Incidence of cirrhosis in Iceland-impact of the TraP HepC nationwide HCV elimination program

OBJECTIVE

In 2016, a nationwide elimination program for hepatitis C virus (HCV) was initiated in Iceland, entitled Treatment as Prevention for Hepatitis C (TraP HepC), providing unrestricted access to antiviral treatment. The aims were to describe the changes in etiology and epidemiology of cirrhosis in Iceland and to assess the trends in HCV-related cirrhosis following TraP HepC.

METHODS

The study included all patients newly diagnosed with cirrhosis in 2016-2022. Diagnosis was based on liver elastography, histology, or 2 of 4 criteria: cirrhosis on imaging, ascites, varices, or elevated international normalized ratio (INR).

RESULTS

Over the study period, 342 new cirrhosis patients were identified, 223 (65%) males, median age 62 years. The crude overall incidence was 13.8 cases per 100,000 inhabitants annually. The most common etiologies were alcohol-related liver disease (ALD) (40%), metabolic dysfunction-associated steatotic liver disease (MASLD) (28%), and HCV with or without alcohol overconsumption (15%). The number of HCV cirrhosis cases was unusually high in 2016 (n = 23) due to intensified case-finding, but decreased significantly over the study period (p < 0.001) to n = 1 (2021) and n = 2 (2022). The overall 5-year survival was 55% (95% CI 48.9-62.3%). The most common causes of death were hepatocellular carcinoma (26%) and liver failure (25%).

CONCLUSION

During the past two decades, the incidence of cirrhosis has increased extraordinarily in Iceland, associated with increased alcohol consumption, obesity, and HCV. ALD and MASLD now collectively make up two thirds of cases in Iceland. Following a nationwide elimination program, incidence of HCV cirrhosis has dropped rapidly in Iceland.

Multiomics study of nonalcoholic fatty liver disease

Nonalcoholic fatty liver (NAFL) and its sequelae are growing health problems. We performed a genome-wide association study of NAFL, cirrhosis and hepatocellular carcinoma, and integrated the findings with expression and proteomic data. For NAFL, we utilized 9,491 clinical cases and proton density fat fraction extracted from 36,116 liver magnetic resonance images. We identified 18 sequence variants associated with NAFL and 4 with cirrhosis, and found rare, protective, predicted loss-of-function variants in MTARC1 and GPAM, underscoring them as potential drug targets. We leveraged messenger RNA expression, splicing and predicted coding effects to identify 16 putative causal genes, of which many are implicated in lipid metabolism. We analyzed levels of 4,907 plasma proteins in 35,559 Icelanders and 1,459 proteins in 47,151 UK Biobank participants, identifying multiple proteins involved in disease pathogenesis. We show that proteomics can discriminate between NAFL and cirrhosis. The present study provides insights into the development of noninvasive evaluation of NAFL and new therapeutic options.

Crop phenotype prediction using biclustering to explain genotype-by-environment interactions

Phenotypic variation in plants is attributed to genotype (G), environment (E), and genotype-by-environment interaction (GEI). Although the main effects of G and E are typically larger and easier to model, the GEI interaction effects are important and a critical factor when considering such issues as to why some genotypes perform consistently well across a range of environments. In plant breeding, a major challenge is limited information, including a single genotype is tested in only a small subset of all possible test environments. The two-way table of phenotype responses will therefore commonly contain missing data. In this paper, we propose a new model of GEI effects that only requires an input of a two-way table of phenotype observations, with genotypes as rows and environments as columns that do not assume the completeness of data. Our analysis can deal with this scenario as it utilizes a novel biclustering algorithm that can handle missing values, resulting in an output of homogeneous cells with no interactions between G and E. In other words, we identify subsets of genotypes and environments where phenotype can be modeled simply. Based on this, we fit no-interaction models to predict phenotypes of a given crop and draw insights into how a particular cultivar will perform in the unused test environments. Our new methodology is validated on data from different plant species and phenotypes and shows superior performance compared to well-studied statistical approaches.

HIGH RATE OF HCV REINFECTION AMONG RECENTLY INJECTING DRUG USERS: RESULTS FROM THE TRAP HEP C PROGRAM - A PROSPECTIVE NATIONWIDE, POPULATION-BASED STUDY

BACKGROUND

The Treatment as Prevention for Hepatitis C program started in 2016 in Iceland, offering treatment with direct-acting antivirals to hepatitis C virus (HCV)-infected individuals. Reinfections through injection drug use (IDU) can hamper elimination efforts. We determined reinfection rates (RIR) of HCV among patients in the program.

METHODS

Clinical data were gathered prospectively. The study cohort consisted of HCV-cured patients with an estimated sustained virologic response between February 1st 2016 and November 20th 2018, with follow-up until November 20th 2019. The observation period and time until reinfection was estimated using a single random point imputation method coupled with Monte Carlo simulation. The RIR was expressed as reinfections/100 person-years (PYs).

RESULTS

640 treatments of 614 patients (417 males, mean age 44.3 years) resulted in cure, with 52 reinfections subsequently confirmed in 50 patients (37 males). Follow-up was 672.1 PYs with median time to reinfection of 231.7 days. History of IDU was reported by 523 patients (84.8%) and recent IDU with 220 (34.4%) treatments. Stimulants were the preferred injected drug in 85.5% of patients with history of IDU. The RIR was 7.7/100 PYs. Using multivariate Cox proportional hazards models for interval-censored data, age (HR 0.96, 95% CI 0.94-0.99) and recent IDU (HR 2.91, 95% CI 1.48-5.76) were significantly associated with reinfection risk.

CONCLUSIONS

The RIR is high in a setting of widespread stimulant use, particularly in young people with recent IDU. Regular follow up is important among high-risk populations to diagnose reinfections early and reduce transmission.

Hepatitis B virus elimination status and strategies in circumpolar countries, 2020

Hepatitis B virus (HBV) infection remains a global health threat. The World Health Organization (WHO) established a goal to eliminate HBV infection as a public health threat by 2030, and defined targets for key interventions to achieve that goal. We evaluated HBV burden and relevant national recommendations for progress towards WHO targets in circumpolar countries. Viral hepatitis experts of circumpolar countries were surveyed regarding their country’s burden of HBV, achievement of WHO targets and national public health authority recommendations for HBV prevention and control. Eight of nine circumpolar countries responded. All countries continue to see new HBV infections. Data about HBV prevalence and progress in reaching WHO 2030 elimination targets are lacking. No country was able to report data for all seven WHO target measures. All countries have recommendations targeting the prevention of mother-to-child transmission. Only the USA and Greenland recommend universal birth dose vaccination. Four countries have recommendations to screen persons at high risk for HBV. Existing recommendations largely address prevention; however, recommendations for universal birth dose vaccination have not been widely introduced. Opportunities remain for the development of trackable targets and national elimination planning to screen and treat for HBV to reduce incidence and mortality.

Cascade of care during the first 36 months of the treatment as prevention for hepatitis C (TraP HepC) programme in Iceland: a population-based study

BACKGROUND

WHO has set targets to eliminate hepatitis C virus (HCV) infection as a global health threat by 2030 through a 65% reduction in HCV-related deaths and 80% reduction in HCV incidence. To achieve these goals, WHO set service coverage targets of 90% of the infected population being diagnosed and 80% of eligible patients being treated. In February, 2016, Iceland initiated a nationwide HCV elimination programme known as treatment as prevention for hepatitis C (TraP HepC), which aimed to maximise diagnosis and treatment access. This analysis reports on the HCV cascade of care in the first 3 years of the programme.

METHODS

This population-based study was done between Feb 10, 2016, and Feb 10, 2019. Participants aged 18 years or older with permanent residence in Iceland and PCR-confirmed HCV were offered direct-acting antiviral (DAA) therapy. The programme used a multidisciplinary team approach in which people who inject drugs were prioritised. Nationwide awareness campaigns, improved access to testing, and harm reduction services were scaled up simultaneously. The number of infected people in the national HCV registry was used in combination with multiple other data sources, including screening of low-risk groups and high-risk groups, to estimate the total number of HCV infections. The number of people diagnosed, linked to care, initiated on treatment, and cured were recorded during the study. This study is registered with ClinicalTrials.gov, NCT02647879.

FINDINGS

In February, 2016, at the onset of the programme, 760 (95% CI 690-851) individuals were estimated to have HCV infection, with 75 (95% CI 6-166) individuals undiagnosed. 682 individuals were confirmed to be HCV PCR positive. Over the next 3 years, 183 new infections (including 42 reinfections) were diagnosed, for a total of 865 infections in 823 individuals. It was estimated that more than 90% of all domestic HCV infections had been diagnosed as early as January, 2017. During the 3 years, 824 (95·3%) of diagnosed infections were linked to care, and treatment was initiated for 795 (96·5%) of infections linked to care. Cure was achieved for 717 (90·2%) of 795 infections.

INTERPRETATION

By using a multidisciplinary public health approach, involving tight integration with addiction treatment services, the core service coverage targets for 2030 set by WHO have been reached. These achievements position Iceland to be among the first nations to subsequently achieve the WHO goal of eliminating HCV as a public health threat.

FUNDING

The Icelandic Government and Gilead Sciences.

A nationwide population-based prospective study of cirrhosis in Iceland

Background & Aims

The incidence of cirrhosis in Iceland has been the lowest in the world with only 3 cases per 100,000 inhabitants. Alcohol consumption has almost doubled in Iceland from 1980 to 2016. Obesity has also risen and hepatitis C virus has spread among people who inject drugs in Iceland. The aim of this study was to evaluate the effects of these risk factors on the incidence and aetiology of cirrhosis in Iceland.

Methods

The study included all patients diagnosed with cirrhosis for the first time during 2010–2015. Diagnosis was based on liver histology or 2 of 4 criteria: cirrhosis on imaging, ascites, varices, and/or elevated INR.

Results

Overall, 157 patients were diagnosed, 105 (67%) males, mean age 61 years. The overall incidence was 9.7 cases per 100,000 inhabitants annually. Alcohol was the only underlying cause in 48/157 (31%), non-alcoholic fatty liver disease (NAFLD) in 34/157(22%), and alcohol and hepatitis C together in 23/157(15%) were the most common causes. Only 6% of patients had an unknown cause of cirrhosis. Upon diagnosis, the median model for end-stage liver disease score was 11 (IQR 8–15), 53% were of Child-Pugh class A whereas 61 (39%) had ascites, 11% encephalopathy, and 8% variceal bleeding. In all, 25% of deaths were from HCC and 25% from liver failure.

Conclusion

A major increase in incidence of cirrhosis has occurred in Iceland associated with increases in alcohol consumption, obesity, and hepatitis C. In a high proportion NAFLD was the aetiology and very few had unknown cause of cirrhosis. The highest death rate was from HCC.

Lay summary

In a nationwide population-based study from Iceland, including all patients diagnosed with cirrhosis of the liver over a period of 5 years, we found the incidence of new cases had increased 3-fold compared with a previous study 20 years ago. The increase is attributable to increased alcohol consumption, an epidemic of diabetes and obesity, and infection with the hepatitis C virus. Furthermore, we found that with thorough investigations, a specific cause for cirrhosis could be found in 94% of patients. Patients with cirrhosis frequently die of liver cancer and other complications related to their liver disease.

•

The incidence of cirrhosis in Iceland has been the lowest among western countries.

•

In this nationwide prospective study, all patients diagnosed with cirrhosis of the liver in Iceland over a period of 5 years were included.

•

The incidence of cirrhosis had increased 3-fold compared with a study 10 years earlier owing to increased alcohol consumption, obesity, and hepatitis C.

•

With thorough investigations a specific cause for cirrhosis could be found in 94% of patients.

Topical moistening of mastectomy wounds with diluted tranexamic acid to reduce bleeding: randomized clinical trial

BACKGROUND

Topical administration of tranexamic acid (TXA) may be an alternative to intravenous administration to reduce bleeding with a lower risk of systemic adverse events. The aim of this study was to investigate whether moistening a surgical wound with TXA before closure, leaving a thin film of drug only, would reduce postoperative bleeding.

METHODS

This was a two-centre, stratified, parallel-group, placebo-controlled, double-blind RCT. Patients undergoing mastectomy with or without axillary lymph node clearance were randomized 1 : 1 to moistening of wound surface before closure with either 25 mg/ml TXA or 0·9 per cent sodium chloride (placebo). The primary endpoint was postoperative bleeding as measured by drain production in the first 24 h. Secondary endpoints were early haematoma, total drain production, postoperative complications and late aspirations of seroma within 3 months.

RESULTS

Between 1 January 2016 and 31 August 2018, 208 patients were randomized. Two patients were converted to a different surgical procedure at surgery, and four did not receive the intervention owing to technical error. Thus, 202 patients were included in the study (101 in the TXA and 101 in the placebo group). TXA reduced mean drain production at 24 h (110 versus 144 ml; mean difference 34 (95 per cent c.i. 8 to 60) ml, P = 0·011). One patient in the TXA group had early haematoma compared with seven in the placebo group (odds ratio (OR) 0·13 (95 per cent c.i. 0·02 to 1·07); P = 0·057). There was no significant difference in postoperative complications between TXA and placebo (13 versus 10; OR 1·11 (0·45 to 2·73), P = 0·824) or need for late seroma aspirations (79 versus 67 per cent; OR 1·83 (0·91 to 3·68), P = 0·089).

CONCLUSION

Moistening the wound with TXA 25 mg/ml before closure reduces postoperative bleeding within the first 24 h in patients undergoing mastectomy. Registration number: NCT02627560 (https://clinicaltrials.gov).

Common and Rare Sequence Variants Influencing Tumor Biomarkers in Blood

BACKGROUND

Alpha-fetoprotein (AFP), cancer antigens 15.3, 19.9, and 125, carcinoembryonic antigen, and alkaline phosphatase (ALP) are widely measured in attempts to detect cancer and to monitor treatment response. However, due to lack of sensitivity and specificity, their utility is debated. The serum levels of these markers are affected by a number of nonmalignant factors, including genotype. Thus, it may be possible to improve both sensitivity and specificity by adjusting test results for genetic effects.

METHODS

We performed genome-wide association studies of serum levels of AFP (N = 22,686), carcinoembryonic antigen (N = 22,309), cancer antigens 15.3 (N = 7,107), 19.9 (N = 9,945), and 125 (N = 9,824), and ALP (N = 162,774). We also examined the correlations between levels of these biomarkers and the presence of cancer, using data from a nationwide cancer registry.

RESULTS

We report a total of 84 associations of 79 sequence variants with levels of the six biomarkers, explaining between 2.3% and 42.3% of the phenotypic variance. Among the 79 variants, 22 are cis (in- or near the gene encoding the biomarker), 18 have minor allele frequency less than 1%, 31 are coding variants, and 7 are associated with gene expression in whole blood. We also find multiple conditions associated with higher biomarker levels.

CONCLUSIONS

Our results provide insights into the genetic contribution to diversity in concentration of tumor biomarkers in blood.

IMPACT

Genetic correction of biomarker values could improve prediction algorithms and decision-making based on these biomarkers.

2895. Threats to Successful Elimination of Viral Hepatitis: Results from the Nationwide Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland

Background

The main driver of the Hepatitis C virus (HCV) epidemic in most western countries is injection drug use (IDU) among people who inject drugs (PWID). Iceland has provided unrestricted access to direct-acting antiviral agents (DAA) to all HCV-infected patients in the country covered by national health insurance, by a program entitled Treatment as Prevention for Hepatitis C (TraP HepC) from 2016 and is on track to become among the first to achieve the WHO goals of eliminating HCV as a public health threat.

Methods

We analyzed data regarding testing for HCV, incidence of IDU, prevalence of HCV viremia among PWID, drug use in the community and trends in homelessness prior to and during the first 24 months of TraP HepC to monitor outcomes and identify new or persistent challenges.

Results

Intensity of nationwide testing for HCV increased by 22% in 2016, 60% in 2017, and 81% in 2018 compared with previous years (P < 0.001). During 2016–2018 the incidence of new injection drug use, as surveyed among those admitted for addiction treatment increased by 48%. The total number of PWID admitted annually with HCV viremia however remained relatively stable during the entire period (2010–2018). The prevalence of HCV viremia among people recently injecting drugs admitted for addiction treatment however dropped from 48.7% to 16.2% in 2017, and to 10.2% in 2018 (P < 0.001). Analysis of data regarding stimulant use, as measured by drug levels in wastewater shows an almost threefold increase of amphetamine and an eightfold increase in cocaine levels during 2016–2018 compared with 2015. Concurrently, the number of homeless has doubled. Two years into TraP HepC > 80% of the estimated total HCV-infected population were started on their first course of DAAs. By intention to treat analysis, the cure rate was 92.4% among patients without history of IDU in the past 6 months, compared with 82.9% among active IDU (P = 0.0006); those with history of recent IDU were more likely to discontinue (P < 0.0001). Homelessness carried the highest relative risk (RR) of treatment failure (RR = 2.4, P = 0.008), mostly due to discontinuation.

Conclusion

Iceland is on track to eliminate HCV, but challenges such as increasing drug use in the community and homelessness need to continuously monitored and addressed; they may jeopardize the success of elimination efforts.

Disclosures

All Authors: No reported Disclosures.

Innovative strategies for the elimination of viral hepatitis at a national level: A country case series

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost-effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence-gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Biochemical response to ursodeoxycholic acid among PBC patients: a nationwide population-based study

Objective: To assess the proportion of PBC patients with a biochemical response to ursodeoxycholic acid (UDCA) in a population-based cohort and the association of biochemical response with outcomes. Methods: All patients diagnosed with PBC in Iceland from 1991-2015 were identified. Patients taking UDCA for an adequate period of time were analyzed for treatment response according to the Barcelona, Paris I, Paris II and Toronto criteria and outcomes. Results: Overall 182 females and 40 males were diagnosed with PBC and 135 patients were treated with UDCA. Overall 99 (73%) patients had adequate data on UDCA treatment and results of liver tests to assess biochemical response according to the Barcelona criteria, 95 (70%) according to the Toronto criterion and 85 (63%) according to the Paris I and II criteria. In all 74% (n = 63), 67% (n = 64), 54% (n = 53) and 46% (n = 39) responded to treatment according to the Paris I, Toronto, Barcelona and Paris II criteria. Among nonresponders according to the Paris I, Toronto, Paris II and Barcelona criteria, 50%, 39%, 33% and 30% developed cirrhosis versus 10%, 6%, 5% and 11% of responders, HR 5.36 (p = .002), 6.61 (p = .002), 10.94 (p = .003) and 2.21(p = .11), respectively. Age-adjusted mortality was significantly lower among responders according to the Paris I and Paris II criteria, HR 0.33 (p = .02) and 0.31 (p = .02), respectively. Conclusion: Development of cirrhosis and higher mortality was significantly associated with a lack of biochemical response to UDCA. Frequent development of cirrhosis and increased mortality in nonresponders underlines the need for a more effective therapy than UDCA for this sizeable subgroup of patients.

Genome-wide association meta-analysis yields 20 loci associated with gallstone disease

Gallstones are responsible for one of the most common diseases in the Western world and are commonly treated with cholecystectomy. We perform a meta-analysis of two genome-wide association studies of gallstone disease in Iceland and the UK, totaling 27,174 cases and 736,838 controls, uncovering 21 novel gallstone-associated variants at 20 loci. Two distinct low frequency missense variants in SLC10A2, encoding the apical sodium-dependent bile acid transporter (ASBT), associate with an increased risk of gallstone disease (Pro290Ser: OR = 1.36 [1.25-1.49], P = 2.1 × 10-12, MAF = 1%; Val98Ile: OR = 1.15 [1.10-1.20], P = 1.8 × 10-10, MAF = 4%). We demonstrate that lower bile acid transport by ASBT is accompanied by greater risk of gallstone disease and highlight the role of the intestinal compartment of the enterohepatic circulation of bile acids in gallstone disease susceptibility. Additionally, two low frequency missense variants in SERPINA1 and HNF4A and 17 common variants represent novel associations with gallstone disease.

928. Major Decrease in Prevalence of Hepatitis C Viremia in Key Populations following the Second Year of Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland

Background

Hepatitis C Virus (HCV) commonly affects people who inject drugs (PWID) and/or with history of injection drug use (IDU). They are also disproportionately represented in addiction treatment centers and the penitentiary system. In order to curtail spread of HCV it is therefore important to approach these groups. PWID and prisoners have been prioritized in the TraP HepC program. The impact can thus be assessed by monitoring HCV prevalence at sentinel sites, such as addiction hospitals and prisons.

Methods

TraP HepC offers direct-acting antiviral agents (DAAs) to all HCV patients in Iceland, starting in January 2016. HCV PCR is performed at the end of treatment and 12 weeks later (SVR12). PWID and prisoners are monitored for reinfection and retreated if needed. We compared the prevalence of HCV viremia among PWID admitted for treatment at Vogur addiction hospital and inmates of the penitentiary system, before and after 2 years of TraP HepC.

Results

Two years into the program 667 patients had been evaluated of which 632 were initiated on their first course of DAAs and 7 were pending, representing 80% of the estimated total patient population. Of those who completed first treatment according to guidelines the SVR12 is 95.5%. Drop-out from first treatment was 8.2%; nevertheless, the SVR12 was &gt;40% and most of the remaining viremic patients completed or are undergoing retreatment. In 2012–2015, prior to TraP HepC the prevalence of HCV viremia among actively injecting PWID admitted for addiction treatment was 47.9%, dropping to 39.8% in 2016 and 16.2% in 2017 (P &lt; 0.001). Likewise, the prevalence of viremia among patients with history of IDU but not recently injecting fell from 27.4% (2012–2015) to 19.8% in 2016 and 4.1% in 2017 (P &lt; 0.001). The prevalence of viremia among inmates of the penitentiary system was 29% prior to initiation of TraP HepC, dropping to 7% in 2017 (P &lt; 0.01). These results are not explained by declining IDU in the community.

Conclusion

On a population level the domestic transmission of HCV can be reduced by DAAs when combined with other efforts. Two years into the TraP HepC program the prevalence of viremia among two of the most important drivers of the epidemic has been markedly reduced. The program is ongoing, with further emphasis on increased intensity of screening, retreatment and harm reduction.

Disclosures

All authors: No reported disclosures.

Using the Icelandic genealogical database to define the familial risk of primary biliary cholangitis

Hereditary factors in primary biliary cholangitis (PBC) have been well defined in genome-wide association studies, but there are few direct data available that define the relative risk (RR) for family members with an affected proband. An increased risk in first-degree relatives has been demonstrated in a variety of studies, but data have been lacking on further detailed associations for subsequent generations. The objective of this study was to use the unique Icelandic genealogical database to study the familiality of PBC. All patients with positive antimitochondrial antibody measurements in Iceland during the period 1991-2015 who fulfilled diagnostic criteria for PBC were included. The Icelandic genealogical database was used to assess familial relations. For each case of PBC, 10,000 control subjects matched for age, sex, and number of known relatives were randomly chosen from this database to calculate the familial RR of PBC. The average kinship coefficient (KC) of the patients was calculated and compared with the average KC of controls. Overall, 222 PBC patients were identified (182 females, 40 males; median age, 62 years). First-, second- and third-degree relatives of the PBC patients had a high RR of the disease: 9.13 (P < 0.0001), 3.61 (P = 0.014) and 2.59 (P = 0.008), respectively. In fourth- and fifth-degree relatives, the RR was also increased to 1.66 (P = 0.08) and 1.42 (P = 0.08), respectively. The average KC of the patients was also higher than that of the control subjects, with 21.34 × 10^-5 versus 9.56 × 10^-5 (P < 0.0001).

CONCLUSION

Relatives of PBC patients had markedly higher risk for development of the disease compared with controls and importantly our data demonstrate that the risk was significantly increased even in second- and third-degree relatives. (Hepatology 2018;68:166-171).

Treatment as Prevention for Hepatitis C (TraP Hep C) - a nationwide elimination programme in Iceland using direct-acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct-acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016-2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale-up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.

Low prevalence of hepatitis E in Iceland: a seroepidemiological study

OBJECTIVE

Hepatitis E virus (HEV) infection has been reported to be more prevalent in the developed countries than previously thought. HEV infection is an important differential diagnosis in patients with drug-induced liver injury (DILI). The prevalence of hepatitis E was investigated in the general population of Iceland, among pig farmers and patients with DILI.

MATERIALS AND METHODS

Serum samples were tested for hepatitis E IgG, with two commercial ELISA tests: Diagnostic Bioprobes Srl. (Dia Pro) and the Wantai HEV IgG and subjects repeatedly reactive were tested with an immunoblot assay (RecomLINE). Three groups were tested: (1) healthy volunteers (HV), (2) pig farm workers (PFWs) and (3) patients participating in a nationwide prospective study on DILI.

RESULTS

Overall 291 individuals were tested, HV (n = 195), PFW (n = 21) and DILI (n = 75). Only 6/291 (2.1%) tested positive for IgG antibodies to HEV in all three tests. Three HV were HEV IgG antibody positive and three in the DILI group. One PFW tested positive in the Dia Pro and Wantai tests but not in the immunoblot assay. All but one of the positive individuals in all three tests was either of foreign national origin or had spent extended period of time outside of Iceland.

CONCLUSIONS

The seroprevalence of hepatitis E appears to be lower in Iceland than majority of recent studies in other western countries have demonstrated. This may be due to relative isolation and severe restriction on import of livestock from other countries.

Rare and Common Variants Conferring Risk of Tooth Agenesis

We present association results from a large genome-wide association study of tooth agenesis (TA) as well as selective TA, including 1,944 subjects with congenitally missing teeth, excluding third molars, and 338,554 controls, all of European ancestry. We also tested the association of previously identified risk variants, for timing of tooth eruption and orofacial clefts, with TA. We report associations between TA and 9 novel risk variants. Five of these variants associate with selective TA, including a variant conferring risk of orofacial clefts. These results contribute to a deeper understanding of the genetic architecture of tooth development and disease. The few variants previously associated with TA were uncovered through candidate gene studies guided by mouse knockouts. Knowing the etiology and clinical features of TA is important for planning oral rehabilitation that often involves an interdisciplinary approach.

Lifetime drinking history in patients with alcoholic liver disease and patients with alcohol use disorder without liver disease

OBJECTIVE

To determine the differences in lifetime alcohol intake (LAI) and drinking patterns between patients with alcoholic liver disease (ALD) and alcohol use disorder (AUD) without notable liver injury and between males and females with ALD.

METHODS

Alcohol drinking patterns were assessed using the Lifetime Drinking History (LDH) a validated questionnaire, during an outpatient visit. Patients with AUD, currently in addiction treatment, were matched for gender and age (±5 years) with the ALD group.

RESULTS

A total of 39 patients with ALD (26 males and 13 females; median age 58) and equal number of AUD patients were included (median age 56 years). The onset age for alcohol drinking and duration of alcohol consumption was similar in ALD and AUD. The number of drinking days was higher in women with ALD than in women with AUD: 4075 [(3224-6504) versus 2092 (1296-3661), p = .0253]. The LAI and drinks per drinking day (DDD) were not significantly different between patients with ALD and AUD. Females with ALD had lower LAI than males with ALD: 32,934 (3224-6504) versus 50,923 (30,360-82,195), p = .0385, fewer DDD (p = .0112), and lower proportion of binge drinking as compared to males with ALD (p = .0274).

CONCLUSIONS

The total LAI was similar in patients with ALD and AUD. The number of drinking days over the lifetime was associated with the development of ALD in females. Females with ALD had significantly lower alcohol consumption than men with ALD despite similar duration in years of alcohol intake which supports the concept of female propensity of ALD.

Treatment as Prevention for Hepatitis C (TraP HepC). A Real-world Experience from the First 12 Months of a Nationwide Elimination Program in Iceland

Background

Hepatitis C virus (HCV) infection is associated with significant morbidity and mortality. Iceland, an island with a population of 330,000 has a HCV seroprevalence of 0.3% and an estimated total of 800–1000 patients. There is good access to health care among people who inject drugs (PWID) and Iceland thus serves as an ideal setting for a proof of concept intervention, aiming for elimination of the disease as a public health threat. If elimination is to be achieved PWID, who are key drivers of transmission, need to be a focus of treatment scale up.

Methods

All patients in the country infected with HCV were offered direct-acting antiviral agents (DAAs) starting in 01/2016. The regimens are chosen according to national guidelines; SOF/LDV +/−RBV through October 2016 and SOF/VEL +/− RBV thereafter. People with recent injection drug use (IDU), prisoners and patients with advanced liver disease are prioritized. PWID receive additional support to facilitate compliance. Various strategies are employed to enhance case detection and harm reduction. The goal is to initiate treatment for every patient in Iceland within 36 months (end-2018), aiming for elimination of domestic transmission of HCV.

Results

Twelve months after launching the nationwide program 527 patients had been evaluated, 53–66% of the estimated total patient population. The mean age is 42 years (range, 17–70 years, 2 males to every female). The reported main route of infection was IDU (90%). At the time of evaluation, 33% reported recent (within 6 months) IDU, 6% were homeless, and 5% in prison. Stimulants were the preferred IV drug among 84% of PWID but opiates by only 14%; overall 15% were receiving opiate substitution therapy (OST). During the first 12 months of the study period treatment with DAAs was initiated in 480 patients and 322 were scheduled to complete protocol. Drop-out rate is 6.5%. Sustained virological response at 12 weeks (SVR12) for the entire group, including patients who dropped out or are lost to follow-up is 90%. It is significantly lower among the homeless (60%) and active IDU (83% vs. 93%, P = 0.007).

Conclusion

A relatively large proportion of HCV infected patients in the community, including people actively injecting drugs, can be initiated on treatment in a short period of time. Current drug use does not preclude treatment success.

Disclosures

M. Gottfredsson, Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Research support; Astellas: Consultant, Speaker honorarium

A prospective study on the causes of notably raised alanine aminotransferase (ALT)

OBJECTIVE

High levels of alanine aminotransferase (ALT) can be a marker of severe liver disease with variable aetiologies and prognosis. Very few prospective studies have been undertaken on the aetiology and prognosis of patients with high ALT levels. No population-based prospective study has systematically evaluated drug-induced liver injury (DILI) among these patients. The objective was to determine the aetiology and prognosis of patients with high ALT.

MATERIALS AND METHODS

In a catchment area of 160,000 inhabitants, a population-based prospective study identified all adult patients with serum level of ALT >500 U/L during a 12-month period. All underwent thorough diagnostic work-up and follow-up. In suspected DILI, causality was assessed with Roussel Uclaf Causality Assessment Method.

RESULTS

A total of 155 patients were identified with ALT >500 U/L, 12 children and one with ALT of non-liver-related origin, leaving 142 patients for the analysis: 73 (51%) males, median age 52 (IQR 36-68, range 19-89 years). The most common causes were choledocholithiasis 48/142 (34%), ischaemic hepatitis 26 (18%), viral hepatitis 16 (11%) and DILI 15 (11%), hepatobiliary malignancy (n = 6), surgery/interventions (n = 8) and other aetiologies (n = 23). No specific aetiology was found in 6% of cases. In the total study cohort 99 (70%) required hospitalisation, 78 (55%) had jaundice and 22 (16%) died, liver-related death in 10%, 35% in IH and 7% in DILI.

CONCLUSIONS

The most common cause of notably high ALT was choledocholithiasis. Ischaemic hepatitis was a common aetiology with approximately 35% liver-related mortality. Viral hepatitis and DILI were important aetiologies among these patients.

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.