Persistent Hepatitis E virus infection across England and Wales 2009-2017: Demography, virology and outcomes

The first clinical case of persistent HEV infection in England was reported in 2009. We describe the demography, virology and outcomes of patients identified with persistent HEV infection in England and Wales between 2009 and 2017. A series of 94 patients with persistent HEV infection, defined by HEV viraemia of more than 12 weeks, was identified through routine reference laboratory testing. Virology, serology and clinical data were recorded through an approved PHE Enhanced Surveillance System. Sixty-six cases (70.2%) were transplant recipients, 16 (17.0%) had an underlying haematological malignancy without stem cell transplantation, six (6.4%) had advanced HIV infection, five (5.3%) were otherwise immunosuppressed, and one patient (1.1%) had no identified immunosuppression. Retrospective analysis of 46 patients demonstrated a median 38 weeks of viraemia before diagnostic HEV testing. At initial diagnosis, 16 patients (17.0%) had no detectable anti-HEV serological response. Of 65 patients treated with ribavirin monotherapy, 11 (16.9%) suffered virological relapse despite undetectable RNA in plasma or stool at treatment cessation. Persistent HEV infection remains a rare diagnosis, but we demonstrate that a broad range of immunocompromised patients are susceptible. Both lack of awareness and the pauci-symptomatic nature of persistent HEV infection likely contribute to significant delays in diagnosis. Diagnosis should rely on molecular testing since anti-HEV serology is insufficient to exclude persistent HEV infection. Finally, despite treatment with ribavirin, relapses occur even after cessation of detectable faecal shedding of HEV RNA, further emphasising the requirement to demonstrate sustained virological responses to treatment.

Improving the management of acute diarrhoea and dehydration in under-5 children in a paediatric referral facility in Lagos, Nigeria

BACKGROUND

Mortality from acute diarrhoea and dehydration (AD/D) in children is high despite existing management guidelines.

AIM

The aim of this study was to identify deficiencies in the management of AD/D by health staff and assess changes in management after a training intervention in a paediatric referral facility in Lagos, Nigeria.

METHODS

In a retrospective review of case notes, the management of AD/D was assessed using WHO guidelines as the standard. An e-learning module was developed that directly addressed deficiencies and was used to train health staff. Changes in the management of AD/D were assessed by re-auditing case notes.

RESULTS

There were learning needs among health staff in the management of AD/D. Altogether, 34 (97.1%) of 35 residents were trained. Training resulted in modest improvements in the number of children in whom nutritional status was assessed, use of oral rather than intravenous fluids for rehydration and reducing unnecessary laboratory tests. Training resulted in marked improvements in the correct volume of (pre- vs. post-training 6.3% vs. 94.1%, P<0.001) and follow-up of fluid therapy (8.1% vs. 98.0%; P<0.001), prescription of zinc (41.6% vs. 85.1%, P<0.001) and providing advice on when to return after discharge (77.6% vs. 96.0%, P<0.001). Although statistically significant, the minimal improvements in antibiotic use (43.8% vs. 56.6%, P = 0.03), re-starting feeds (10.6% vs. 38.6%, P<0.001) and counselling about feeding (11.8% vs. 33.7%, P<0.001) highlighted areas for further training.

CONCLUSIONS

In low-resource countries, clinical auditing and training can significantly improve the management of illnesses that contribute to child deaths and identify areas where further training is required.

Cost and Impact on Patient Length of Stay of Rapid Molecular Testing for Clostridium difficile

Introduction

A study was performed to assess the cost of a rapid molecular assay (PCR) for diagnosis of Clostridium difficile infection (CDI) and the impact of its routine use on patient length of stay (LOS) in comparison with cell culture cytotoxin neutralization assay (CCNA).

Methods

From March 2011 to September 2011, Xpert^®C. difficile (Cepheid, Sunnyvale, CA, USA) PCR was used on patients with suspicion of CDI in two acute care hospitals in Abertawe Bro Morgannwg University Health Board, Swansea, Wales, UK. Test results were used for patient management. LOS and time to reportable result were compared for negative and positive prospective patients tested by PCR and historic control patients tested by CCNA during March 2010 to September 2010. Tests were priced using micro-costing and a cost comparison analysis was undertaken.

Results

In total, 506 patients were included. Time to reportable result for PCR samples was 1.53 h compared to 46.54 h for CCNA negatives and 22.45 h for CCNA positives. Patients tested by CCNA stayed 4.88 days longer in hospital compared to PCR patients if they tested positive and 7.03 days if tests were negative. The mean reduction in LOS observed in our study has the potential to generate cost savings of up to £2,292.62 for every patient with suspected CDI, if samples were to be tested routinely with PCR instead of CCNA.

Conclusion

A rapid molecular test for C. difficile in an acute hospital setting produced quick results that led to a decrease in LOS compared to historic CCNA control patients. This could result in considerable savings through reduced excess inpatient days.

Electronic supplementary material

The online version of this article (doi:10.1007/s40121-014-0034-x) contains supplementary material, which is available to authorized users.

A comprehensive analysis of common genetic variation around six candidate loci for intrahepatic cholestasis of pregnancy

OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) has a complex etiology with a significant genetic component. Heterozygous mutations of canalicular transporters occur in a subset of ICP cases and a population susceptibility allele (p.444A) has been identified in ABCB11. We sought to expand our knowledge of the detailed genetic contribution to ICP by investigation of common variation around candidate loci with biological plausibility for a role in ICP (ABCB4, ABCB11, ABCC2, ATP8B1, NR1H4, and FGF19).

METHODS

ICP patients (n=563) of white western European origin and controls (n=642) were analyzed in a case-control design. Single-nucleotide polymorphism (SNP) markers (n=83) were selected from the HapMap data set (Tagger, Haploview 4.1 (build 22)). Genotyping was performed by allelic discrimination assay on a robotic platform. Following quality control, SNP data were analyzed by Armitage's trend test.

RESULTS

Cochran-Armitage trend testing identified six SNPs in ABCB11 together with six SNPs in ABCB4 that showed significant evidence of association. The minimum Bonferroni corrected P value for trend testing ABCB11 was 5.81×10(-4) (rs3815676) and for ABCB4 it was 4.6×10(-7)(rs2109505). Conditional analysis of the two clusters of association signals suggested a single signal in ABCB4 but evidence for two independent signals in ABCB11. To confirm these findings, a second study was performed in a further 227 cases, which confirmed and strengthened the original findings.

CONCLUSIONS

Our analysis of a large cohort of ICP cases has identified a key role for common variation around the ABCB4 and ABCB11 loci, identified the core associations, and expanded our knowledge of ICP susceptibility.

Clinical characteristics of hepatitis E in a "Non-Endemic" population

Hepatitis E virus (HEV) is a ribonucleic acid (RNA) virus with predominant fecal oral spread. Traditionally in Western Europe it is associated with travel to endemic countries, but an increasing number of locally acquired cases have been reported throughout England. Patients presenting with acute non-travel associated HEV infection in south Wales over a 25-month period were monitored, in an attempt to understand the clinical picture and epidemiology in our patient population. Twenty-four patients were identified with non-travel associated HEV infection and studied prospectively. Patient demographics, symptoms, and serial laboratory results were recorded. There was a male/female ratio of 3:1, with a median patient age of 65.5 years old. Patients developed a significant icteric hepatitis (median peak bilirubin: 139 µmol/L, median peak AST: 1,973 IU/L and ALT: 2,021 IU/L), with liver function remaining abnormal for ∼7 weeks. All patients in whom HEV RNA was isolated were infected with genotype 3. Forty-six percent of patients presented during winter months. The data show a group mortality rate of 4.2%, similar to that reported in endemic countries. HEV results in a severe and occasionally fatal hepatitis. Testing for hepatitis E is now recommended in any patient presenting with acute hepatitis of unknown etiology.

Celiac disease and autoimmune thyroid disease

Celiac disease (CD) or gluten sensitive enteropathy is relatively common in western populations with prevalence around 1%. With the recent availability of sensitive and specific serological testing, many patients who are either asymptomatic or have subtle symptoms can be shown to have CD. Patients with CD have modest increases in risks of malignancy and mortality compared to controls. The mortality among CD patients who comply poorly with a gluten-free diet is greater than in compliant patients. The pattern of presentation of CD has altered over the past three decades. Many cases are now detected in adulthood during investigation of problems as diverse as anemia, osteoporosis, autoimmune disorders, unexplained neurological syndromes, infertility and chronic hypertransaminasemia of uncertain cause. Among autoimmune disorders, increased prevalence of CD has been found in patients with autoimmune thyroid disease, type 1 diabetes mellitus, autoimmune liver diseases and inflammatory bowel disease. Prevalence of CD was noted to be 1% to 19% in patients with type 1 diabetes mellitus, 2% to 5% in autoimmune thyroid disorders and 3% to 7% in primary biliary cirrhosis in prospective studies. Conversely, there is also an increased prevalence of immune based disorders among patients with CD. The pathogenesis of co-existent autoimmune thyroid disease and CD is not known, but these conditions share similar HLA haplotypes and are associated with the gene encoding cytotoxic T-lymphocyte-associated antigen-4. Screening high risk patients for CD, such as those with autoimmune diseases, is a reasonable strategy given the increased prevalence. Treatment of CD with a gluten-free diet should reduce the recognized complications of this disease and provide benefits in both general health and perhaps life expectancy. It also improves glycemic control in patients with type 1 diabetes mellitus and enhances the absorption of medications for associated hypothyroidism and osteoporosis. It probably does not change the natural history of associated autoimmune disorders.

Prospective screening for coeliac disease in patients with Graves' hyperthyroidism using anti-gliadin and tissue transglutaminase antibodies

INTRODUCTION

Coeliac disease (CD) is associated with autoimmune thyroid disease (AITD) although its prevalence among those with Graves' hyperthyroidism in the UK is unknown. We determined the prevalence and evaluated the role of screening for CD prospectively in a consecutive cohort of patients with Graves' hyperthyroidism using IgA class antibodies to gliadin (AGA) and tissue transglutaminase (anti-tTG).

METHODS

All patients with Graves' hyperthyroidism attending the thyroid clinic over a 9-month period were offered screening for CD using AGA (normal < 3 mg/l) and anti-tTG (normal < 15 micro/ml). Comparison was made with an age- and sex-matched healthy control group from the local population whose sera were tested for anti-tTG. In patients with borderline or raised anti-tTG (> 7 micro/ml) endomysial antibody (EmA) was measured. Serum IgA was also measured to exclude IgA deficiency. Patients with raised AGA, raised or borderline anti-tTG, positive EmA, IgA deficiency or haematinic deficiencies were offered endoscopic duodenal biopsy.

RESULTS

A total of 115 patients (97 female and 18 male) with Graves' hyperthyroidism were offered screening tests and 111 accepted. AGA was raised in 15 patients, anti-tTG was raised in two (both positive for EmA) and equivocal in six (one positive for EmA). IgA deficiency was present in three. Four patients were known to have haematinic deficiencies. Twenty-five patients were invited and 19 agreed to have endoscopic duodenal biopsy. Three new patients were found to have CD while two patients were already known to have CD, thus five of 111 patients with Graves' hyperthyroidism had CD. One of 115 healthy controls had a strong positive anti-tTG (> 200 micro/ml) and EmA indicating probable CD.

CONCLUSIONS

Screening 111 consecutive patients with Graves' hyperthyroidism revealed AGA in 14%, anti-tTG in 2% and IgA deficiency in 3%. Two patients were known to have CD. Screening detected three new cases. The prevalence of CD in patients with Graves' hyperthyroidism was 4.5% as compared with 0.9% in matched healthy controls. Routine screening for CD should be considered.

Prospective study of liver dysfunction in pregnancy in Southwest Wales

BACKGROUND

Liver dysfunction in pregnancy has serious consequences. Its frequency and characteristics have not been systematically documented in Britain. We have prospectively determined incidence, causes, and outcome of liver dysfunction in pregnancy in an obstetric unit in Southwest Wales, UK.

METHODS

A central laboratory identified all abnormal liver tests (bilirubin >25 micro mol/l, aspartate transaminase >40 U/l, or gamma glutamyl transpeptidase >35 U/l) from patients in antenatal clinics and wards of an obstetric unit serving a population of 250 000. Patients with abnormal liver tests were assessed and followed throughout and after pregnancy [corrected]. Medical advice was provided to obstetric teams.

FINDINGS

There were 4377 deliveries during the 15 month study. A total of 142 patients had abnormal liver tests. There were 206 contributing diagnoses, the great majority being pregnancy specific. Among the most important were pre-eclampsia (68), HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome (30), obstetric cholestasis (23), hyperemesis gravidarum (11), acute fatty liver of pregnancy (five), and hepatic infarct (one). Sepsis, postoperative factors, and placental pathology (51) were not uncommonly responsible but incidental or pre-existing hepatobiliary disease was infrequent (17). Sixty five patients were delivered early by induction or caesarean section because of liver dysfunction. Despite substantial liver related morbidity, there were no maternal deaths and only two intrauterine deaths.

CONCLUSIONS

Liver dysfunction was seen in 3% of deliveries during a 15 month prospective study and was usually directly related to pregnancy with spontaneous recovery in the puerperium. Incidence of the most serious conditions, acute fatty liver of pregnancy and HELLP syndrome, was much greater than previously reported. Profound effects on maternal and infant health were observed but close medical and obstetric collaboration ensured low mortality.

Scoring systems and risk assessment for upper gastrointestinal bleeding

Mortality associated with acute upper gastrointestinal bleeding remains high despite advances in diagnosis and therapy. This was emphasized by the findings of the seminal English National Audit of acute gastrointestinal haemorrhage undertaken by Rockall and associates in the mid-1990s. The apparent lack of progress is largely due to less selective reporting in an ageing population with greater co-morbidity. Thus some deaths will be unavoidable even with exemplary treatment. Managing high risk patients in a dedicated area with close cooperation between medical and surgical gastroenterologists has been shown to improve outcome. The challenge is to select those patients who have most to gain from such a scarce and expensive resource so that their treatment can be optimized. Various risk factors have been identified to help achieve this end. Rockall's national audit data suggest that avoidable deaths remain a problem in most district general hospitals. A simple numerical score was derived from these audit data (Rockall score) to predict rebleeding and mortality. The score is based on five variables: age, shock, co-morbidity, endoscopic diagnosis and stigmata of recent haemorrhage. It has the advantage that pre-endoscopic assessment can be made by inexperienced medical or nursing staff. The system was validated internally in a second audit by Rockall and co-workers, and subsequent external validation has come from New Zealand and the Netherlands. The score is less reliable at predicting rebleeding than death and so is, as yet, an imperfect instrument. The scoring system has also proven valuable in selecting low risk patients for early discharge (resulting in health care economies) and for comparing outcome data from different hospitals or populations. Endoscopic treatment has recently been shown to reduce rebleeding rates and perhaps mortality. These advances in therapy are becoming more widely adopted and may influence the predictive ability of the Rockall score. The study from Edinburgh, in this issue, although small and with wide confidence intervals, supports the ability of the Rockall score to identify high risk cases amongst those given endoscopic treatment. It also suggests that an adjustment of the score may be required in these circumstances to prevent overcalling the risk of rebleeding and death.