Genetic Diversity of CYP3A5 and ABCB1 Variants in East-Central and South European Populations

BACKGROUND

CYP3A5 enzyme encoded by CYP3A5 is important for drug metabolism in gut and liver, whereas P-glycoprotein by ABCB1, is an ATP-dependent drug efflux pump which exports endo- and exogenous substances outside the cell. Aim: The study was to assess the prevalence of CYP3A5 alleles: *1, *2, *3, *4, *6 and *7, and C and T of ABCB1 in Poles, Belarusians and Bosnians and to compare it with the data reported from other European populations. Subjects and methods: Overall, 511 unrelated healthy subjects from Poland (n = 239), Belarus (n = 104) and Bosnia and Herzegovina (n = 168) were included in this study. Allele frequencies and statistical parameters (AMOVA version 2.9.3) were determined. Results: In Poles, Belarusians and Bosnians the *3 allele of CYP3A5 was the most common, and wild-type allele *1, were: 5.8%, 1.6% and 2.1%, respectively. Allele *2 was very rare, and alleles *4, *6 and *7 were not detected. For the populations mentioned above, the ABCB1 allele C was: 48.1%, 51.4%, 52.4%, respectively.

CONCLUSION

In compared populations, the distribution of CYP3A5 variants but not ABCB1, differed significantly. Alleles *4, *6 and *7 of CYP3A5 did not occur or occurred rarely.

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.

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.

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.

NOD2/CARD15 mutations in Polish and Bosnian populations with and without Crohn's disease: prevalence and genotype-phenotype analysis

Data on prevalence and phenotypic consequences of nucleotide-binding oligomerisation domain 2/caspase recruitment domains 15 (NOD2/CARD15) variants in Crohn's disease (CD) population in Poland and Bosnia and Herzegovina (B&amp;H) are nonexistent. We aimed to determine the prevalence of NOD2/CARD15 mutations and their association with disease phenotype in Polish and Bosnian patients with CD and in healthy controls. We prospectively recruited 86 CD patients and 83 controls in Poland and 30 CD patients and 30 controls in B&amp;H, 229 in total. We determined the prevalence of NOD2/CARD15 mutations and their association with the disease phenotype according to Montreal classification. Participants were genotyped for Leu1007fsinsC and Gly908Arg mutations. At least one CD-associated allele was found in 29/86 (33.7%) of Polish CD patients and in 9/83 (10.8%) of healthy controls (p&lt;0.001). In both CD patients and controls in Bosnian sample, at least one NOD2 mutation was found in equal number of patients (3/30; 10%) with all of the NOD2 mutation positive CD patients being homozygous, while controls being heterozygous. In Polish sample, perianal disease was less frequent in CD patients with any NOD2 mutation (1/21; 4.8%) compared to those without (11/41; 26.8%; p=0.046). Higher percentage of patients with NOD2 mutations had history of CD related surgery when compared with those without mutations (66.7% vs. 43.3%; p=0.05). The risk for CD is increased in patients with NOD2 mutations (Poland) and especially in the presence of homozygous NOD2 mutations (Poland and Bosnia). The presence of variant NOD2 alleles is associated with increased need for surgery and reduced occurrence of perianal 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.

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.

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.

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.

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.

Risk factors for intrafamilial spread of hepatitis B in northeastern Bosnia and Herzegovina

BACKGROUND

Accurate estimations of hepatitis B virus transmission risk for any region in Bosnia and Herzegovina are not clearly established. We aimed to determine levels of risk associated with intrafamilial transmission of hepatitis B infection within families in our region.

PATIENTS AND METHODS

Family members of 81 chronic carriers of hepatitis B surface antigen (>6 months positive and considered as index case) were tested for hepatitis B markers. For family members, we recorded their age, sex, and family relationship to the index case, and vaccination status.

RESULTS

The proportion of HBsAg positive family members was 25/207 (12.1%), while the proportion of family members with evidence of exposure to HBV was 80/207 (38.6%). Only 17/207 (8.2%) family members had evidence of past HBV vaccination. Age was found to be a significant predictor of HBV exposure of family members (odds ratio 1.05, 95% CI 1.03-1.07, P<.001). In a multivariate analysis, HBsAg positivity was associated with a female index case (odds ratio 11.31, 95% CI 3.73-34.32, P<.001), HBeAg positivity in the index case (odds ratio 5.56, 95% CI 1.80-17.23, P<.005) and being a mother of the index case (odds ratio 9.82, 95% CI 2.43-39.68, P<.005). A female index case (odds ratio 4.87, 95% CI 2.21-10.72, P<.001), HBeAg positivity in the index case (odds ratio 3.22, 95% CI 1.15-9.00, P<.05) and being a mother of the index case (odds ratio 3.72, 95% CI 1.19-11.64, P<.05) were also risk factors for HBV exposure among family members. The combination of HBeAg positivity and female index case was a significant predictor for HBsAg positivity of family members (odds ratio 70.39, 95% CI 8.20-604.61, P<.001).

CONCLUSIONS

Children of HBeAg positive mothers are at highest risk for becoming chronic carriers themselves and generally, the combination of female sex and HBeAg positivity dramatically increases the chances of HBV transmission within the family.

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.