Infection risk related to gastrointestinal endoscopic procedures during the SARS-CoV-2 pandemic / Tápcsatornai endoszkópos eljárásokkal összefüggo infekciós kockázat a SARS-CoV-2-járvány idején

Introduction: COVID­19 significantly affects endoscopic labs' workflow. Endoscopic examinations are considered high-risk for virus transmission. Objectives: To determine impact of COVID­19 pandemic on Hungarian endoscopic labs' workflow and on infection risk of endoscopic staff. Method: A nation-wide, cross-sectional online questionnaire was sent to heads of endoscopic labs in Hungary. The average number (with 95% confidence intervals) of upper and lower gastrointestinal endoscopies performed in 2020 was compared to that in 2019. The number of SARS-CoV-2-infected endoscopic staff members and the source of infection was also investigated. Results: Completion rate was 30% (33/111). Neither the number of upper (1.593 [743­1.514] vs. 1.129 [1.020­2.166], p = 0.053), nor that of lower gastrointestinal endoscopies (1.181 [823­1.538] vs. 871 [591­1.150], p = 0.072) decreased in 2020, but both upper and lower gastrointestinal endoscopies' number decreased by 80% during peak phases. Separate examination room was available in 12% of institutes. Appropriate quality personal protective equipment (PPE) was available during the first and second peak phase in 70% and 82%, respectively. Infection risk stratification by questionnaire and PCR testing was routinely performed in 85% and 42%, respectively. Employee number decreased by 33% and 26% for physicians, and by 19% and 21% for assistants during peak phases, mainly due to age restrictions and COVID care assignments. 32% of assistants and 41% of physicians were infected (associated with inappropriate PPE use in 16% and 18%, respectively). Conclusion: Peak phases' restrictions increase endoscopic workload afterwards. Despite PPE availability, 15% of employees' COVID infection resulted from inappropriate PPE use in pre-vaccination era.

Screening and treatment of hepatitis C virus in prisons: 10 years of experience / A hepatitis C-vírus szurésének és kezelésének 10 éves tapasztalata a börtönökben

Introduction and objective: Two-thirds of patients with hepatitis C virus (HCV) infection are unaware of their infection in the European Union. The WHO aims to reduce the number of new cases of chronic hepatitis by 90% by 2030. The proportion of people infected with HCV in prisons can be up to ten times higher compared to the general population. This article is a summary of the results of the HCV screening carried out in the Hungarian prisons between 2007 and 2017. Method: Screening of anti-HCV antibodies has been performed on a voluntary basis followed by HCV PCR and genotyping in positive cases. After obtaining written informed consent from the patients, treatment was started. Treatments were performed under the guidance of hepatologists in collaboration with prison medical staff. Results: HCV screening programs and treatments are in place in 84% of Hungarian prisons. A total of 25 384 patients underwent anti-HCV screening. Anti-HCV positive result was detected in 6.6% and HCV PCR positivity was confirmed in 3.8% of the screened inmates. 55.2% patients from the HCV PCR positive population were put on treatment. Only 143 patients received full treatment, while 162 (42.6%) treatments were terminated prematurely, and the duration of treatment was unknown in 75 patients. Based on the results available on the 24th week after the end of treatment, sustained virologic response rate was 88%. Discussion: Education of patients and collaboration between hepatologists and prison medical staff play an important role in the successful result of treatment. Conclusion: Our experience demonstrates that the test and treat principle is feasible and effective at microeliminating HCV in prisons.

[Type 2 diabetes mellitus, insulin resistance and hepatocellular carcinoma in chronic hepatitis C patients. Data from Northeastern Hungary]. / 2-es típusú diabetes mellitus, inzulinrezisztencia és májrák idült hepatitis C-fertozésben. Északkelet-magyarországi adatok.

Introduction: Liver cirrhosis (20-25%), hepatocellular carcinoma (1.5-3%), insulin resistance (30-40%) and type 2 diabetes (25-30%) are common complications in patients with chronic hepatitis C virus (HCV) infection; however, data are missing from Hungary. Aim: To determine the prevalence of diabetes and insulin resistance in Hungarian HCV patients; to evaluate treatment-induced metabolic changes in relation to diabetes/insulin resistance and virological response and to perform a sustained follow-up for hepatocellular carcinoma detection. Method: We enrolled 150 Hungarian HCV genotype 1 patients (mean age: 48.55 ± 8.55 years, male/female ratio: 45/55%) from 2007-2012. We analysed their baseline, week 12, and end of therapeutic follow-up (24 weeks after interferon-based therapy completion) laboratory data. We performed a 5-year follow-up (2012-2017). Results: The prevalence of insulin sensitivity, insulin resistance and diabetes was 37.4%, 35.3% and 27.3%, respectively. Insulin resistant and diabetic patients showed a decrease in fasting glucose from baseline to end of follow-up (5.47 ± 0.66 vs. 5.08 ± 0.60, p<0.001; 7.90 ± 2.67 vs. 7.04 ± 2.75, p = 0.006), as did both the sustained responder and non-responder groups. Treatment efficacy rate was poor in diabetic vs. insulin sensitive and insulin resistant groups (17% vs. 46% and 40%); insulin sensitivity was not a predictor of virological response. Three participants with diabetes were diagnosed with hepatocellular carcinoma during follow-up by regular ultrasound examinations. Conclusion: Hungarian HCV patients showed high prevalence of diabetes and insulin resistance, though antiviral therapy caused favourable changes in their carbohydrate metabolism. Antiviral therapy was less effective in diabetic patients. Follow-up ultrasound examinations are required for hepatocellular carcinoma in HCV patients, especially those with diabetes. Orv Hetil. 2019; 160(40): 1591-1602.

[Obesity, hormonal and metabolic abnormalities in adolescent girls with polycystic ovary syndrome]. / Elhízás, hormonális és anyagcserezavarok serdülokori polycystás ovarium szindrómában.

INTRODUCTION: Polycystic ovary syndrome is associated with metabolic abnormalities, such as dyslipidemia, obesity, glucose intolerance, which are also components of the metabolic syndrome. Central obesity and insulin resistance appear to play an important role in the pathogenesis of polycystic ovary syndrome, perhaps via subsequent steroidogenic dysregulation. AIM: The aim of the authors was to assess metabolic and hormonal abnormalities in adolescent girls with polycystic ovary syndrome. METHOD: The study included 52 adolescents diagnosed with polycystic ovary syndrome based on the Rotterdam criteria. Anthropometric, hormonal and metabolic parameters were evaluated among all subjects. 20 healthy, age-matched, non-obese, regularly menstruating girls were used as controls. Of the 52 patients, 15 patients were born with low-birth-weight and 37 patients were born with normal birth weight. Oral glucose tolerance test was performed in all patients and controls. The age of patients was 16.8±3.1 years, and the age of controls was 16.95±2.1 years. RESULTS: Among patients with polycystic ovary syndrome the prevalence of overweight and obesity was 35% (n = 18), while impaired fasting glucose occurred in one patient, impaired glucose tolerance in 8 patients, insulin resistance in 25 patients and metabolic syndrome in 12 patients. Serum triglyceride levels in patients and controls were 1.4±0.8 and 0.9±0.3 mmol/l, respectively (p<0.05), while fasting blood glucose, total cholesterol, HDL and LDL cholesterol were not different in the two groups. Metabolic abnormalities and obesity were more severe and more frequent in patients with low-birth-weight compared to those born with normal weight. There was a negative correlation between birth weight and body mass index SDS values and a positive correlation between fasting insulin levels and body mass index SDS (r = 0.37) in patients born with low-birth-weight. CONCLUSIONS: Abnormal glucose metabolism is frequently present in adolescents with polycystic ovary syndrome. It is possible that early diagnosis of polycystic ovary syndrome in adolescence may prevent some of the long-term complications associated with this syndrome.

[Effect of treatment with gonadotropin releasing hormone analogues in girls with idiopathic central precocious puberty]. / Az idiopathiás centrális pubertas praecox gonadotropin releasing hormon analóg terápiájának hosszú távú hatása leányoknál.

UNLABELLED: It has been proven for more than two decades that gonadotropin releasing hormone analogue therapy is the only choice of treatment in patients with central precocious puberty. AIMS: The aim of the authors was to assess the effect of gonadotropin releasing hormone analogue treatment on final height, body mass index, bone mineral density and ovarian function in girls with idiopathic central precocious puberty. METHODS: Predicted adult height, target height and achieved height due to therapy was assessed in 15 girls with idiopathic precocious puberty treated with gonadotropin releasing hormone analogue. At the beginning of the treatment, the age of the girls was 7.0±0.8 years (mean±SD) and at the end of the treatment 12±0.8 years. The duration of gonadotropin-releasing hormone analogue treatment was 4.48±0.8 years. At the time of achieving final height, the age of the patients was 18.2±2.0 years and the height was 160.4±7.1 cm. When final height was reached, the authors evaluated bone mineral density Z-score values, levels of bone markers and the function of the hypothalamic-pituitary-gonadal axis. 15 healthy prepubertal girls, 15 pubertal girls and 15 girls who reached final height matched for chronological age were selected as control groups. RESULTS: The majority of the gonadotropin releasing hormone-treated girls reached or almost reached their expected height predicted on the basis of the heights of their parents, but the therapy resulted only in a modest beneficial effect on height gain. Despite the fact that the body weight of patients increased during the treatment, there was no significant difference in their body mass index when they reached their final height as compared to controls. As compared to controls, patients had a decreased bone mineral density at the time when they reached their final height (lumbar spine 2-4 Z score, -0.27±1.2 vs. 0.5±0.7 in controls; p = 0.0377), which could be explained by their overweight that already existed before treatment, lack of exercise and poor calcium uptake. Their menarche occurred 12±4.6 months after discontinuing the treatment. CONCLUSIONS: Gonadotropin releasing hormone analogue therapy exerts a modest beneficial effect on final height gain. There are no detrimental effects on body mass index, bone mineral density and ovarian function after treatment. Side-effects are of minor severity and they are tolerable.

Presence of anti-microbial antibodies in liver cirrhosis--a tell-tale sign of compromised immunity?

BACKGROUND: Bacterial translocation plays important role in the complications of liver cirrhosis. Antibody formation against various microbial antigens is common in Crohn's disease and considered to be caused by sustained exposure to gut microflora constituents. We hypothesized that anti-microbial antibodies are present in patients with liver cirrhosis and may be associated with the development of bacterial infections. METHODOLOGY/PRINCIPAL FINDINGS: Sera of 676 patients with various chronic liver diseases (autoimmune diseases: 266, viral hepatitis C: 124, and liver cirrhosis of different etiology: 286) and 100 controls were assayed for antibodies to Saccharomyces cerevisiae (ASCA) and to antigens derived from two intestinal bacterial isolates (one gram positive, one gram negative, neither is Escherichia coli). In patients with liver cirrhosis, we also prospectively recorded the development of severe episodes of bacterial infection. ASCA and anti-OMP Plus™ antibodies were present in 38.5% and 62.6% of patients with cirrhosis and in 16% and 20% of controls, respectively (p<0.001). Occurrence of these antibodies was more frequent in cases of advanced cirrhosis (according to Child-Pugh and MELD score; p<0.001) or in the presence of ascites (p<0.001). During the median follow-up of 425 days, 81 patients (28.3%) presented with severe bacterial infections. Anti-microbial antibody titers (p = 0.003), as well as multiple seroreactivity (p = 0.036), was associated with infectious events. In logistic regression analysis, the presence of ascites (OR: 1.62, 95%CI: 1.16-2.25), co-morbidities (OR: 2.22, 95%CI: 1.27-3.86), and ASCA positivity (OR: 1.59, 95%CI: 1.07-2.36) were independent risk factors for severe infections. A shorter time period until the first infection was associated with the presence of ASCA (p = 0.03) and multiple seropositivity (p = 0.037) by Kaplan-Meier analysis, and with Child-Pugh stage (p = 0.018, OR: 1.85) and co-morbidities (p<0.001, OR: 2.02) by Cox-regression analysis. CONCLUSIONS/SIGNIFICANCE: The present study suggests that systemic reactivity to microbial components reflects compromised mucosal immunity in patients with liver cirrhosis, further supporting the possible role of bacterial translocation in the formation of anti-microbial antibodies.

Mannose-binding lectin deficiency confers risk for bacterial infections in a large Hungarian cohort of patients with liver cirrhosis.

BACKGROUND & AIMS: Mannose-binding lectin (MBL) is a serum lectin synthesized by the liver and involved in innate host defense. MBL deficiency increases the risk of various infectious diseases mostly in immune-deficient conditions. Bacterial infections are a significant cause of morbidity and mortality in liver cirrhosis due to the relative immuncompromised state. METHODS: Sera of 929 patients with various chronic liver diseases [autoimmune liver diseases (ALD), 406; viral hepatitis C (HCV), 185; and liver cirrhosis (LC) with various etiologies, 338] and 296 healthy controls (HC) were assayed for MBL concentration. Furthermore, a follow-up, observational study was conducted to assess MBL level as a risk factor for clinically significant bacterial infections in cirrhotic patients. RESULTS: MBL level and the prevalence of absolute MBL deficiency (<100 ng/ml) was not significantly different between patients and controls (ALD: 14.5%, HCV: 11.9%, LC: 10.7%, HC: 15.6%). In cirrhotic patients, the risk for infection was significantly higher among MBL deficient subjects as compared to non-deficient ones (50.0% vs. 31.8%, p=0.039). In a logistic regression analysis, MBL deficiency was an independent risk factor for infections (OR: 2.14 95% CI: 1.03-4.45, p=0.04) after adjusting for Child-Pugh score, co-morbidities, gender, and age. In a Kaplan-Meier analysis, MBL deficiency was associated with a shorter time to develop the first infectious complication (median days: 579 vs. 944, pBreslow=0.016, pLogRank=0.027) and was identified as an independent predictor in a multivariate Cox-regression analysis (p=0.003, OR: 2.33, 95% CI: 1.34-4.03). CONCLUSIONS: MBL deficiency is associated with a higher probability and shorter time of developing infections in liver cirrhosis, further supporting the impact of the MBL molecule on the host defense.

[Clinical aspects of hepatitis C in women of child-bearing age]. / Fertilis korú nôk hepatitis C-vírus-fertôzésének klinikai vonatkozásai.

It is difficult to define the optimal timing of antiviral treatment in women infected with viral hepatitis C, who have child-bearing potential. Antiviral treatment is strictly contraindicated during pregnancy and the breast-feeding period. Data are conflicting about the question of treatment with modern drugs (peginterferon and ribavirin) before or after pregnancy. The risk of vertical transmission from mother to child is estimated about 5%. The mother's viraemia seems to be the main transmission factor. There is a worse prognosis in nulliparous and postmenopausal women in the natural history of viral hepatitis C. Poor outcome in gestational age, maturity and Apgar score were not associated with hepatitis C virus infection. Combined treatment has frequent gynecological and other side effects. The timing of antiviral therapy in women in child-bearing period is recommended individually.

Urinary flow disturbance as an early sign of autonomic neuropathy in diabetic children and adolescents.

AIMS: Urinary bladder dysfunction is a frequent complication of diabetes mellitus in adults. The aim of this study is to determine the early disturbances of the detrusor contractility in children, and adolescents with type 1 diabetes. MATERIALS AND METHODS: The bladder urine flow parameters were investigated in 37 children with type 1 diabetes, 10/37 with cardiovascular autonomic dysfunction (CAD) voided 482 +/- 128 mils (Group A), 27/37 without CAD voided 258 +/- 52 mils (Group B). From an earlier uroflow screening study 20 healthy children formed group control A, who had voided 488 +/- 94 mils, and another 30 healthy children formed group control B, who had voided 260 +/- 50 mils. The compared groups were matched for voided volume, age, weight, and height. There was no evidence of urinary tract abnormalities in any of the children. RESULTS: Time to maximum flow was longer in both diabetic groups as compared with controls (P < 0.01), and the acceleration (the ratio of maximum flow and the time to maximum flow) of diabetics was significantly lower (P < 0.01). Bladder emptying was complete in each subject. Bladder wall disturbances were not seen by ultrasound. CONCLUSIONS: The decreased acceleration of detrusor muscle contraction may be interpreted as an early sign of autonomic neuropathy in children and adolescent with type 1 diabetes, even in patients without CAD. Clinicians may be able to determine autonomic neuropathy by using uroflowmetry that is easy to perform, sensitive, reproducible, and needs only a child's minimal cooperation.

Videourodynamics in the diagnosis of urinary tract abnormalities in a single center.

The lower urinary tract is a complicated structure and there has been some controversy regarding the biomechanics and dynamics of bladder and sphincter function. Investigation of the function and morphological anomalies is very important. Videourodynamics (VUD) combined with conventional voiding cystourethrography (VCUG) seems to be the most appropriate method. Over a 12-year study period (January 1990 to December 2001), 422 children (aged 5 days to 20 years) prospectively underwent VUD to further define their urinary tract abnormalities. In all children the history was recorded, clinical examination, urinalysis, culture, and ultrasonography performed, and serum creatinine determined before VUD. The selection criteria included a history of recurrent urinary tract infections (UTI) in 310 patients (74%), urinary tract dilatation without UTI in 31 patients (7%), suspected neurogenic bladder dysfunction in 42 patients (10%), and voiding difficulties in 39 patients (9%). VUD consists of cystometry (CM), which is the measurement of detrusor pressure during controlled bladder filling and subsequent voiding, and was combined with VCUG using X-ray contrast material. CM is used to assess detrusor activity, sensation, capacity, and compliance. CM measurements were recorded on a computer and vesicoureteric reflux (VUR) was documented at the same time with plain films and later in a PACS system. The VUD diagnosis was of normal bladder function in 46 patients (9%), VUR in 212 (43%), unstable bladder dysfunction in 152 (31%), neurogenic bladder dysfunction in 35 (7%), urine outflow obstruction in 15 (3%), wide bladder neck in 22 (4%), and vaginal reflux in 9 (2%). Neurogenic bladder dysfunction was excluded in 7 patients (1%). VUD is useful for the investigation of the lower urinary tract function together with X-ray morphology. The advantage of these studies is that they combine the objectivity of urodynamics with the visual radiographic image, leading to lower radiation doses and a more logical interpretation of the results.