FibroTest/Fibrosure for significant liver fibrosis and cirrhosis in chronic hepatitis B: a meta-analysis

OBJECTIVES

Extent of liver fibrosis is one of the most important factors in determining prognosis and the need for active treatment in chronic hepatitis B (CHB). Noninvasive alternatives such as FibroTest/Fibrosure (FT) have been developed in order to overcome the shortcomings of liver biopsy (LB). We aimed to systematically review studies describing the diagnostic accuracy of FT for predicting CHB-related fibrosis.

METHODS

MEDLINE and EMBASE searches and hand searching methods were performed to identify studies that assessed the diagnostic accuracy of FibroTest in HB patients using LB as a reference standard. We used a hierarchical summary receiver operating curves model and the bivariate model to produce summary receiver operating characteristic curves and pooled estimates of sensitivity and specificity.

RESULTS

We included 16 studies (N=2494) and 13 studies (N=1754) in the heterogenous meta-analysis for liver fibrosis and cirrhosis, respectively. The area under the hierarchical summary receiver operating curve for significant liver fibrosis and for all included studies was 0.84 (95% confidence interval (CI): 0.78-0.88). At the FT threshold of 0.48, the sensitivity, specificity, and diagnostic odds ratio (DOR) of FT for significant fibrosis were 61 (48-72%), 80 (72-86%), and 6.2% (3.3-11.9), respectively. The area under the hierarchical summary receiver operating curve for liver cirrhosis and for all included studies was 0.87 (95% CI: 0.85-0.90). At the FT threshold of 0.74, the sensitivity, specificity, and DOR of FT for cirrhosis were 62 (47-75%), 91 (88-93%), and 15.7% (8.6-28.8), respectively.

CONCLUSIONS

FibroTest is of value in exclusion of patients with CHB-related cirrhosis, but has suboptimal accuracy in the detection of significant fibrosis and cirrhosis. It is necessary to further improve the test or combine it with other noninvasive modalities in order to improve accuracy.

Probiotics for standard triple Helicobacter pylori eradication: a randomized, double-blind, placebo-controlled trial

The primary objective in the study is determination of efficacy of probiotic preparation as a supportive therapy in eradication of Helicobacter pylori.The study was multicenter, prospective, randomized, placebo controlled, and double-blind. The subjects first filled out a specially designed questionnaire to assess the severity of the 10 symptoms, which can be related to eradication therapy to be monitored during the trial. Each subject then received 28 capsules of probiotic preparation or matching placebo capsules, which they were supposed to take over the following 14 days, twice a day, at least 2 hours prior to or after the antibiotic therapy administration.A total of 804 patients were enrolled in the trial, of which 650 (80.85%) were included in the analysis. The results show a significantly larger share of cured subjects in the probiotic arm versus the placebo arm (87.38% vs 72.55%; P < 0.001). Additionally, presence and intensity of epigastric pain, bloating, flatulence, taste disturbance, loss of appetite, nausea, vomiting, heartburn, rash, and diarrhea were monitored over the study period. At 15 days postinclusion, probiotic treatment was found superior to placebo in 7 of 10 mentioned symptoms. Average intensity for symptoms potentially related to antibiotic therapy was significantly higher in the placebo group, 0.76 vs 0.55 (P < 0.001).Adding probiotics to the standard triple therapy for H pylori eradication significantly contributes to treatment efficacy and distinctly decreases the adverse effects of therapy and the symptoms of the underlying disease.

Artificial neural network predicts the need for therapeutic ERCP in patients with suspected choledocholithiasis

BACKGROUND

Selection of patients with the highest probability for therapeutic ERCP remains an important task in a clinical workup of patients with suspected choledocholithiasis (CDL).

OBJECTIVE

To determine whether an artificial neural network (ANN) model can improve the accuracy of selecting patients with a high probability of undergoing therapeutic ERCP among those with strong clinical suspicion of CDL and to compare it with our previously reported prediction model.

DESIGN

Prospective, observational study.

SETTING

Single, tertiary-care endoscopy center.

PATIENTS

Between January 2010 and September 2012, we prospectively recruited 291 consecutive patients who underwent ERCP after being referred to our center with firm suspicion for CDL.

INTERVENTIONS

Predictive scores for CDL based on a multivariate logistic regression model and ANN model.

MAIN OUTCOME MEASUREMENTS

The presence of common bile duct stones confirmed by ERCP.

RESULTS

There were 80.4% of patients with positive findings on ERCP. The area under the receiver-operating characteristic curve for our previously established multivariate logistic regression model was 0.787 (95% CI, 0.720-0.854; P < .001), whereas area under the curve for the ANN model was 0.884 (95% CI, 0.831-0.938; P < .001). The ANN model correctly classified 92.3% of patients with positive findings on ERCP and 69.6% patients with negative findings on ERCP.

LIMITATIONS

Only those variables believed to be related to the outcome of interest were included. The majority of patients in our sample had positive findings on ERCP.

CONCLUSIONS

An ANN model has better discriminant ability and accuracy than a multivariate logistic regression model in selecting patients for therapeutic ERCP.

Liver elastography malignancy prediction score for noninvasive characterization of focal liver lesions

BACKGROUND & AIMS

To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real-time two-dimensional shear-wave elastography (RT-2D-SWE) in order to differentiate benign and malignant FLLs.

METHODS

Consecutive patients diagnosed with FLL by abdominal ultrasound (US) underwent RT-2D-SWE of FLL and non-infiltrated liver by intercostal approach over the right liver lobe. The nature of FLL was determined by diagnostic work-up, including at least one contrast-enhanced imaging modality (MDCT/MRI), check-up of target organs when metastatic disease was suspected and FLL biopsy in inconclusive cases.

RESULTS

We analysed 196 patients (median age 60 [range 50-68], 50.5% males) with 259 FLLs (57 hepatocellular carcinomas, 17 cholangiocarcinomas, 94 metastases, 71 haemangiomas, 20 focal nodular hyperplasia) of which 70 (27%) were in cirrhotic liver. Malignant lesions were stiffer (P < .001) with higher variability in intralesional stiffness (P = .001). The best performing cut-off of lesion stiffness was 22.3 kPa (sensitivity 83%; specificity 86%; positive predictive value [PPV] 91.5%; negative predictive value [NPV] 73%) for malignancy. Lesion stiffness <14 kPa had NPV of 96%, while values >32.5 kPa had PPV of 96% for malignancy. Lesion stiffness, lesion/liver stiffness ratio and lesion stiffness variability significantly predicted malignancy in stepwise logistic regression (P < .05), and were used to construct a new Liver Elastography Malignancy Prediction (LEMP) score with accuracy of 96.1% in validation cohort (online calculator available at http://bit.do/lemps).

CONCLUSION

The comprehensive approach demonstrated in this study enables correct differentiation of benign and malignant FLL in 96% of patients by using RT-2D-SWE.

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess: is appendectomy always necessary after perforation of appendix?

BACKGROUND

The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess.

METHODS

In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess > or = 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient's baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed.

RESULTS

Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22-0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0-7.9; p < 0.05).

CONCLUSIONS

Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess > or = 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.

Crohn's disease in Tuzla region of Bosnia and Herzegovina: a 12-year study (1995-2006)

BACKGROUND

Bosnia and Herzegovina (B&H) is one of the Eastern European countries with lacking data on Crohn's disease (CD) epidemiology.

GOAL

We aimed to assess incidence of CD in Tuzla Canton of B&H during a 12-year period (1995-2006).

METHODS

We retrospectively evaluated hospital records of both CD inpatients and outpatients residing in Tuzla Canton of B&H (total of 496,280 inhabitants) between 1995 and 2006. Patient that satisfied previously described criteria were included in the study. Incidence rates were calculated with age standardisation using European standard population. Trends in incidence were evaluated as moving 3-year averages.

RESULTS

During the observed period, 140 patients met the diagnostic criteria for CD. Mean annual incidence was found to be 2.3/10(5) (95% CI=1.6-3.0) inhabitants ranging from 0.20 to 6.45 per 10(5). Mean annual crude incidence during the last 5 years of study (2002-2006) was 4.15/10(5) (95% CI=3.35-4.95). The prevalence of CD, at the end of the observed period was found to be 28.2/10(5) (95% CI=23.5-32.9). CD incidence increased dramatically from 0.27/10(5) in 1995-1997 to 4.84/10(5) in 2004-2006, as well as did the number of colonoscopies performed; from 29 in 1995 to 850 in 2006. We observed almost constant trend of around three new cases of CD per 100 colonoscopies performed.

CONCLUSIONS

(1)Our area is the region of moderate incidence of CD with the trend that remains toward continuing increase in the rates of CD, which is most likely a direct consequence of the growing number of performed colonoscopies. (2) We believe that in the future years, CD incidence in our region will probably further increase and stabilise at a level of around five cases per 10(5) inhabitants.

Predictive score for anastomotic leakage after elective colorectal cancer surgery: a decision making tool for choice of protective measures

BACKGROUND

Anastomotic leakage is the most severe complication after colorectal surgery and a major cause of postoperative morbidity and mortality. We aimed to identify a predictive score for postoperative leakage after colorectal cancer surgery and to evaluate its usefulness in assessing various protective measures.

METHODS

A total of 159 patients were divided into test (79 patients) and validation (40 patients) groups in order to identify the risk factors and construct the predictive score. The remaining 40 patients (intervention group) were prospectively evaluated with the application of protective measures guided by risk stratification according to the predictive score.

RESULTS

A total of 23 of 159 (14.5 %) patients had anastomotic leakage, with 7 of 23 (30.4 %) of them needing reoperation. 11 of 159 (6.9 %) patients died, with 10 (6.3 %) deaths directly associated with anastomotic leakage. The rate of leakage in the test and validation groups (nonintervention group) was 22 of 119 (18.5 %), while the rate of leakage in the intervention group was 3 of 40 (7.5 %). The odds ratio for anastomotic leakage in the intervention group was 0.23 compared to the nonintervention group, with a relative risk reduction of 73 % for unfavorable event. The number needed to treat was 8 patients. There were also 10 of 119 (8.4 %) deaths in the nonintervention group compared to 1 of 40 (2.5 %) in the intervention group (Fisher's test; p = 0.18).

CONCLUSIONS

Our simple predictive score may be a valuable decision making tool that can help surgeons reliably identify patients at high risk for postoperative anastomotic leakage and apply guided intraoperative protective measures.

Diagnosis of Irritable Bowel Syndrome: Role of Potential Biomarkers

Irritable bowel syndrome is a disorder diagnosed on symptom-based criteria without inclusion of any objective parameter measurable by known diagnostic methods. Heterogeneity of the disorder and overlapping with more serious organic diseases increase uncertainty for the physician's work and increase the cost of confirming the diagnosis. This paper is an attempt to summarize the efforts to find adequate biomarkers for irritable bowel syndrome, which should shorten the time to diagnosis and reduce the cost. Most of the reviewed papers were observational studies from secondary care institutions. Since publication of the Rome III criteria in 2006, most recent studies use these for the recruitment of IBS patients. This is a positive step forward as future studies should use the same criteria, facilitating comparison of their results. Among the studied biomarkers, most evidence is provided for fecal calprotectin. Cutoff values for fecal calprotectin have still to be investigated prior to inclusion in the irritable bowel syndrome diagnostic algorithm.

Circulating cytokines reflect mucosal inflammatory status in patients with Crohn's disease

BACKGROUND

There is a great need for a simple activity assessment tool that can reliably predict activity in patients with Crohn's disease (CD).

AIM

To investigate the relationship between serum cytokines and endoscopic activity of CD using Crohn's Disease Endoscopic Index of Severity (CDEIS) as a gold standard.

METHODS

We prospectively evaluated 32 firmly established CD patients using ileocolonoscopy, CDEIS score, and Crohn's Disease Activity Index (CDAI) score. Blood samples for cytokine analysis were obtained 1 day prior to procedure.

RESULTS

The correlation between CDEIS and CDAI was moderate (r = 0.43; P = 0.01); however, the correlation between CDEIS and inflammatory cytokines was excellent, with the highest coefficients for tumor necrosis factor alpha (TNFalpha) and interleukin-6 (IL-6) (r = 0.96 and r = 0.96, respectively; P < 0.001). CDEIS and anti-inflammatory cytokines were correlated nonlinearly (power function). We identified two separate models for predicting CDEIS value, based on the best performing pro-inflammatory [CDEIS = 0.445 x (IL-6) - 5,143] and anti-inflammatory [CDEIS = 27.478 x (IL-10)(-0.71)] cytokines. Both IL-6 and IL-10 models had high adjusted R(2) values (0.916 and 0.954, respectively). IL-6 had excellent diagnostic accuracy for detecting patients with CDEIS >7 (active disease), with area under the receiver operating characteristic (ROC) curve of 1.0 [95% confidence interval (CI) = 0.89-1.0; P < 0.001].

CONCLUSION

Serum cytokine levels are excellent predictors of endoscopic activity in patients with CD.

Biochemical and ultrasound parameters may help predict the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with a firm clinical and biochemical suspicion for choledocholithiasis

BACKGROUND

Prediction of the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected choledocholithiasis (CDL) remains a challenging task.

AIMS

We aimed to evaluate the predictive value of biochemical and ultrasound parameters and to create a corresponding model for prediction of the need for therapeutic ERCP.

METHODS

203 consecutive patients referred to our center due to a firm clinical and/or biochemical suspicion for CDL. All patients underwent ERCP. Biochemical and ultrasound variables were analyzed.

RESULTS

The sample was divided into testing group (103; 50.7%) and validation group (100; 49.3%) which did not differ in their baseline characteristics. Elevated gamma glutamil transaminase (GGT), common bile duct (CBD) diameter and presence of hyperechoic structures in CBD were found to be significant predictors for presence of CBD stones on ERCP (p<0.05) in the testing group. We used these variables to construct a predictive model for the presence of CBD stones on ERCP. The model was tested on a second, validation group of patients using ROC analysis with the area under the ROC curve of 0.81 (%95 CI=0.75-0.86; p<0.001). We identified a threshold (0.86) above which, patients had a high probability (93.1%) for the need for interventional ERCP.

CONCLUSION

Our predictive model may help predict the need for therapeutic ERCP in patients with a suspicion for choledocholithiasis.

The First Mediterranean Seminar on Science Writing, Editing and Publishing, Sarajevo, December 2-3, 2016

The First Mediterranean Seminar on Science Writing, Editing & Publishing (SWEP 2016) was held in Sarajevo, Bosnia & Herzegovina from 2nd to 3rd December 2016. It was organized by Academy of Medical Sciences of Bosnia and Herzegovina, running concurrent sessions as part of its Annual Meeting titled " "Days of AMNuBiH - Theory and Practice in Science Communication and Scientometrics". Hotel Bosnia in the city centre was the chosen venue. On the first day, nineteen presentations on various issues of science writing and publication ethics were delivered by speakers from Croatia, Serbia, Macedonia, Albania, Bosnia & Herzegovina and the UK (Asim Kurjak, Milivoj Boranić, Doncho Donev, Osman Sinanović, Miro Jakovljević, Enver Zerem, Dejan Milošević, Silva Dobrić, Srećko Gajović, Izet Mašić, Armen Yuri Gasparyan, Šekib Sokolović, Nermin Salkić, Selma Uzunović, Admir Kurtčehajić, Edin Begić and Floreta Kurti). Each presentation had a take-home message for novice and seasoned authors, encountering numerous problems in non-Anglophone research environment. Lecturers, who were internationally recognized editors of regional journals, generously shared their experience of adhering to the best ethical guidance. Elegant presentations by Srećko Gajović (Editor-in-Chief of the Croatian Medical Journal) and Armen Yuri Gasparyan (past Chief Editor of the European Science Editing) showcased their accomplishments that strengthened ties between authors from all over the world. Gasparyan reflected on educational resources of editorial associations, such as the International Committee of Medical Journal Editors (ICMJE) and the Committee on Publication Ethics (COPE), and called not just to declare the adherence to, but also to enforce their ethical guidance in daily practice. Editors of Medical Archives, Croatian Medica Journal, Vojnosanitetski Pregled, Psychiatria Danubina, Acta Informatica Medica, Materia Socio-Medica, The Donald School Journal of Ultrasound in Obstretics and Gynecology, Acta Medica Saliniana and Medicinski Glasnik presented their editorial strategies aimed at attracting best authors and resolving problems with authorship, conflicts of interest, and plagiarism. Topical education on science writing and editing was considered as an inseparable part of continuing professional development in biomedicine. Armen Yuri Gasparyan (UK) was offered an opportunity to interact with more than 70 participants, attending the SWEP 2016 on the second day. The lecturer talked about author contributions, disclosures of conflicts of interests, plagiarism of ideas and words, research performance and impact indicators, and targeting ethical journals. Topics were presented in a way to help non-Anglophone authors, reviewers and editors avoid common ethical problems. Dr Gasparyan stressed the importance of regularly arranging such meetings across Balkan and Mediterranean countries to eradicate plagiarism and other forms research misconduct. The organizers of the SWEP 2016 awarded selected keynote speakers with certificates of lifetime achievement in journal editing, and decided to run the Seminar annually with support of Balkan and Mediterranean editors and publishers. The SWEP 2016 marked a turning point in the process of regional developments since all attending editors opted for nurturing enthusiasm of the organizers and launching the Mediterranean Association of Science Editors and Publishers (MASEP). The Seminar was a great success with its impressive scientific and social activities. It attracted more than 100 students, researchers, editors, and publishers from Bosnia & Herzegovina and neighbouring countries. Proceedings, in the form of short reports, were published in Acta Informatica Medica and archived in PubMed Central. New friendships were forged between regional experts in editing and young specialists during those unforgettable two days of intensive discussions and informal interactions (a-y).

Availability of hepatitis C diagnostics and therapeutics in European and Eurasia countries

BACKGROUND

Treatment with direct acting antiviral agents (DAAs) has provided sustained virological response rates in >95% of patients with chronic hepatitis C virus (HCV) infection. However treatment is costly and market access, reimbursement and governmental restrictions differ among countries. We aimed to analyze these differences among European and Eurasian countries.

METHODS

A survey including 20-item questionnaire was sent to experts in viral hepatitis. Countries were evaluated according to their income categories by the World Bank stratification.

RESULTS

Experts from 26 countries responded to the survey. As of May 2016, HCV prevalence was reported as low (≤1%) in Croatia, Czech Republic, Denmark, France, Germany, Hungary, the Netherlands, Portugal, Slovenia, Spain, Sweden, UK; intermediate (1-4%) in Azerbaijan, Bosnia and Herzegovina, Italy, Kosovo, Greece, Kazakhstan, Romania, Russia, Serbia and high in Georgia (6.7%). All countries had national guidelines except Albania, Kosovo, Serbia, Tunisia, and UK. Transient elastography was available in all countries, but reimbursed in 61%. HCV-RNA was reimbursed in 81%. PegIFN/RBV was reimbursed in 54% of the countries. No DAAs were available in four countries: Kazakhstan, Kosovo, Serbia, and Tunisia. In others, at least one DAA combination with either PegIFN/RBV or another DAA was available. In Germany and the Netherlands all DAAs were reimbursed without restrictions: Sofosbuvir and sofosbuvir/ledipasvir were free of charge in Georgia.

CONCLUSION

Prevalence of HCV is relatively higher in lower-middle and upper-middle income countries. DAAs are not available or reimbursed in many Eurasia and European countries. Effective screening and access to care are essential for reducing liver-related morbidity and mortality.

Intrafamilial transmission of hepatitis B in Tuzla region of Bosnia and Herzegovina

OBJECTIVE

To determine (i) the prevalence of HBV infection in families of confirmed chronic carriers, (ii) possible routes of transmission and risk factors for the intrafamilial transmission, (iii) vaccination rate among family members of chronic carriers and (iv) family members with highest risk for infection.

METHODS

A total of 172 family members of 67 hepatitis B surface antigen chronic carriers were tested for hepatitis B markers; 716 first-time blood donors from the same area were used as controls.

RESULTS

Prevalence of hepatitis B surface antigen was higher (P<0.001) among family members of index cases (12.2%; 21/172) than among controls (3.6%; 26/716) with relative risk of 3.3 (95% confidence Intervals=1.9-5.8; P<0.05). Rate of exposure among family members was 37.8% (65/172); only 8.7% (15/172) had been vaccinated for hepatitis B virus. Difference (P<0.001) in exposure existed among family members; exposure increased with age (rhos=0.34; P<0.001). Prevalences of hepatitis B surface antigen positivity and hepatitis B virus exposure were higher among parents of index cases (P<0.005) and among offspring of female index cases (P<0.001). There were more (P<0.001) hepatitis B surface antigen-positive family members among those with mother-children relationship with index case (13/31; 41.9%) than among those with father-children (19/85; 22.4%) and horizontal (siblings and spouses) relationship (2/56; 3.6%). Significantly more (P<0.001) hepatitis B surface antigen-positive and hepatitis B virus-exposed offspring were found in families where only mother was hepatitis B surface antigen positive. Among family members of HBeAg-positive cases more hepatitis B surface antigen-positive cases and hepatitis B virus-exposed cases have been found (P<0.001). Combination of HBeAg positivity and female sex of index case significantly increased risk for chronic carriage among family members (relative risk=24.06; 95% confidence interval=8.88-65.21; P<0.05).

CONCLUSION

In the area studied, both horizontal and vertical transmission exists, but maternal route is predominant. Female sex, HBeAg positivity of index carrier and presence of hepatitis B surface antigen-positive mother inside family increased risk for hepatitis B surface antigen positivity and exposure among family members. Vaccination rate of family members of index cases is alarmingly low.

Hepatitis C virus genotypes in chronic hepatitis C patients and in first time blood donors in northeastern Bosnia and Herzegovina

Prevalence of hepatitis C virus (HCV) genotypes in Bosnia and Herzegovina (B&H) is an issue that is not sufficiently researched and there is a need for studies that would explore this in detail.The aim of this study was to determine the distribution of HCV genotypes in the group of patients with chronic hepatitis C and also in the group of first time blood donors that tested positive for anti HCV antibodies during the blood screening process. Our secondary goal was to compare the proportions of HCV genotypes between these two groups.We analyzed 75 blood samples of patients with confirmed chronic hepatitis C. We also analyzed 13/16082 blood samples of first time blood donors found to be HCV positive during the blood screening process. We also determined HCV genotype in HCV RNA positive samples.We have found that genotype 1b was more prevalent in chronic hepatitis C patients (52/75; 69,3%) than in first time blood donors (6/13; 46,1%), however this difference was not statistically significant (c2=1,721; df=1; p=0,19). Genotype 1a was more prevalent in the group of first time blood donors (3/13; 23,1%) than in the group of chronic hepatitis C patients (3/75; 4%), but this was also with limited statistical significance (c2=3,71; df=1; p=0,054). We have not found any significant difference in prevalence of genotypes 1a (p=0,2) and genotypes 3 (p=0,70) when compared between chronic patients (3/75 and 16/75; respectively) and first time blood donors (3/13 and 4/13; respectively). Our study confirmed domination of genotype 1b in the region of northeastern B&H which is in accordance with HCV genotype prevalence in other countries in our part of Europe.

Allele frequency distribution of 1691G >A F5 (which confers Factor V Leiden) across Europe, including Slavic populations

The allele 1691A F5, conferring Factor V Leiden, is a common risk factor in venous thromboembolism. The frequency distribution for this allele in Western Europe has been well documented; but here data from Central, Eastern and South-Eastern Europe has been included. In order to assess the significance of the collated data, a chi-squared test was applied, and Tukey tests and z-tests with Bonferroni correction were compared. Results: A distribution with a North-Southeast band of high frequency of the 1691A F5 allele was discovered with a pocket including some Southern Slavic populations with low frequency. European countries/regions can be arbitrarily delimited into low (group 1, <2.8 %, mean 1.9 % 1691A F5 allele) or high (group 2, ≥2.8 %, mean 4.0 %) frequency groups, with many significant differences between groups, but only one intra-group difference (the Tukey test is suggested to be superior to the z-tests). Conclusion: In Europe a North-Southeast band of 1691A F5 high frequency has been found, clarified by inclusion of data from Central, Eastern and South-Eastern Europe, which surrounds a pocket of low frequency in the Balkans which could possibly be explained by Slavic migration. There seem to be no indications of variation in environmental selection due to geographical location.

Ulcerative colitis in the Tuzla region of Bosnia and Herzegovina between 1995 and 2006: epidemiological and clinical characteristics

BACKGROUND

Bosnia and Herzegovina (B&H) is one of the Eastern European countries that lacks data on the epidemiology of ulcerative colitis (UC).

AIMS

We aimed to assess the epidemiological and clinical characteristics of UC in Tuzla Canton of B&H during a 12-year period (1995-2006).

PATIENTS AND METHODS

We retrospectively evaluated hospital records of both UC inpatients and outpatients residing in Tuzla Canton of B&H (total of 496 280 inhabitants) between 1995 and 2006. Patients that firmly satisfied the diagnostic criteria for UC were included in the study. Incidence rates were calculated with age standardization using European population standards. Trends in incidence were evaluated as moving 3-year averages.

RESULTS

During the observed period, 214 patients met the diagnostic criteria for UC. The average age-standardized incidence was found to be 3.43/10 inhabitants [95% confidence interval (CI) = 2.97-3.89], ranging from 0.22 to 7.44 per 10. The mean annual crude incidence in the last 5 years of study (2002-2006) was 5.55/10 (95% CI = 4.63-6.48). The prevalence of UC during the observed period was found to be 43.1/10 (95% CI = 37.3-48.8). The incidence of UC increased dramatically from the average of 1.01/10 in the period between 1995 and 1997 to 6.04/10 between 2004 and 2006, as did the number of colonoscopies performed, from 29 in 1995 to 850 in 2006. The average yearly incidence of confirmed UC cases detected on colonoscopy was 5.56 per 100 colonoscopies per year (95% CI = 4.81-6.30) and only 3.92 per 100 colonoscopies (95% CI = 3.26-4.57) in the last 5 years of the observed period.

CONCLUSION

Tuzla Canton of B&H is a region with an increasing incidence of UC, which is most likely a direct consequence of a wider use of colonoscopy. We believe that in the next few years, the incidence of UC in this region will probably reach the annual incidence rate of 6 per 10 inhabitants.

Liver and Nonliver-Related Outcomes at 2 Years Are Not Influenced by the Results of the FIB-4 Test and Liver Elastography in a Real-Life Cohort of Patients with Type 2 Diabetes

AIMS

To investigate morbidity and mortality in a real-life cohort of patients with type 2 diabetes (T2D) in relation to prevalence and severity of nonalcoholic fatty liver disease (NAFLD).

METHODS

Patients with T2D were referred for assessment of liver fibrosis by the FIB-4 test and liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE). Liver steatosis was quantified by the controlled attenuation parameter (CAP). These patients were followed until death or censored date.

RESULTS

Among 454 patients (52% males, mean age 62.5 years, BMI 30.9 kg/m²), 82.6% was overweight, 77.8% had fatty liver, and 9.9% and 3.1% had LSM and FIB-4 values suggestive of advanced fibrosis, respectively. During the follow-up period of median 2 years, 106 (23%) patients experienced adverse event (11% cardiovascular) and 17 (3.7%) died, whereas no liver-related morbidity or mortality was observed. Independent predictors of adverse outcomes were age and higher platelet count, while FIB-4, LSM, and CAP were not.

CONCLUSION

In a cohort of T2D patients, no liver-related morbidity or mortality occurred during 2 years. Our patients probably have low real prevalence of advanced fibrosis which is likely overestimated by LSM ≥ 9.6 kPa. Liver fibrosis may be safely reassessed in the 2 years interval in noncirrhotic patients with T2D.

Online combination algorithm for non-invasive assessment of chronic hepatitis B related liver fibrosis and cirrhosis in resource-limited settings

OBJECTIVE

The use of commercially available noninvasive markers for chronic hepatitis B (CHB) related fibrosis is not widely available in developing countries so clinicians in those countries frequently use free alternatives. We aimed to create an optimized algorithm for selection of patients with the highest probability for presence/absence of significant liver fibrosis and cirrhosis based on the use of multiple free scores.

METHODS

We evaluated six free noninvasive markers for CHB related fibrosis against liver biopsy and selected the best thresholds for prediction/exclusion of significant fibrosis and cirrhosis in CHB patients. Algorithm based on four scores and their corresponding thresholds was created.

RESULTS

The calculator based on developed algorithm can be found at http://www.chb-lfc.com. We evaluated 211 patients in main group and 65 patients in external validation group. We selected four scores for creation of combination algorithm. The algorithm was able to classify 123/211 (58.3%) patients with a 93.5% accuracy of correct classification for prediction of presence/absence of significant fibrosis in main group. In validation group, the algorithm was able to classify 48/65 (73.8%) of patients with 93.8% (45/48) overall accuracy. When used to predict presence/absence of cirrhosis, the algorithm was able to correctly classify 181/211 (85.8%) and 59/65 (90.8%) of patients in main and validation group, respectively, with an overall accuracy of 97.8% and 98.3%, respectively.

CONCLUSION

Developed algorithm based on routine laboratory tests is a usable, applicable and accurate tool for diagnosis of CHB related fibrosis and cirrhosis, suitable for resource-limited settings where more expensive modalities are unavailable.

Prevalence of 1691G>A FV mutation in Poland compared with that in other Central, Eastern and South-Eastern European countries

The 1691G>A FV variant has been described as a common genetic risk factor in venous thromboembolism. The purpose of this study was to provide a further frequency value for 1691G>A FV in Poland and to collate summary data from Central (Poland, Czech, Slovakia), Eastern (Russia, Belarus, Ukraine) and South-Eastern (Slovenia, Croatia, Bosnia and Herzegovina, Serbia, Montenegro, Macedonia, Bulgaria) European countries. For this purpose in 2007 the 1691G>A FV variant was analyzed by polymerase chain reaction-restriction fragment length polymorphism from DNA collected in 2005-2006. We studied 650 subjects: 400 newborns and 250 older individuals (mean age 46.1 y) from Poland and compared results with reports from other countries, as well as with the frequency trend of 845G>A HFE across South-Eastern European countries using centroid cities. From our 1691G>A FV study we identified 626 GG homozygotes, 23 GA heterozygotes, and 1 AA homozygote (n = 650), giving an A allele frequency of 1.9%, and a summed frequency value for Poland of 2.0% (n = 1588); the frequency in Central European countries was 3.9% (n = 4559), mostly due to the high value in the Czech Republic: 5.1% (n = 2819); the South-Eastern European countries had 2.5% (n = 2410). Among the Eastern European countries the 1691G>A FV allele frequency was 1.9% (n=791), between the South-Eastern and Eastern European countries there was no significant difference (p=0.17). We confirm that the 1691G>A FV allele frequency in Poland, as well as other countries compared, is significantly lower than that in Czech.

Prevalence of chronic hepatitis B and hepatitis C among first time blood donors in Northeast Bosnia and Herzegovina: an estimate of prevalence in general population

BACKGROUND

Data on the epidemiology of hepatitis B and C in Bosnia and Herzegovina (B&H) are lacking.

OBJECTIVES

To assess the prevalence of hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (anti-HCV) in blood samples of first time blood donors in a well-defined region of B&H. Our secondary goal was to estimate the prevalence of HBsAg and anti-HCV in the general population of the same region.

PATIENTS AND METHODS

We evaluated 8196 blood samples for the presence of HBsAg and/or anti-HCV, adjusted for differences in gender, and used the ratio estimation method to determine the prevalence in the general population.

RESULTS

We analyzed 1263 (15.4%) female and 6933 (84.6%) male blood donors (male-to-female ratio: 5.49 to 1). The adjusted prevalence of HBsAg among blood donors was 0.787% (95% CI = 0.535-1.038), while the prevalence of anti-HCV was 0.267% (95% CI = 0.016-0.519). There was no difference in the prevalence of HBsAg or anti-HCV between men and women. We estimate that the prevalence of HBsAg and anti-HCV in the general population is 1.057% to 1.535% and 0.29% to 0.89%, respectively.

CONCLUSIONS

The prevalence of HBsAg and anti-HCV among blood donors suggests that our region has low endemicity for both hepatitis B and hepatitis C.

Simple uninvestigated dyspepsia: age threshold for early endoscopy in Bosnia and Herzegovina

OBJECTIVE

To establish an optimal age threshold for endoscopy referral in patients with simple uninvestigated dyspepsia in the setting of European developing country (Bosnia and Herzegovina) with low availability and high workload of endoscopy units.

METHODS

We reviewed patient information on all upper endoscopies performed during a 6-year period (2000-2005). Different age thresholds were evaluated in terms of their predictive power for absence of malignancy.

RESULTS

A total of 82 of 4403 (1.86%) dyspeptic patients had upper gastrointestinal (GI) malignancy. Age cutoffs of 40 years for men and 45 years for women had the best predictive power, without any cases of upper GI malignancies below those thresholds. Age cutoffs of 45 years for men and 50 years for women also had excellent negative predictive values (99.7 and 99.9%, respectively) with 1.45 and 0.98 cases of missed upper GI malignancies per 1000 endoscopies, respectively. A total of 1709 of 4403 (38.8%) of endoscopies might have been avoided in men of less than 45 and women of less than 50 with uninvestigated dyspepsia.

CONCLUSION

(i) Age thresholds for endoscopy referral are lower than in Western countries and should be different for men and women. (ii) Cutoff values of 40 and 45 years for men and women, respectively, are completely safe to use. (iii) Thresholds of 45 years for males and 50 years for females have a small level of risk of missing upper GI malignancy, but are acceptable to use in areas of low availability of endoscopy.

Prevalence of genetic prothrombotic risk factors: 1691G > A FV, 20210G > A PT and 677C > T MTHFR mutations in the Bosnian population

BACKGROUND

Venous thrombosis (VT) affects 1-2 out of 10(3) individuals each year. Mutations of 1691G > A FV gene, 20210G > A PT gene and 677C > T gene MTHFR are common in Europe and increase the risk of venous thrombosis. To the authors' knowledge, this is the first report on the prevalence of these mutations in the general population of Bosnia and Herzegovina.

AIM

The aim of this study was to simultaneously analyse main VT associated polymorphisms and compare the results with those published for other European populations.

DATA SOURCES

Electronic databases including Medline and Embase were searched from 1995 to December 2013.

SUBJECTS AND METHODS

The subjects of the study consisted of 100 unrelated healthy people from Bosnia and Herzegovina (82 female and 18 male). The mean age of the cohort was 58.8 (± 10.7) years. PCR-RFLP was used for measurement of allele frequencies.

RESULTS

All three SNPs were found to be polymorphic, with allele frequencies of 6.0%, 6.0% and 37.5% for 1691A FV, 20210A PT and 677T MTHFR, respectively.

CONCLUSION

Further studies on larger cohorts with an adequate female-to-male ratio are necessary to confirm a high prevalence of hereditary thrombophilia in the Bosnian population.

Diclofenac sodium versus ceftazidime for preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a prospective, randomized, controlled trial

BACKGROUND AND AIMS

We aimed to compare the efficacy of prophylactic, parenterally administered ceftazidime and rectally applied diclofenac sodium for the prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS

We prospectively enrolled patients who underwent ERCP. In a double-blind, randomized, controlled trial, patients received a suppository containing diclofenac sodium rectally (100 mg) and placebo intravenously (group A) or ceftazidime intravenously (1 g) and placebo rectally (group B) immediately before the procedure. The serum and urine amylase levels were recorded and the patients were clinically evaluated after ERCP.

RESULTS

Of the 272 patients enrolled (group A: 129; group B: 143), 32 developed pancreatitis (group A: 11 [8.5 %]; group B: 21 [14.7 %]; P = 0.17; relative risk = 1.72; 95 % confidence interval [CI] = 0.86-3.43). The severity of the pancreatitis or complications did not significantly differ between the groups. A serum amylase level of ≥560 U/L and urine amylase level of ≥1150 U/L indicated a positive likelihood ratio for post-ERCP pancreatitis of ≥10. Moreover, the threshold visual analog scale score of ≤5 for abdominal pain after ERCP had excellent diagnostic potential for predicting the presence or absence of post-ERCP pancreatitis.

CONCLUSIONS

The PEP incidence did not differ between the ceftazidime and diclofenac sodium groups. In patients with nonsteroidal anti-inflammatory drug contraindications, antibiotics can be considered a safe alternative to diclofenac sodium for PEP prevention. Moreover, the visual analog scale for abdominal pain has excellent diagnostic value for predicting PEP. CLINICAL TRIALS.

GOV NUMBER

NCT 01784445.