontinence called overflow incontinence. Overflow incontinence can be the result of problems with the nerves that signal the bladder or scar tissue blocking the flow of urine out of the bladder (see Chapter 1). A sample of urine from the catheter is usually sent to the laboratory and cultured to test for in­fection. If there is an infection, it is treated with antibiotics.

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During the first office visit, your doctor will probably ask you how often you urinate, how much liquid you drink in a day, and how often you have accidents. The answers to these questions are a good start, but a written record of these events may more speci­fically illustrate what happens with your bladder during the course of your day. This written record is called a voiding diary, or urolog. It is intended to be a one- or two-day record of how much liquid you drink, the amount and frequency of your urination, and how much leaking you have. Because a written record is better than relying on your memory, the voiding diary is a very accurate method of determining just how significant the incontinence problem is. All of the patients in our practice fill out a voiding diary. The voiding diary is important because it gives the doctor an idea of what your problem is like in real life. It can also point out medical problems, and sometimes it helps us find a “lifestyle” rather than a medical or surgical solution. After treatment, we may ask you to keep the diary again to see exactly how the solution works for you.

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Multaq Side Effects: Among its other functions, the liver serves as storage space for vita­mins A, B12, D, E, and K, as well as the minerals copper and iron. Because the human body maintains stores of these vitamins and minerals normally, it is relatively easy to overload the liver with them, causing liver damage. That’s why healthy people with nor­mal liver function should be cautious about taking supplements of vitamins and minerals. Iron, for instance, is harmful to people with a genetic abnormality known as hemochromatosis, which causes them to absorb too much iron.

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Vitamins A, D, E, and K (commonly referred to as “fat-soluble vitamins”) can exist only in fatty solutions, so when a liver disease causes the bile flow to be interrupted, the body can’t digest the fats it needs to absorb these vitamins. That’s a serious situation in the case of vitamin K, which we need at all times to help our blood to clot. Another little-known function of the liver is its role in processing amino acids, which link together to form proteins, the primary component of muscle. Without a healthy liver, the human body can’t produce and maintain the muscles not only in out arms, legs, and face, but also in our other organs, such as the heart.

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The liver is also involved in regulating our energy level, by stor­ing extra glucose as a carbohydrate known as glycogen and releas­ing glucose into the blood when we need an energy boost. When the liver isn’t functioning well, it doesn’t efficiently regulate the blood’s glucose levels.

The liver even affects our mental sharpness. When we eat animal proteins, the intestines produce harmful ammonia during digestion, and the liver is responsible for converting that ammonia into urea, a harmless substance that travels to the kidneys and eventually is elimi­nated from the body. When the liver is diseased, the ammonia doesn’t get converted but builds up in the blood and brain, contributing to a form of mental confusion called encephalopathy.

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Multaq Liver Damage: In the United States, relatively few adult patients with acute hepati­tis B develop the chronic form of this illness, and generally patients are not treated with medications. When HBV patients drink fluids and get plenty of rest, their illness usually resolves on its own. If the acute hepatitis B develops into chronic HBV, however, treatment is often prescribed. The majority of patients are treated with daily oral antiviral medications. Others are treated with inter­feron or sometimes with a long-acting form known as pegylated interferon. Oral antivirals. Developed in 1989, lamivudine was the first drug in this class and was originally used to treat HIV/AIDS patients. Lamivudine (brand name Epivir-HBV) is a pill with very few side effects and is generally very tolerable. Lamivudine does have two major drawbacks, however. Nearly half of patients treated with lamivudine will relapse after they stop taking the drug. Even worse, in nearly one-third of patients taking lami­vudine, a new strain of HBV evolves and is resistant to lamivu­dine after the first year. (Lamivudine-resistant strains of HBV are known scientifically as the so-called “YMDD mutations.”) The percentage of viral resistance increases with the duration of treat­ment. Viral resistance increases from 60 percent to 70 percent after five years of treatment.

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Another drug effective in treating chronic HBV is adefovir (brand name Hepsera), approved by the FDA in 2002. Unlike lamivudine, adefovir does not result in YMDD mutations, but most patients, unfortunately, experience a relapse of their HBV after they stop taking adefovir. Resistance rates for adefovir are somewhat different, depending on the hepatitis Be antigen (HBeAg) status. The estimated cumulative rates of resistance are 0 percent at one year, 3 percent at two years, 11 percent at three years, 18 percent at four years, and 29 percent at five years.

Entecavir (brand name Baraclude) and telbivudine (brand nameTyzeka) and tenofovir (brand name Viread) are three antiviral medications recently approved for treating chronic hepatitis B in the United States. These newer drugs have been shown to develop resistance at much lower rates than is the case with lamivudine. The drawback to antiviral drugs is that, eventually, some users will develop viral resistance, albeit at different rates. One of the advantages to choosing a newer agent is the lower likelihood of developing a resistance. These newer drugs also have variable degrees of potency and onset of action. The clinician choosing the medication will keep this in mind when selecting the most appropriate therapy. In addition, there can be cross-resistance between certain antivirals, so selection should be performed by a professional well versed in treating this disease.

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The drawback to antiviral drugs is that, eventually, some users will develop viral resistance, albeit at different rates. One of the advantages to choosing a newer agent is the lower likelihood of developing a resistance. These newer drugs also have variable degrees of potency and onset of action. The clinician choosing the medication will keep this in mind when selecting the most appropriate therapy. In addition, there can be cross-resistance between certain antivirals, so selection should be performed by a professional well versed in treating this disease. body longer and be long-acting. These medica­tions are typically taken only once a week. This long-acting form was created by adding a peg (polyethylene glycol) molecule to standard interferon. This peg delays the drug’s excretion by the kidneys.

The current recommendation for treating chronic hepatitis B with with pegylated interferon is a 48-week course of medication. Unlike the approach to treating chronic hepatitis G, in this case no ribavirin is given. The response rates to treatment vary and depend upon a number of factors. One of the biggest determina­tions of outcome is whether a person is hepatitis BeAg-positive or -negative. Those who need therapy and are hepatitis BeAg-negative are less likely to respond. The side effects of pegylated interferon are generally well tolerated, especially in the absence of ribavirin. Studies have shown that the response to interferon therapy (given as subcutaneous injections) lasts longer than the response achieved with antiviral pills. The durability of the response is one reason why physicians elect to treat hepatitis B with interferon as opposed to oral medications.

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Multaq Lawyer : There is no question that the after-effects of surgical removal of the bladder (cystectomy) can be unsettling to think about. You won’t have a bladder or maybe even a ure­thra any longer. How will you be able to pass urine? Will you have to have some type of urine-collecting bag? Will there be an odor? Will it show when you wear certain clothing? We will talk about all those issues in more detail, but in brief, your team will need to surgically create an artificial urine-collection system for you. This is known as a urinary diversion system. In years past, the only option was a urine- collection bag worn outside the body, which many people found to be unpleasant or even embarrassing. The good news is that now, in many cases, an artificial bladder (sometimes called a neobladder) can be fashioned from a piece taken from the intestine (bowel), enabling you to void urine in a normal or near-normal fashion. You will have to learn to use a different set of muscles when uri­nating, and there may be some leakage now and then, par­ticularly at night. Leakage can be controlled by wearing underwear designed with a disposable pad or, for men, a sort of condom. Overall, it’s a more attractive option that makes it easier to face a complicated and often scary surgery such as cystectomy. With modern techniques, most patients no longer have to contend with urinary leakage, except on rare occasions.

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Even if the creation of an internal urinary diversion sys­tem is not possible in your situation, keep in mind that there is also no question that cystectomy is a powerful weapon against invasive bladder cancer that can increase your odds of living a long, cancer-free life. Cystectomy is the most common treatment option for invasive bladder cancer. In most cases, your medical team will recommend a complete (or radical) cystectomy. This means that your bladder, the lymph nodes tucked around your bladder in the abdomen, the prostate in men, and the uterus, ovaries, and part of the vaginal wall in women will be surgically removed. Depending on where the cancer is located, the urethra may also be removed.

It is easy to confuse some of the terms your doctors use, such as “cystoscopy (a diagnostic procedure that introduces a tube into the bladder so the doctor can look at the inner sur­face and take a biopsy) and cystectomy (the surgical removal of the bladder). If you are unsure, don’t hesitate to ask your doctors for clarification. Through the kidney ure­ters, and urethra, and there is a possibility that tumors may be forming in those organs, too. In particular, the tissues lin­ing the bladder, ureters, and urethra (known as the urothelial tissues) may be at risk from the after-effects of cancer-causing substances, such as agents in cigarette smoke or industrial dyes. Also, because your cancer may have penetrated the muscle wall, it is possible that organs surrounding the blad­der, such as the prostate, uterus, or vagina, may also be at risk of further growth of the cancer cells.

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In the case of bladder cancer, which often tecurs or spreads to other organs, you will have a much better chance of a cure once organs and tissue have been removed in areas where the disease is likely to spread or where it may already have infiltrated. And a cure, after all, is what you and your doctors are striving to attain. Sometimes if the cancer is very localized and surrounded by plenty of healthy, noncancerous tissue, a partial cystec­tomy might be recommended. During this procedure, only a portion of the bladder is removed and some or all of the surrounding organs may be saved.

You probably have already figured out that cystectomy is a surgical procedure performed under general anesthesia in a hospital setting. Depending on what kind of bladder reconstruction you have, you may stay in the hospital any­where from 5 to 14 days. During a cystectomy, an incision is made through the abdominal wall, so you can expect some mild discomfort at the incision site. The incision will be covered after the sur­gery is finished, and you probably wont be able to shower or get the incision wet for about a week to 10 days. Your surgeon may have inserted a drain from the incision site, a flexible tube with a hollow bulb on the end that you will remove, empty, flush out, and reattach as needed. Your doc­tor will remove the drain (a painless procedure) and any stitches or staples in a follow-up visit to his or her office 10 days or so after your surgery.

Our use of the term or terms Multaq Lawyer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Multaq Class Action: For relatively few people, chronic HBV will progress to cir­rhosis before they notice serious symptoms, such as accumulated fluid in the abdomen (ascites), alteration in mental status (enceph­alopathy), or, in extreme cases, primary liver cancer (hepatocellular carcinoma, or HCC). Even more unusual are the individuals with chronic hepatitis B who develop cancer in the liver even if it is working normally and shows no evidence of cirrhosis. Chronic HBV is diagnosed with a battery of hepatitis B lab tests that includes nearly a dozen different blood tests. The tests will show whether che person is infectious and confirm that the disease is chronic, among other findings. The findings are usually supported with results of imaging studies and a liver biopsy.

Chronic hepatitis B is further categorized as (a) inactive hepati­tis B surface antigen (HBsAg) carrier state; (b) chronic hepatitis B, either HBeAg-positive or HBeAg-negative; and (c) resolved chronic hepatitis B. Patients in the first group, the inactive HBsAg carrier state, typically display no symptoms. They feel fine, their AST and ALT levels are normal, and their livers show no significant damage. Doctors advise these patients to get tested at least once a year and sometimes more frequently. Their viral load (HBV-DNA level) is usually low.

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Chronic HBV patients, the second group, carry HBV DNA, usually at a higher level, meaning that whether they test positive or negative for HBeAg, they are contagious, and their AST/ALT levels remain elevated. HBeAg-positive patients have a small chance (up to 15 percent) of seeing a spontaneous remission. Those in the third group, individuals diagnosed with resolved chronic HBV, face the most optimistic futures. In patients who resolve, liver enzymes return to normal levels and the risk of devel­oping cirrhosis or liver cancer decreases dramatically. However, if their immune systems ever become deeply suppressed, as happens following chemotherapy or an organ transplant, their chronic hep­atitis B can reemerge.

Overall, the long-term prognosis for chronic HBV patients is hopeful: only about 20 percent develop cirrhosis in the five years following their diagnosis. These rates are variable and depend on where the virus was acquired. Patients whose HBV was detected in the early stages seem to fare better, as do those who abstain from alcohol and those who have not also contracted hepatitis C or D.

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Patients diagnosed with HBV will often hear the phrase “HBV genotype,” which refers to the genetic nature or category of a patient’s HBV There are seven different hepatitis B genotypes, labeled genotype A through G, and each is identified with a blood test. In the United States and Europe, genotypes A and D are the most prevalent, while other genotypes are more common in other parts of the world. The significance of HBV genotypes isn’t entirely clear, though researchers are evaluating certain HBV gen­otypes in terms of the severity of the patients liver disease and response to treatment. Hepatitis D (delta hepatitis) is an infection of the liver that exists only in patients with HBV. While it is a rare form of hepatitis, HDV also has a wide variation in presentation. The worst presen­tation is thought to occur in IV-drug abusers, who may develop severe or fulminant hepatitis.

Our use of the term or terms Multaq Class Action is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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