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Konishi F, Miyake T, Watanabe T, Tokumoto Y, Furukawa S, Matsuura B, Yoshida O, Miyazaki M, Shiomi A, Kanzaki S, Nakaguchi H, Nakamura Y, Imai Y, Koizumi M, Yamamoto Y, Koizumi Y, Hirooka M, Takeshita E, Kumagi T, Ikeda Y, Abe M, Hiasa Y. Association of abnormal glucose tolerance with liver-related disease and cardiovascular diseases in patients with chronic hepatitis C. Hepatol Res 2023; 53:806-814. [PMID: 37183992 DOI: 10.1111/hepr.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
AIM Hepatitis C complicated by diabetes mellitus (DM) is considered a risk factor for the progression of fibrosis and development of hepatocellular carcinoma (HCC) and cardiovascular diseases. However, several studies may have lacked appropriate diagnosis of glucose intolerance. We aimed to examine the risk associated with abnormal glucose intolerance in the development of liver-related diseases, including HCC and complications of liver cirrhosis, such as ascites, esophageal and gastric varices, and hepatic encephalopathy, and cardiovascular diseases in patients with hepatitis C accurately diagnosed with impaired glucose tolerance. METHODS This longitudinal retrospective study included 365 patients with chronic hepatitis C admitted to Ehime University Hospital for anti-hepatitis C therapy between September 1991 and January 2015. Patients were classified into normal glucose tolerance (NGT), prediabetes, and DM groups based on 75-g oral glucose tolerance test results. RESULTS Both univariate and multivariate (adjusted for potential confounders) analyses revealed a significantly higher risk of developing HCC and cardiovascular events in the DM group than in the NGT group. However, in multivariate analysis, liver-related events, particularly liver cirrhosis complications, revealed no significant association. In addition, the prediabetes group had no significant risk of any outcome. CONCLUSIONS Patients with hepatitis C complicated by DM, compared with patients with hepatitis C with NGT or complicated with prediabetes, have a higher risk of HCC and cardiovascular disease events, but not liver-related events, particularly in not developing liver cirrhosis complications. Therefore, appropriate follow-up is required for patients with hepatitis C based on their glucose tolerance status.
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Affiliation(s)
| | - Teruki Miyake
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takao Watanabe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshio Tokumoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Shinya Furukawa
- Health Services Center, Ehime University, Matsuyama, Ehime, Japan
| | - Bunzo Matsuura
- Department of Lifestyle-related Medicine and Endocrinology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Osamu Yoshida
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masumi Miyazaki
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Akihito Shiomi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Sayaka Kanzaki
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hironobu Nakaguchi
- Department of Lifestyle-related Medicine and Endocrinology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshiko Nakamura
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yusuke Imai
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Mitsuhito Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yasunori Yamamoto
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Eiji Takeshita
- Department of Inflammatory Bowel Diseases and Therapeutics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Teru Kumagi
- Postgraduate Medical Education Center, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshio Ikeda
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Masanori Abe
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Tan CH, Chang MC, Tsai WF, Chuang WL, Huang JF, Lin ZY, Dai CY, Yeh ML, Li CT, Yu RL. Different profiles of neurocognitive impairment in patients with hepatitis B and C virus infections. Sci Rep 2022; 12:10625. [PMID: 35739162 PMCID: PMC9226189 DOI: 10.1038/s41598-022-14736-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/13/2022] [Indexed: 11/20/2022] Open
Abstract
The direct impact of chronic hepatitis B and hepatitis C on neurocognition remains elusive due to the frequent comorbidities, and the domains of the neurocognitive functions affected have rarely been investigated comprehensively. We cross-sectionally assessed the neurocognitive functions of the individuals with chronic hepatitis B, chronic hepatitis C, treated chronic hepatitis C with a sustained virologic response, and their healthy control counterparts. Laboratory examinations were used to investigate the impact of inflammation on neurocognition, exclude the medical conditions that could interfere with neurocognition assessment, and assess liver function and fibrotic severity of the liver of the participants. This study found the detrimental impact of chronic hepatitis B on language and executive functions. In contrast, individuals with chronic hepatitis C showed deficits in executive functions, psychomotor speed, memory, and attention. Successful elimination of hepatitis C resulted in improved liver function, but not neuropsychological test performance. Moreover, erythrocyte sedimentation rate level was found to mediate the deficits in the attention of individuals with chronic hepatitis C. These results demonstrate the neurocognitive deficits and the difference in the profiles of neurocognitive deficits in individuals with chronic hepatitis B and chronic hepatitis C. Our study also provided results suggesting the mediation by systemic inflammation on the attention deficit in individuals with chronic hepatitis C.
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Affiliation(s)
- Chun-Hsiang Tan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Meng-Chia Chang
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Fang Tsai
- M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Zu-Yau Lin
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lun Yeh
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Ting Li
- Department of Psychology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Rwei-Ling Yu
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Tarasov D, Lebedev I, Nekrasov D, Verbakh T, Nesterova O. The structure of stroke and the effect of somatic and addiction diseases on its appearance and course in patients with HIV infection. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:11-17. [DOI: 10.17116/jnevro202212208211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Moretti R, Giuffrè M, Merli N, Caruso P, Di Bella S, Tiribelli C, Crocè LS. Hepatitis C Virus-Related Central and Peripheral Nervous System Disorders. Brain Sci 2021; 11:1569. [PMID: 34942871 PMCID: PMC8699483 DOI: 10.3390/brainsci11121569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/19/2022] Open
Abstract
Hepatitis C Virus (HCV), despite being a hepatotropic virus, is the causative agent of many systemic disorders, such as vasculitis, autoimmune diseases, lymphoproliferative disorders, and a broad spectrum of neurological and psychiatric manifestations. Although symptoms have been misdiagnosed or underdiagnosed, only recently, evidence of direct (inflammatory) or indirect (immune-mediated) HCV-dependent cerebral effects has been established. HCV infection can promote acute inflammatory response, pro-coagulative status and ischemic disorders, and neurodegeneration. These effects rely on cerebral HCV replication, possibly mediated by blood-brain barrier alterations. Further study is needed to better understand the HCV-related mechanisms of brain damage.
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Affiliation(s)
- Rita Moretti
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Mauro Giuffrè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Nicola Merli
- Department Neurological Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Paola Caruso
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | - Stefano Di Bella
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
| | | | - Lory Saveria Crocè
- Department Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (R.M.); (P.C.); (S.D.B.); (L.S.C.)
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Rocha LCD, Estofolete CF, Milhim BHGDA, Augusto MT, Zini N, Silva GCDD, Ferraz-Junior HC, Brienze VMS, Liso E, Cunha MS, Sabino EC, da Costa AC, Nogueira ML, Luchs A, Terzian ACB. Enteric viruses circulating in undiagnosed central nervous system infections at tertiary hospital in São José do Rio Preto, São Paulo, Brazil. J Med Virol 2021; 93:3539-3548. [PMID: 32579291 DOI: 10.1002/jmv.26216] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/15/2020] [Accepted: 06/20/2020] [Indexed: 12/18/2022]
Abstract
Enterovirus (EV) is commonly associated with central nervous system (CNS) syndromes. Recently, gastroenteric viruses, including rotavirus (RVA), human astrovirus (HAstV), and norovirus (NoV), have also been associated with CNS neurological disorders. The aim of the present study was to investigate the presence of EV, RVA, HAst, and NoV associated to CNS infections with undiagnosed etiology in Northwest region of São Paulo State, Brazil, and to conduct the molecular characterization of the positive samples detected. A total of 288 cerebrospinal fluid samples collected from July to December 2017 were tested for EV and NoV by quantitative real-time polymerase chain reaction (RT-qPCR), HAstV by conventional RT-PCR, and RVA by enzyme-linked immunosorbent assay. Positive-EV samples were inoculated in cells lines, amplified by RT-PCR and sequenced. RVA, NoV, and HAstV were not detected. EV infection was detected in 5.5% (16/288), and five samples successful genotyped: echovirus 3 (E3) (1/5), coxsackie virus A6 (CVA6) (1/5), and coxsackie virus B4 (CVB4) (3/5). Meningitis was the main syndrome observed (12/16; 75%). CVA6, CVB4, and E3 were identified associated with aseptic meningitis. Reports of CVA6 associated with aseptic meningitis are rare, E3 had not been previously reported in Brazil, and epidemiological data on CVB4 in the country is virtually unknown. The present investigation illustrates the circulation of diverse EV types in a small regional sample set and in a short period of time, highlighting the importance of an active EV surveillance system in CNS infections. Enhanced understanding of undiagnosed CNS infections will assist in public health and health care planning.
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Affiliation(s)
| | | | | | | | - Nathalia Zini
- São José do Rio Preto School of Medicine (FAMERP), São Paulo, Brazil
| | | | | | | | | | - Mariana Sequetin Cunha
- Vector Borne Disease Laboratory, Virology Center, Adolfo Lutz Institute, São Paulo, Brazil
| | - Ester Cerdeira Sabino
- LIM/46, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
- Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Adriana Luchs
- Enteric Disease Laboratory, Virology Center, Adolfo Lutz Institute, São Paulo, Brazil
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Li KY, Chou MC, Wei JCC, Lin MC, Hung YM, Chang R. Newly Diagnosed Leptospirosis and Subsequent Hemorrhagic Stroke: A Nationwide Population-Based Cohort Study. Stroke 2021; 52:913-921. [PMID: 33494640 DOI: 10.1161/strokeaha.120.029998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Preceding infection as an important risk factor for ischemic stroke has been reported but neglected for hemorrhagic stroke, especially in young and middle-aged patients. This study investigates whether newly diagnosed leptospirosis is associated with an increased risk of stroke. METHODS We identified 3699 in-patients who were aged ≥18 years and newly diagnosed with leptospirosis. We also randomly selected a comparison cohort 14 796 in-patients from the general population by using a propensity score matching method (at a 1:4 ratio). We analyzed the risks of stroke by using Cox proportional hazard regression models. RESULTS The adjusted hazard ratio (HR; 95% CI) of stroke for the leptospirosis group was 1.14 (0.93-1.38; P=0.200) as opposed to the comparison group after adjusting sex, age, and comorbidities. However, adjusted HR (95% CI) of ischemic stroke and hemorrhagic stroke was 1.01 (0.80-1.29) and 1.58 (1.12-2.23), respectively. The strength of association between leptospirosis and hemorrhagic stroke remained statistically significant after variation of leptospirosis and stroke definitions. The post hoc subgroup analysis indicated that a patient with leptospirosis had a significantly greater risk of hemorrhagic stroke in male (adjusted HR, 1.62 [95% CI, 1.08-2.44]) and individuals between age 18 and 39 (adjusted HR, 3.67 [95% CI, 1.33-10.14]). The risk of hemorrhagic stroke among people with leptospirosis was highest in the first 2 years after diagnosis (adjusted HR, 1.97 [95% CI, 1.15-3.38]). CONCLUSIONS A 2.49-fold risk of stroke was found among the leptospirosis cohort of aged younger than 39 years. Age acted as an effect modifier between the leptospirosis and risk of new-onset stroke.
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Affiliation(s)
- Kuan-Ying Li
- Department of Neurology, Kaohsiung Medical University Hospital, Taiwan (K.-Y.L.).,Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Taiwan (K.-Y.L.)
| | - Mei-Chia Chou
- Department of Recreation Sports Management, Tajen University, Pingtung, Taiwan (M.-C.C., R.C.).,Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung, Taiwan (M.-C.C.)
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan (J.C.-C.W.).,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan (J.C.-C.W., Y.-M.H.).,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan (J.C.-C.W.)
| | - Mei-Chen Lin
- Department of Neurology, Kaohsiung Medical University Hospital, Taiwan (K.-Y.L.)
| | - Yao-Min Hung
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan (J.C.-C.W., Y.-M.H.).,Department of Internal Medicine, Kaohsiung Municipal United Hospital, Taiwan (Y.-M.H.).,College of Health and Nursing, Meiho University, Pingtung, Taiwan (Y.-M.H.).,Tajen University, Pingtung, Taiwan (Y.-M.H.)
| | - Renin Chang
- Department of Recreation Sports Management, Tajen University, Pingtung, Taiwan (M.-C.C., R.C.).,Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Taiwan (R.C.)
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7
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Kleefeld F, Arendt G, Neuen-Jacob E, Maschke M, Husstedt I, Obermann M, Schmidt H, Hahn K. [Neurological complications of hepatitis C infections]. DER NERVENARZT 2020; 92:144-149. [PMID: 33001263 PMCID: PMC7873080 DOI: 10.1007/s00115-020-00999-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 12/26/2022]
Abstract
Die chronische Hepatitis-C-Virus(HCV)-Infektion ist eine hochprävalente Systemerkrankung, die verschiedene neurologische Komplikationen verursachen kann. Es lassen sich HCV-assoziierte Symptome im zentralen und peripheren Nervensystem sowie der Muskulatur unterscheiden. Wichtige Pathomechanismen sind die HCV-assoziierte Autoimmunität (z. B. gemischte Kryoglobulinämie mit Polyneuropathie) und direkte Neurotoxizität (z. B. bei HCV-assoziierten kognitiven Defiziten). Die häufigsten neurologischen Komplikationen sind distal-symmetrische Polyneuropathien, Small-fiber-Neuropathien und kognitive Defizite. Die HCV-Infektion stellt außerdem einen Risikofaktor für ischämische und hämorrhagische Schlaganfälle sowie den Morbus Parkinson dar. Die frühe Identifikation und antivirale Behandlung HCV-positiver Patienten steht im Zentrum der Behandlung. Durch neue antivirale Therapien können >90 % der Patienten dauerhaft von der HCV-Infektion geheilt werden.
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Affiliation(s)
- Felix Kleefeld
- Klinik für Neurologie, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Gabriele Arendt
- Neurologie, Neuro-Centrum Düsseldorf, Hohenzollernstr. 5, 40211, Düsseldorf, Deutschland
| | - Eva Neuen-Jacob
- Institut für Neuropathologie, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Matthias Maschke
- Klinik für Neurologie, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292, Trier, Deutschland
| | - Ingo Husstedt
- Praxis an der Klinik Maria Frieden, Am Krankenhaus 1, 48291, Telgte/Münster, Deutschland
| | - Mark Obermann
- Klinik für Neurologie, Asklepios Kliniken Schildautal, Karl-Herold-Str. 1, 38723, Seesen, Deutschland
| | - Holger Schmidt
- Klinik für Neurologie, Elbe-Kliniken Stade, Bremervörder Str. 111, 21682, Stade, Deutschland
| | - Katrin Hahn
- Klinik für Neurologie, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Deutschland.
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8
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Lin MS, Chung CM, Lin WY, Wei KL, Wang J, Lee YY, Hu JH, Tung TH, Lin YS. Antiviral therapy reduces risk of haemorrhagic stroke in patients with HCV infection: a nationwide cohort study. Antivir Ther 2019; 23:43-52. [PMID: 28471350 DOI: 10.3851/imp3172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The tendency for haemorrhagic stroke in patients with chronic HCV infection has emerged recently but the finding may be confounded by comorbidities. Proving the causality between HCV infection and haemorrhagic stroke is mandatory. Our study was designed to investigate the incidence of intracranial haemorrhage in HCV-infected patients with and without treatment. METHODS In the 11-year and population-based retrospective study, we acquired data from the Taiwan National Health Insurance Research Database. The patients with major comorbidities were excluded and 97,198 HCV-infected patients were included for analysis. Treated and untreated cohorts were matched with propensity score to make the confounding factors in two groups comparable. Cox proportional hazard regression analysis was performed to evaluate the hazard ratio of haemorrhagic stroke in the cohorts. We applied survival analysis to compare the cumulative incidence of outcome events between the two cohorts. RESULTS After matching, the incidence density (ID) of haemorrhagic stroke in the untreated cohort is significantly higher than in the treated cohort (ID: 1.0 versus 0.6 events per 1,000 person-years; P=0.0014). The adjusted hazard ratio (aHR) of haemorrhagic stroke is significantly reduced in the treated group (P<0.05). Cumulative incidence of haemorrhagic stroke is significantly lower in the treated group than in the untreated group (P=0.013). CONCLUSIONS The study demonstrates that antiviral therapy significantly reduces the events of intracranial haemorrhage in HCV-infected patients and consolidates the novel concept that chronic HCV infection is a risk factor for haemorrhagic stroke.
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Affiliation(s)
- Ming-Shyan Lin
- Department of Cardiology, Department of Internal Medicine, Liver Research Center, Chang-Gung Memorial Hospital, Yunlin, Taiwan
| | - Chang-Min Chung
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wey-Yil Lin
- Department of Neurology and Neuroscience Research Center, Chang Gung Memorial Hospital, and Chang Gung University, Linkou, Taiwan
| | - Kuo-Liang Wei
- Department of Hepato-Gastroenterology and Liver Research Center, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jui Wang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ying-Ying Lee
- Department of Neurology, Landseed Hospital, Taoyuan, Taiwan
| | - Jing-Hong Hu
- Department of Hepato-Gastroenterology and Liver Research Center, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Tao-Hsin Tung
- Department of Medical Research and Education, Cheng Hsin General Hospital, Taipei, Taiwan.,Department of Public Health, School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Yu-Sheng Lin
- Department of Neurology and Neuroscience Research Center, Chang Gung Memorial Hospital, and Chang Gung University, Linkou, Taiwan
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Hatleberg CI, Ryom L, Kamara D, De Wit S, Law M, Phillips A, Reiss P, D'Arminio Monforte A, Mocroft A, Pradier C, Kirk O, Kovari H, Bonnet F, El-Sadr W, Lundgren JD, Sabin C. Predictors of Ischemic and Hemorrhagic Strokes Among People Living With HIV: The D:A:D International Prospective Multicohort Study. EClinicalMedicine 2019; 13:91-100. [PMID: 31517266 PMCID: PMC6737207 DOI: 10.1016/j.eclinm.2019.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 06/25/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hypertension is a stronger predictor of hemorrhagic than ischemic strokes in the general population. We aimed to identify whether hypertension or other risk factors, including HIV-related factors, differ in their associations with stroke subtypes in people living with HIV (PLWHIV). METHODS HIV-1-positive individuals from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study were followed from the time of first blood pressure (BP) measurement after 1/1/1999 or study entry until the first of a validated stroke, 6 months after last follow-up or 1/2/2014. Stroke events were centrally validated using standardized criteria. Hypertension was defined as one systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg. Poisson and Cox proportional hazards regression models determined associations of established cerebro/cardiovascular disease and HIV-related risk factors with stroke and tested whether these differed by stroke subtype. FINDINGS 590 strokes (83 hemorrhagic, 296 ischemic, 211 unknown) occurred over 339,979 person-years (PYRS) (incidence rate/1000 PYRS 1.74 [95% confidence interval (CI) 1.60-1.88]). Common predictors of both hemorrhagic and ischemic strokes were hypertension (relative hazard 3.55 [95% CI 2.29-5.50] and 2.24 [1.77-2.84] respectively) and older age (1.28 [1.17-1.39] and 1.19 [1.12-1.25]). Male gender (1.62 [1.14-2.31] and 0.60 [0.35-0.91]), previous cardiovascular events (4.03 [2.91-5.57] and 1.44 [0.66-3.16]) and smoking (1.90 [1.41-2.56] and 1.08 [0.68-1.71]) were stronger predictors of ischemic then hemorrhagic strokes, whereas hypertension, hepatitis C (1.32 [0.72-2.40] and 0.46 [0.30-0.70]) and estimated glomerular filtration rate < 60 mL/min/1.72 m3 (4.80 [2.47-9.36] and 1.04 [0.67-1.60]) were stronger predictors of hemorrhagic than ischemic strokes. A CD4 count < 200 cells/μL was associated with an increased risk of hemorrhagic stroke only. INTERPRETATION Risk factors for stroke may differ by subtype in PLWHIV, emphasizing the importance of further research to increase the precision of stroke risk estimation.
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Affiliation(s)
- Camilla Ingrid Hatleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
- Corresponding author at: Dept. of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | - Lene Ryom
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - David Kamara
- Institute for Global Health, UCL, London, United Kingdom
| | - Stephane De Wit
- Division of Infectious Diseases, Saint Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Matthew Law
- The Kirby Institute, UNSW Australia, Sydney, Australia
| | | | - Peter Reiss
- Amsterdam University Medical Center (location AMC), Dept. of Global Health and Div. of Infectious Diseases, University of Amsterdam, Amsterdam, the Netherlands
- HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Antonella D'Arminio Monforte
- Dipartimento di Scienze della Salute, Clinica di Malattie Infettive e Tropicali, Azienda Ospedaliera-Polo Universitario San Paolo, Milan, Italy
| | - Amanda Mocroft
- Institute for Global Health, UCL, London, United Kingdom
| | | | - Ole Kirk
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - Helen Kovari
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Switzerland
| | - Fabrice Bonnet
- Université de Bordeaux, ISPED, INSERM U1219, CHU de Bordeaux, Bordeaux, France
| | - Wafaa El-Sadr
- ICAP-Columbia University, Harlem Hospital, New York, USA
| | - Jens D. Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Denmark
| | - Caroline Sabin
- Institute for Global Health, UCL, London, United Kingdom
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Romano C, Cuomo G, Ferrara R, Del Mastro A, Esposito S, Sellitto A, Adinolfi LE. Uncommon immune-mediated extrahepatic manifestations of HCV infection. Expert Rev Clin Immunol 2018; 14:1089-1099. [PMID: 30338718 DOI: 10.1080/1744666x.2018.1538790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Chronic hepatitis C virus (HCV) infection has been associated with myriad extrahepatic manifestations, often resulting from aberrant immune responses. Among the most common immune-mediated manifestations of HCV infection, mixed cryoglobulinemia is the best known extra-hepatic complication. Areas covered: Here we review less common extrahepatic manifestations of HCV infection, with ascertained or presumed immune pathogenesis and the role of the new all oral direct-acting antiviral agents. Rheumatologic, dermatologic, ophthalmologic, renal, pulmonary, hematologic, cardiovascular, and neuropsychiatric manifestations of HCV infection have been considered. Expert commentary: Pathogenesis of HCV-induced aberrant immune responses resulting in peculiar clinical manifestations is not restricted to a single mechanism. A sound approach would therefore consider implementation of an etiologic treatment, through use of antiviral medications, to stop upstream in the pathogenic process all the immune mechanisms leading to hepatic and extrahepatic abnormalities. With the recent introduction of interferon-free, direct antiviral agents, capable of warranting cure for nearly all HCV-infected patients subjected to therapy, both common and uncommon extrahepatic manifestations of chronic hepatitis C are expected to no longer constitute a matter of comorbidity in the course of HCV infection.
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Affiliation(s)
- Ciro Romano
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy
| | - Giovanna Cuomo
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy
| | - Roberta Ferrara
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy
| | - Andrea Del Mastro
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy.,b Department of Emergency and Admittance , Cardarelli Hospital , Naples , Italy
| | - Sergio Esposito
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy
| | - Ausilia Sellitto
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy.,c Department of Emergency and Admittance , "San Giuseppe Moscati" Hospital , Avellino , Italy
| | - Luigi Elio Adinolfi
- a Division of Internal Medicine, Department of Medical and Surgical Sciences , "Luigi Vanvitelli" University of Campania , Naples , Italy
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Abstract
Purpose of review Decision-making on resuming oral anticoagulant (OAC) after intracerebral hemorrhage (ICH) evokes significant debate among clinicians. Such patients have been excluded from randomized clinical trials. This review article provides a comprehensive summary of the evidence on anticoagulation resumption after ICH. Recent findings OAC resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality. OAC cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption. The optimal timing of anticoagulation resumption after ICH is still unknown. Both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism. The introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives. Summary Given the lack of high-quality evidence to guide clinical decision-making, clinicians must carefully balance the risks of thromboembolism and recurrent ICH in individual patients. We propose a management approach which would facilitate the decision-making process on whether anticoagulation is appropriate, as well as when and how to restart anticoagulation after ICH.
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Iqbal S, Yousuf MH, Yousaf MI. Dramatic response of hepatitis C patients chronically infected with hepatitis C virus genotype 3 to sofosbuvir-based therapies in Punjab, Pakistan: A prospective study. World J Gastroenterol 2017; 23:7899-7905. [PMID: 29209131 PMCID: PMC5703919 DOI: 10.3748/wjg.v23.i44.7899] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/06/2017] [Accepted: 09/13/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To prospectively evaluate the efficacy of sofobuvir (SOF) in hepatitis C patients infected with hepatitis C virus (HCV) genotype 3 in Pakistan.
METHODS The present study was performed with the coordination of gastroenterology and pathology departments of Shalamar Hospital Lahore from August 2014 to May 2016. The total number of patients included in this study was 1375 and all of them were infected with HCV genotype 3. On the basis of drug combinations, all the patients were separated into two groups. The first group of patients was treated for 24 wk with SOF (Sovaldi® by Gilead Sciences) plus ribavirin (RBV) [Ribazol® by Getz Pharma Pakistan (PVT) Ltd], while the patients of the second group were treated with SOF + RBV + pegylated-interferon (pegIFN) alfa-2a (Ropegra by Roach) for 12 wk. HCV genotyping and viral load measurement were performed on fully automated Abbott Real-Time PCR system (Abbott m24sp automated nucleic acid extraction system and Abbott m2000rt amplification system; abbott Molecular, Des Plaines, IL, United States). For the assessment of sustained virological response (SVR), all HCV RNA negative patients were followed for 12 weeks after the treatment completion. Any patient with less than 12 IU/mL viral load after 12 wk of treatment completion was considered as a sustained virological responder (SVR-12).
RESULTS A total of 1375 patients chronically infected with HCV genotype 3 were treated with two drug combinations SOF + RBV and SOF + RBV + pegIFN alfa-2a. On the basis of these drug combinations, patients were divided into two groups (first and second). Overall SVR-12 was excellent in both groups (99.17% and 97.91%). Older patients (> 40 years) of second group showed lower SVR-12 (93.46%) compared to first group older patients (98.79%), while in the younger patients of both groups, the SVR-12 rate was almost the same (99.54% in first group and 99.05% in second group). No such difference regarding SVR-12 rate was seen in males and females of first group patients (99.68% and 98.88%, respectively), while in second group the males were found to be better responders compared to females (98.96% and 95%). The SVR-12 rate in previously treated patients of first group was better (99.34%) than second group (93.70%), while naïve patients of second group were marginally better responders (99.25%) than first group (97.80%). Rapid viral response at week-4 was found to be a very effective predictor for assessing the SVR rate at this stage of therapy in both groups. Headache, anemia and fatigue were common side effects in both groups either treated with SOF + RBV or SOF + RBV + pegIFN alfa-2a, while the overall percentage of the side effects was higher in second group.
CONCLUSION The remarkable SVR response rate of HCV genotype 3 infected patients to SOF provided a new way to look forward to eliminate hepatitis C from our region.
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Affiliation(s)
- Sajjad Iqbal
- Department of Pathology, Shalamar Hospital, Lahore 54840, Pakistan
| | - Muhammad Haroon Yousuf
- Department of Gastroenterology and Hepatology, Shalamar Hospital, Lahore 54840, Pakistan
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13
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Lin MS, Chen TH, Lin WY, Liu CH, Hsieh YY, Chiu WN, Chang CH, Chen MY, Chung CM, Lin YS. Add-on neurological benefits of antiviral therapy in HCV patients with chronic kidney disease - a nationwide cohort study. BMC Gastroenterol 2017; 17:99. [PMID: 28814273 PMCID: PMC5559858 DOI: 10.1186/s12876-017-0653-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 07/31/2017] [Indexed: 12/18/2022] Open
Abstract
Background Hepatitis C virus (HCV)-infected patients with chronic kidney disease (CKD) have rarely been studied because they rarely accept interferon-based therapy (IBT) and have been difficult to follow up. We investigated long-term outcomes of IBT on the population. Methods This population-based cohort study used the Taiwan National Health Insurance Research Database as its data source. HCV patients diagnosed with CKD between Jan. 1, 2003, and Dec. 31, 2013, were selected. They were then divided into two groups based on whether they had undergone IBT. All-cause mortality, acute myocardial infarction (AMI), ischemic stroke (IS), hemorrhagic stroke, and new-onset dialysis were evaluated using a Cox proportional hazard regression analysis after propensity score matching. Results We enrolled 9872 HCV patients with CKD: 1684 patients in the treated cohort and 8188 patients in the untreated cohort. The annual incidence of all-cause mortality (19.00 vs. 42.89 events per 1000 person-years; p < 0.001) and the incidences of hemorrhagic stroke (1.21 vs. 4.19 events per 1000 person-years; p = 0.006) were lower in the treated cohort. New-onset dialysis was also lower in the treated cohort (aHR: 0.31; 95% CI: 0.20–0.48; p < 0.001). Conclusion Antiviral therapy might provide protective benefits on all-cause mortality, hemorrhagic stroke, and new-onset dialysis in HCV-infected patients with CKD. Electronic supplementary material The online version of this article (doi:10.1186/s12876-017-0653-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ming-Shyan Lin
- Department of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Keelung, Taiwan
| | - Wey-Yil Lin
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Yu Hsieh
- Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wen-Nan Chiu
- Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney research center, Chang Gung Memorial Hospital, Chang Gung University, College of medicine, Taoyuan, Taiwan
| | - Mei-Yen Chen
- College of Nursing, Chang Gung University of Science and Technology (CGUST), Taoyuan, Taiwan.,Department of Nursing, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Min Chung
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan. .,Department of Cardiology, Chiayi Chang Gung Memorial Hospital, 6, Sec. West Chai-Pu Road, Pu-TZ City, Chai Yi Hsien, 61363, Taiwan.
| | - Yu-Sheng Lin
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan County, Taiwan. .,Department of Cardiology, Chiayi Chang Gung Memorial Hospital, 6, Sec. West Chai-Pu Road, Pu-TZ City, Chai Yi Hsien, 61363, Taiwan.
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Abstract
Hepatitis C virus (HCV) infection is a prevalent condition associated with numerous extrahepatic manifestations. Epidemiologic studies have found that HCV is associated with increased cardiovascular morbidity and mortality, in particular with carotid atherosclerosis, cerebrovascular events, and coronary heart disease. The mechanisms involved encompass a chronic systemic inflammatory state, insulin resistance, and a potential, direct infection of the vascular endothelium. Sustained virologic response with interferon-based regimens is associated with reduced cardiovascular events, although this must be validated with newer direct-acting antivirals. This clear association between HCV and cardiovascular events may have significant economical and public health implications.
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Affiliation(s)
- Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, Geneva 4 1211, Switzerland
| | - Francesco Negro
- Division of Gastroenterology and Hepatology, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, Geneva 4 1211, Switzerland; Division of Clinical Pathology, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, Geneva 4 1211, Switzerland.
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Lonardo A, Ballestri S, Guaraldi G, Nascimbeni F, Romagnoli D, Zona S, Targher G. Fatty liver is associated with an increased risk of diabetes and cardiovascular disease - Evidence from three different disease models: NAFLD, HCV and HIV. World J Gastroenterol 2016; 22:9674-9693. [PMID: 27956792 PMCID: PMC5124973 DOI: 10.3748/wjg.v22.i44.9674] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/29/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
Fatty liver, which frequently coexists with necro-inflammatory and fibrotic changes, may occur in the setting of nonalcoholic fatty liver disease (NAFLD) and chronic infections due to either hepatitis C virus (HCV) or human immunodeficiency virus (HIV). These three pathologic conditions are associated with an increased prevalence and incidence of cardiovascular disease (CVD) and type 2 diabetes (T2D). In this multidisciplinary clinical review, we aim to discuss the ever-expanding wealth of clinical and epidemiological evidence supporting a key role of fatty liver in the development of T2D and CVD in patients with NAFLD and in those with HCV or HIV infections. For each of these three common diseases, the epidemiological features, pathophysiologic mechanisms and clinical implications of the presence of fatty liver in predicting the risk of incident T2D and CVD are examined in depth. Collectively, the data discussed in this updated review, which follows an innovative comparative approach, further reinforce the conclusion that the presence of fatty/inflamed/fibrotic liver might be a shared important determinant for the development of T2D and CVD in patients with NAFLD, HCV or HIV. This review may also open new avenues in the clinical and research arenas and paves the way for the planning of future, well-designed prospective and intervention studies.
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Onyekwere CA, O Ogbera A, Olusola Dada A, O Adeleye O, O Dosunmu A, Akinbami AA, Osikomaiya B, Hameed O. Hepatitis C Virus (HCV) Prevalence in Special Populations and Associated Risk Factors: A Report From a Tertiary Hospital. HEPATITIS MONTHLY 2016; 16:e35532. [PMID: 27313634 PMCID: PMC4908612 DOI: 10.5812/hepatmon.35532] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/15/2016] [Accepted: 03/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND With the advent of highly effective anti-hepatitis C virus (HCV) drugs, efforts to identify infected cases, high-risk groups, and associated risk factors have become the focus of current control measures. OBJECTIVES To determine the prevalence of the HCV antibody among diabetics and patients with lymphoproliferative disorders (LPD) who presented to the outpatient clinics of a university hospital and its associated risk factors. PATIENTS AND METHODS Consecutively consenting patients who had been previously diagnosed with diabetes mellitus and LPD at the outpatient department of the Lagos State University teaching hospital were recruited. A case record form was used to extract their demographics and physical examination findings as well as any risk factors for HCV infection; blood was also drawn to run a serological assay for the HCV antibody. All data were collated and analyzed using the Statistical Package for the Social Sciences version 20. Student T-test, Chi square, and logistic regression were some of the inferential statistics used in addition to descriptive statistics. RESULTS In all, 438 patients (405 diabetics and 33 patients with LPD) were recruited. Their ages ranged from 17 - 87 years with a mean + Standard deviation of 59.61 + 11.859 years. The prevalence of hepatitis C among the diabetic subgroup was 0.7%, while the antibody was present in 9.1% of the LPD patients. The occurrence of the HCV antibody was, however, not significantly associated with age, sex, educational level, or marital status (P > 0.05). Having multiple sexual partners was identified as the only significant risk factor for hepatitis C (OR = 9.148; P = 0.017). CONCLUSIONS This survey suggested that a higher HCV prevalence exists in this population than is currently reported in the general population, and having sex with multiple partners was a risk factor for HCV infection.
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Affiliation(s)
- Charles Asabamaka Onyekwere
- Department of Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
- Corresponding Author: Charles Asabamaka Onyekwere, Department of Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria, E-mail:
| | - Anthonia O Ogbera
- Department of Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Akinola Olusola Dada
- Department of Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Olufunke O Adeleye
- Department of Medicine, Ogun State University Medical School, Ago-Iwoye, Nigeria
| | | | | | | | - Oladipupo Hameed
- Department of Medical Affairs, Roche Pharma (PLC), Lagos, Nigeria
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