The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Incidence, presentation, and outcomes in patients with drug-induced liver injury in the general population of Iceland

BACKGROUND & AIMS

Little is known about the incidence of drug-induced liver injury (DILI) in the general population. We investigated the incidence and the quantitative risk of DILI in a population-based cohort.

METHODS

We performed a prospective study and collected data from 96 individuals diagnosed with DILI in Iceland from 2010 through 2011 (54 women; median age, 55 y). Liver injury was defined based on levels of alanine aminotransferase that were more than 3-fold the upper limit of normal and/or alkaline phosphatase levels more than 2-fold the upper limit of normal. Patients with acetaminophen toxicity were excluded. Drug history and clinical outcome were analyzed. Causality was assessed using the Roussel Uclaf Causality Assessment Method. The patients were registered in prescription databases for outpatients and inpatients.

RESULTS

The crude annual incidence rate of DILI was 19.1 (95% confidence interval [CI], 15.4-23.3) cases per 100,000 inhabitants. DILI was caused by a single prescription medication in 75% of cases, by dietary supplements in 16% of cases, and by multiple agents in 9% of cases. The most commonly implicated drugs were amoxicillin-clavulanate (21 of 96; 22%), diclofenac (6%), azathioprine (4%), infliximab (4%), and nitrofurantoin (4%). The median duration of therapy was 20 days (range, 8-77 days); 26 patients had jaundice (27%) and 22 patients were hospitalized (23%) for a median of 5 days (range, 2-8 days). Overall 35,252 patients received amoxicillin-clavulanate as outpatients, and DILI occurred in 1 of 2350 (43 of 100,000; 95% CI, 24-70). DILI also occurred in 1 of 9480 patients taking diclofenac (11 of 100,000; 95% CI, 4-24), 1 of 133 patients taking azathioprine (752 of 100,000; 95% CI, 205-1914), 1 of 148 patients taking infliximab (675 of 100,000; 95% CI, 184-718), and 1 of 1369 patients taking nitrofurantoin (73 of 100,000; 95% CI, 20-187).

CONCLUSIONS

In a population-based study in Iceland, the incidence of DILI was the highest reported to date. Amoxicillin-clavulanate was the most commonly implicated agent. The highest risk of hepatotoxicity was associated with azathioprine and infliximab, but the actual number of cases attributed to these agents was small.

Magnetic self-organized atomic laminate from first principles and thin film synthesis

The first experimental realization of a magnetic M(n+1)AX(n) (MAX) phase, (Cr(0.75)Mn(0.25))(2)GeC, is presented, synthesized as a heteroepitaxial single crystal thin film, exhibiting excellent structural quality. This self-organized atomic laminate is based on the well-known Cr(2)GeC, with Mn, a new element in MAX phase research, substituting Cr. The compound was predicted using first-principles calculations, from which a variety of magnetic behavior is envisaged, depending on the Mn concentration and Cr/Mn atomic configuration within the sublattice. The analyzed thin films display a magnetic signal at room temperature.

Fe charge state adjustment in ZnO upon ion implantation

The influence of the ion implantation process on the charge state of dilute (57)Fe impurities implanted as radioactive (57)Mn in ZnO is investigated by (57)Fe emission Mössbauer spectroscopy. One sample is additionally implanted with stable (23)Na impurities. Both Fe(2+) and Fe(3+) charge states are observed, and the Fe(3+)/Fe(2+) ratio is found to increase with the fluence of both (57)Mn/(57)Fe and (23)Na ions, demonstrating that the build-up of Fe(3+) is not related to the chemical nature of the implanted ions. The results are interpreted in terms of radiation damage induced changes of the Fermi level, and illustrate that the Fe(3+)/Fe(2+) ratio can be adjusted by ion implantation. The spin-lattice relaxation time for Fe(3+) in ZnO is found to be independent of the implantation fluence, and is evidently an intrinsic property of the system.

Hepatitis E masquerading as drug-induced liver injury

The patient presented below gives us the opportunity to discuss challenges in the diagnosis of drug-induced liver injury in an era of increasing awareness of hepatitis E.

Comparing resonant photon tunneling via cavity modes and Tamm plasmon polariton modes in metal-coated Bragg mirrors

Resonant photon tunneling was investigated experimentally in multilayer structures containing a high-contrast (TiO(2)/SiO(2)) Bragg mirror capped with a semitransparent gold film. Transmission via a fundamental cavity resonance was compared with transmission via the Tamm plasmon polariton resonance that appears at the interface between a metal film and a one-dimensional photonic bandgap structure. The Tamm-plasmon-mediated transmission exhibits a smaller dependence on the angle and polarization of the incident light for similar values of peak transmission, resonance wavelength, and finesse. Implications for transparent electrical contacts based on resonant tunneling structures are discussed.

Liver cirrhosis in Iceland and Sweden: incidence, aetiology and outcomes

OBJECTIVE

The objectives of this study were to investigate the incidence, aetiology and mortality of liver cirrhosis in Iceland and in Gothenburg in Sweden. Further objectives were prognosis in relation to different aetiologies and to evaluate the relationship between alcohol consumption in these countries and the incidence of alcoholic cirrhosis in recent decades. The incidence and mortality of liver cirrhosis in Iceland has been reported to be the lowest in the Western world. There are very few data on aetiology, incidence and prognosis among cirrhotics in Sweden.

MATERIAL AND METHODS

All patients diagnosed with liver cirrhosis in Gothenburg (600,000 inhabitants) and Iceland (300,000 inhabitants) during the period 1994-2003 were included.

RESULTS

A total of 918 patients in Gothenburg and 98 in Iceland were identified. The annual incidence in Gothenburg was 15.3+/-2.4/100,000 compared to 3.3+/-1.2/100,000 in Iceland (p<0.0001). In Gothenburg, 69% were male and in Iceland 52% (p<0.001). In Gothenburg, 50% of the patients had alcoholic cirrhosis compared to 29% in Iceland (p<0.0001). In Gothenburg, the patients had a higher Child-Pugh score (9.0) (SD 2.5) compared to Iceland (7.3) (SD 2.7) (p<0.0001). There was no difference in survival between patients with alcoholic liver disease and those with other aetiologies.

CONCLUSIONS

The incidence of liver cirrhosis is low in Iceland, i.e. 24% of the incidence in Gothenburg, due to the lower incidence of alcoholic and hepatitis C cirrhosis in Iceland. No increasing trends in the incidence of cirrhosis in these two countries were observed during the study period.

Macroglobulinaemia in an Icelandic family

Macroglobulinaemia in an Icelandic family is presented. A woman had Waldenström's macroglobulinaemia, and two of her brothers had monoclonal macroglobulinaemia of the benign form. One was asymptomatic, but the other had polyneuropathy and IgM deposits in peripheral nerves. A third brother of these siblings died of a lymphoreticular disease, which presented with a widespread neuropathy. A second sister had polyclonal increase in serum IgA and two other brothers of this sibship had IgM slightly elevated. A study of all descendants (45 in all and 19 spouses) revealed seven individuals with elevated IgM levels. No other immunoglobulin abnormalities were detected.

[Hepatitis C: a clinical-histopathological study]

OBJECTIVE

Hepatitis C is a common cause of chronic hepatitis and cirrhosis in Western countries. In recent years a large group of individuals have been diagnosed with the disease in Iceland. The aim of this study was to investigate histological parameters of patients with hepatitis C and to correlate histological findings with clinical findings.

MATERIALS AND METHODS

In this retrospective study, all patients diagnosed with hepatitis C in Iceland that had a liver biopsy in the years 1991-2001 were included. Data on age, route of infection, duration of infection and co-infection was obtained from medical records. Liver biopsy specimens were evaluated and inflammatory activity graded and the degree of fibrosis staged.

RESULTS

In all 97 patients (58 males, 39 females) were included in the study. The mean age was 35.6 years (range 11-64). Risk factors were intravenous drug abuse in 70 (72.6%), blood transfusion in 12 (12.4%) and eight had no known risk factors. Estimated duration of infection was 8.85 years (range 1-31). Average inflammatory grade was 2.84 (range 0-8) and average fibrosis stage was 0.95 (range 0-6). The majority (72.6%) of patients had minimal or no inflammation and 85.5% had minimal or no fibrosis. Only four patients had cirrhosis. Significant correlation was observed between the age at infection and the degree of fibrosis. No correlation was detected between the duration of infection or route of infection and histopathological parameters.

CONCLUSION

Patients with hepatitis C that underwent a liver biopsy in 1991-2000 had mild histopathological changes in the liver. This is most likely due to short duration of infection and young age of the patients in this study.

A magnetron sputtering system for the preparation of patterned thin films and in situ thin film electrical resistance measurements

We describe a versatile three gun magnetron sputtering system with a custom made sample holder for in situ electrical resistance measurements, both during film growth and ambient changes on film electrical properties. The sample holder allows for the preparation of patterned thin film structures, using up to five different shadow masks without breaking vacuum. We show how the system is used to monitor the electrical resistance of thin metallic films during growth and to study the thermodynamics of hydrogen uptake in metallic thin films. Furthermore, we demonstrate the growth of thin film capacitors, where patterned films are created using shadow masks.

[Viral hepatitis B and C among immigrants in Iceland]

BACKGROUND

Viral hepatitis B and C are a major health problem worldwide. The prevalence of these diseases varies throughout the world. In Iceland, the incidence of hepatitis B and C has increased in recent years. At the same time, the number of immigrants from countries where viral hepatitis is endemic, has also increased. The aim of this study was to investigate the epidemiology of hepatitis B and C among immigrants in Iceland.

MATERIAL AND METHODS

Immigrants from outside the European Economic Area (EEA) were screened for hepatitis B and C. Medical records for the years 2000-2002 were reviewed for country of origin, viral serology and liver transaminases. Information was gathered from the State Epidemiologist's central registry of notifiable diseases and from the Icelandic Directorate of Immigration on the number of residence permits issued.

RESULTS

70% of all immigrants from countries outside the EEA during the study period were included in the study. Blood samples were obtained from 2946 immigrants. 83 (2.8%) had hepatitis B and 24 (0.8%) had hepatitis C. Prevalence of hepatitis B was highest among immigrants from Africa,11/171 (6.4%; 95% CI: 3.3-11.2%) and hepatitis C among immigrants from Eastern Europe, 16/1502 (1.1%; 95% CI: 0.6-1.7%). 482 (16%) had serological markers of previous hepatitis B infection. Of all registered cases of hepatitis B, immigrants were 56% and of hepatitis C 10%.

CONCLUSIONS

1. Majority of those diagnosed with hepatitis B during the study period were immigrants. 2. Among immigrants, hepatitis B was more prevalent than hepatitis C. 3) The high prevalence of hepatitis B justifies screening for the disease in this population.

Ultrasound examination shows disturbed proximal gastric function in symptomatic gallstone patients with dyspepsia and improvement after cholecystectomy--gallstones and gastric emptying

AIM

The aim of our study was to examine gastric function, gallbladder emptying, and dyspepsia in symptomatic gallbladder stone patients (SGBS) to see if a motility disorder, expressed by gastric function and gallbladder emptying, may cause dyspepsia in SBGS.

MATERIALS AND METHODS

Gastric function and gallbladder emptying in 21 SGBS referred for surgical treatment were measured by ultrasound after ingestion of 500 ml of a meat soup (bouillon). Dyspeptic symptoms were simultaneously recorded on a Visual Analog Scale (VAS). The patients were re-examined 10 months after cholecystectomy. Hospital staff (n = 14) served as control subjects (C).

RESULTS

In SGBS, the frontal diameter of the proximal stomach was wider than in C at both 10 minutes (55.7 vs. 48.3 mm; p = 0.053) and 20 minutes (49.3 vs. 39.5 mm; p = 0.002), and the sagittal area of the proximal stomach was larger at 10 minutes (25.0 vs. 20.9 cm (2); p = 0.03). The postprandial frontal diameter decreased significantly after cholecystectomy (immediately after the meal: 51.3 mm; p = 0.03, at 10 minutes: 47.6 mm; p = 0.05, and at 20 minutes: 39.1 mm; p = 0.004). Twenty minutes after meal ingestion, gallbladder emptying was significantly less in SGBS than in C with a mean (SD) emptying of 20 % (17) versus 33 % (18); p < 0.04. In the fasting state, SGBS felt more hunger than C (VAS 67 mm vs. 39 mm; p = 0.03). After cholecystectomy, the feeling of hunger decreased (VAS 27 mm; p = 0.01).

CONCLUSION

SGBS had a wider proximal stomach and more hunger in the fasting state than C. After cholecystectomy the proximal stomach function and the hunger score improved. Our results suggest a physiological link between symptomatic gallstone disease and dyspepsia expressed by impaired proximal gastric function.

Antimitochondrial antibodies and reactivity to N. aromaticivorans proteins in Icelandic patients with primary biliary cirrhosis and their relatives

OBJECTIVES

Primary biliary cirrhosis (PBC) is a chronic, progressive cholestatic disease of unknown etiology characterized by serum antimitochondrial antibodies (AMA) directed against a functionally related family of mitochondrial enzymes. We recently suggested that N. aromaticivorans might be the trigger of autoimmunity in PBC. No data are available on the specificity and crossreactivity of AMA in a genetically homogenous group of patients, such as the Icelandic population.

METHODS

To address these issues and to confirm previous findings in a unique population, we obtained sera from 14 PBC patients and 85 first-degree relatives, all of Icelandic descent. We analyzed such sera for AMA specificity using recombinant mitochondrial antigens and for reactivity against N. aromaticivorans proteins.

RESULTS

Thirteen of the 14 Icelandic patients with PBC (93%) were found AMA positive. We found that 5/13 AMA positive sera (38%) reacted against PDC-E2 only; 5/13 (or 38%) reacted against BCOADC-E2; and 2/13 (15%) reacted against all three antigens. There was no reactivity against OGDC-E2. Reactivities of patients' sera against N. aromaticivorans were consistent with the AMA status. One serum among the 85 first-degree relatives (1.2%) was found to be AMA-positive, as well as reactive against N. aromaticivorans.

CONCLUSIONS

Interestingly, despite the homogenous genetic background, the group of Icelandic patients with PBC was heterogeneous in their AMA reactive patterns and also reacted with N. aromaticivorans proteins.

Changes in food tolerance and lifestyle after eradication of Helicobacter pylori

BACKGROUND

It is known that patients with peptic ulcer disease (PUD) often have an unhealthy lifestyle that results in increased mortality because of smoking-related diseases. No thorough study has been done to see what changes, if any, the patient makes to lifestyle after eradication of Helicobacter pylori.

METHODS

One-hundred-and-eighty-three patients were enrolled in an open-endoscopy setting; 58% had PUD and 42% gastritis and/or duodenitis (G/D). They filled out a lifestyle questionnaire before the start of anti-Helicobacter therapy and again 1 year later.

RESULTS

The prevalence of food intolerance decreased from 71% to 44% among patients with PUD (P < 0.0001) and from 76% to 63% among patients with G/D (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits. There was no significant change in smoking or alcohol consumption after eradication. Coffee and tea consumption was unchanged. Milk consumption decreased from 4.2 dL/day to 3.3 (P = 0.01). The number of meals decreased from 3.5/day to 3.4 (P = 0.005) and snacking from 1.3 snacks/day to 1.1 (P = 0.02). Consumption of fruit increased from 4.0 to 4.3 times/week (P = 0.04), but the frequency of meat, fish, vegetables, spicy foods, salty foods, sweets and cakes did not change. The time spent on each meal was unchanged. There was no change in the time spent exercising. There were few significant differences between PUD and G/D patients.

CONCLUSIONS

Food was better tolerated, but there were no major changes in lifestyle after eradication of H. pylori. Patients therefore do not abuse the privilege of a more tolerant digestion by indulging in a more unhealthy lifestyle.

Patients with endoscopic gastritis and/or duodenitis improve markedly following eradication of Helicobacter pylori, although less so than patients with ulcers

BACKGROUND

It is well documented that dyspepsia in patients with peptic ulcer disease (PUD) improves markedly after eradication of Helicobacter pylori, while rarely does it improve in patients with functional dyspepsia. There is a large group of H. pylori-infected patients who do not qualify for either diagnosis, but in whom eradication may be considered. The aim of this study was to compare symptom severity, change in gastrointestinal symptoms 1 year after eradication and satisfaction with therapy between PUD patients and patients with endoscopic diagnoses of gastritis and/or duodenitis (G/D patients).

METHODS

The patients were randomized to one of four triple regimens containing ranitidine bismuth and metronidazole, and either oxytetracycline or spiramycine. Eradication was assessed with the 14C-urea breath test. GI symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcer Esophagitis Subjective Symptoms Scale (UESS) questionnaires.

RESULTS

One-hundred-and-eighty-three patients were recruited from GI outpatient clinics. Patients with PUD and G/D had similar severity of symptoms before eradication therapy. One year after H. pylori eradication, 99% of the PUD patients and 75% of the G/D patients felt better regarding their main upper GI complaint. Abdominal pain score decreased by 48% as measured by GSRS and by 78% as measured by UESS in the PUD group and by 25% and 47%, respectively, in the G/D group. Reflux symptoms decreased by 41% and 63% in PUD patients and by 28% and 45% in G/D patients; indigestion by 30% and 47% in PUD and by 20% and 34% in G/D; eating discomfort by 60% in PUD and by 35% in G/D. Sleep quality score improved by 68% in PUD and by 41% in NU patients. Constipation decreased by 22% in the PUD group. All these differences in symptoms were highly significant compared to baseline. Diarrhoea was unchanged.

CONCLUSIONS

Abdominal pain, reflux symptoms, indigestion and the ability to eat and sleep improved in both PUD and G/D patients 1 year after H. pylori eradication. Chronic diarrhoea was not induced. Abdominal pain improved significantly more in PUD than in G/D patients. Further study of the effect of H.pylori eradication in G/D patients is warranted.

Vagal tone and meal-induced abdominal symptoms in healthy subjects

BACKGROUND/AIMS

Patients with functional dyspepsia often have meal-induced dyspeptic symptoms and low vagal tone. We examined whether these variables are related in healthy subjects.

METHODOLOGY

In 40 healthy subjects vagal tone and abdominal symptoms were recorded before and after a 500-ml soup meal ingested in 1 and 4 min on separate visits. Vagal tone was indexed by respiratory sinus arrhythmia (RSA).

RESULTS

Scores for nausea and discomfort were higher when the soup was ingested in 1 min as compared with 4 min (nausea: p = 0.02; discomfort: p = 0.04). There was no difference in fullness or abdominal pain. RSA was unrelated to meal-induced symptom scores. RSA varied with respiration and body position: It was highest while breathing deeply in the sitting position (24.0 beats/min). With normal breathing RSA was highest in the supine position (9.0 beats/min), lower while sitting (7.0 beats/min) and lowest while standing (6.2 beats/min).

CONCLUSIONS

Epigastric discomfort in response to rapid ingestion of a test meal in healthy subjects was not related to vagal tone as indexed by RSA. Vagal tone varied with breathing pattern and body position. It is possible that increasing vagal tone by such measures can be beneficial in the treatment of patients with functional dyspepsia.

Chemical control of Penthaleus major (Acari: Prostigmata) in hayfields in Iceland

The plant parasitic mite Penthaleus major (Dugès) occurs as a pest on perennial grasses in hayfields in Iceland, northern Norway, and southern Greenland. In these areas it appears as a summer phenomenon, contrary to more southern locations, where it appears as a pest on winter crops. Up to 500 individuals of P. major were collected per day in pitfall traps. Spring application of 44 ml/ha of permethrin and 5 ml of deltamethrin significantly reduced but did not eliminate the populations of P. major the following weeks. In addition to this immediate effect, spring application also decreased the mite populations in the fall and even the following spring. Additional effects might be obtained by earlier spring application. Despite a significant reduction in mite populations and reduction in visible plant damage, significant differences on dry matter yield were rarely registered. A side effect of application was a small but significant reduction in potassium-content of the yield, and the reduction in mite population was accompanied by a corresponding reduction in the number of spiders.