Noninvasive assessment of liver fibrosis in chronic hepatitis C virus patients compared to liver biopsy: the experience of tertiary level hospital in Serbia.

BACKGROUND: Chronic hepatitis C virus (HCV) infection, that is defined by active carriage of HCV RNA in the blood, is represents one of the major public health problems worldwide. In Serbia, the prevalence of anti-HCV positive persons in the general population, is estimated on average 1.13%. METHODS: The aim of our study was to evaluate the ability of noninvasive scores in order to define the degree of liver fibrosis, and to assess the effect of host and viral factors on fibrosis in chronic HCV patients. In a retrospective analysis a total of 814 patients with chronic HCV infection were included. Liver fibrosis scores were calculated, and in particular AST/ALT Score APRI, Forns Index, and FIB-4 score, and all of them compared with histological classification. RESULTS: We found that noninvasive biochemical scores of fibrosis, have a good performance especially to distinguish mild and moderate fibrosis to advanced fibrosis. In particular, we found that FIB-4 score is a useful screening tool to accurately exclude patients with advanced disease. CONCLUSIONS: Noninvasive liver fibrosis scores are efficient tools in the management and follow-up of HCV patients in clinical practice.

Inflammation in gastrointestinal disorders: prevalent socioeconomic factors.

Western populations harbor a chronic inflammation pattern that lacks organ cardinal signs (edema, increased temperature, pain, and impaired function), releases increased levels of C-reactive protein, and often runs a creeping clinical course with generalized debilitating disease superimposed on system-specific involvement, mostly including nervous tissue (multiple sclerosis, Parkinson's syndromes), joints (arthritis), and skin (psoriasis). A finalistic interpretation may apply to the consideration of the gut as the source of inflammation. In fact, these kind of local events as well as the remote manifestations named above, could be conditioned by the microbiome, the huge cell population indwelling the gut which is under growing scrutiny. The role of the gut as a barrier organ justifies lingering submucosal inflammation as a patrolling activity to maintain bodily integrity; the microbiome, launching inflammogenic signals in response to abrupt diet changes, confers to gut inflammation a socioeconomic vector calling for hitherto unrecognized multi-disciplinary interventions.

Irritable bowel syndrome: the clinical approach.

Irritable bowel syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder which presents with abdominal pain associated with alteration of bowel habits. IBS is a common condition affecting 9-23% of the general population, being the 80% female, with considerable impact on quality of life and health care costs. The exact pathogenesis of IBS remains elusive, but is clearly multifactorial and includes environmental and host factors. Management of patients with IBS is challenging since diagnosis and treatment could require several approaches with unsatisfactory results. In any case, the diagnosis of IBS is based on the positive identification of symptoms consistent with this condition and by excluding an underling organic disease. Before choosing therapeutic options, a strong reassuring physician-patient relationship is crucial. The therapeutic approach of IBS may consist of both non-pharmacological therapies and pharmacotherapy and should be based on prevalent symptomatology. Lifestyle modifications such as stress reduction and increased physical activity seem to be useful to improve symptoms and should be encouraged. The same for dietary modifications that represent an important first-line therapeutic option. The pharmacological treatment should take into account the predominant symptom and test one drug at a time with a predefined time point for effectiveness evaluation and dosage adjustment. This clinical review offers an updated overview on epidemiology, pathogenesis, diagnosis and treatment of IBS.

Inflammatory bowel disease: Efficient remission maintenance is crucial for cost containment.

The inflammatory bowel diseases (IBD) are chronic incurable inflammatory disorders of the gut. Some 10% run a downhill course, requiring emergency medical support and often surgery; another small subset are monogenic, and, threatening pediatric patients, are the challenge of these days. The majority of the IBDs, however, are polygenic low-penetrance diseases, running a lifetime waxing-and-waning course. The prevalent trend is towards a slow worsening and steady cost increase. Each and all drugs of the available arsenal exhibit strengths and weaknesses: Mesalamines are chiefly effectively for mild-moderate colitis, and do not work in Crohn's; steroids do not control some 40% of the ulcerative colitis cases, and are not indicated for Crohn's; thiopurines are effective in the maintenance of the IBDs but do not prevent relapses on withdrawal; biologics are still being used empirically (not monitored) causing further increase of their cost over that of hospitalization. Against all these caveats, two simple rules still hold true: Strict adherence maintenance and avoidance of colitogenic drugs. This matter is expanded in this minireview.

Prevention program for Clostridium difficile infection: a single-centre Serbian experience.

BACKGROUND: Clostridium difficile (C. difficile) diarrhea is a common, iatrogenic, nosocomial disease with a worldwide diffusion. Recent studies reported that the incidence of C. difficile infection (CDI) is rising, due to aging of the population and to greater prevalence of hypervirulent strains. We investigated whether the application of a prevention program lead to a decline in the incidence of intrahospital CDI. METHODS: The study was designed as observational, to compare the efficacy of Schülke preventive program with the standard protocols, in a period of 4 months. For every patient with community-onset healthcare facility-associated (HCFA) CDI, we randomly selected four controls (1:4) with the same ICD code but without HCFA CDI. For statistical analysis the nonparametric, one-way ANOVA, univariate regression analysis, univariate analysis of variance, and Welch and Brown-Forsythe Test were used. RESULTS: Clinical features of HCFA CDI were typical. HCFA CDI group was significantly older than control group (P=0.008 and F=6.686; Partial Eta Square=0.013). Patients with HCFA CDI stayed significantly longer in hospital (P=0.000 and F=69.379; Partial Eta Square=0.117). Acquiring CDI prolonged the hospitalization of 14.52 days. HCFA CDI significantly increases the total cost of hospitalization as well as each element of the price respectively. With the application of the prevention program the annual incidence of CDI dropped from 49.01 in 2013 to 18.22/10000 bed days in 2014. CONCLUSIONS: Applying Schülke preventive program, implemented in 2014, has led to significant savings for the hospital compared to previous methods.

Noninvasive assessment of liver fibrosis: key messages for clinicians.

The management of patients with chronic liver disease (CLD) requires an accurate definition of the staging and grading, as the latter is related to the progression of liver fibrosis. Albeit liver biopsy (LB) is an invasive procedure with possible complications, it is currently the "gold standard" for the assessment of hepatic fibrosis. Over the past decade, several noninvasive approaches have been proposed as surrogates in the evaluation of liver fibrosis. These include serum direct and indirect markers of fibrosis linked, respectively, to fibrogenesis and hepatic function, and instrumental techniques, which measure liver stiffness, a parameter directly correlated with liver fibrosis. Although accuracy of noninvasive methods was initially investigated in chronic hepatitis C, there are now increasing data referred to their application in other CLDs. While in specific settings, there is still need for LB, noninvasive methods have an increasing and crucial role in clinical practice to monitor fibrosis progression in patients with CLD. The aim of this review is to present the current status of knowledge in this new exciting field and to highlight the key messages useful for clinicians.

Non-invasive methods for the assessment of hepatic fibrosis: transient elastography, hyaluronic acid, 13C-aminopyrine breath test and cytokeratin 18 fragment.

BACKGROUND. In the management of chronic hepatitis C (CHC) patients, liver biopsy is the gold standard for liver fibrosis assessment despite some technical limits and risks. Non-invasive approaches have been proposed as alternative methods to evaluate structural liver damage. AIM. To investigate the diagnostic accuracy of transient elastography, 13C-aminopyrine breath test (13C-ABT), serum hyaluronic acid (HA) and cytokeratin 18 Asp396 fragment (CK-18) as non-invasive methods of liver fibrosis assessment ad their correlation to METAVIR score. MATERIAL AND METHODS. In a cohort of 57 CHC patients, liver stiffness, cumulative percentage of administered dose of 13C-aminopyrine at 120 min, serum HA and serum CK-18 concentration were determined. Diagnostic accuracy in detecting significant fibrosis (F ≥ 2), severe fibrosis (F ≥ 3) and cirrhosis (F = 4) was assessed by the area under the receiver operating characteristic curve. RESULTS. Liver fibrosis score showed a strong correlation with liver stiffness (r = 0.667; p < 0.0001) and a significant inverse correlation with 13C-ABT results (r = -0.418; p = 0.0012). A weaker correlation was found with CK18 (r = 0.329; p = 0.0126) and no correlation with HA. Areas under the curve of elastography, 13C-ABT, HA and CK18 were: 0.98, 0.75, 0.69, 0.64, respectively, for F ≥ 2; 0.97, 0.69, 0.80, 0.66, respectively, for F ≥ 3; 0.95, 0.64, 0.70, 0.56, respectively, for F = 4. CONCLUSION. Elastography has the best diagnostic accuracy for the assessment of the degree of liver fibrosis in CHC patients. Its application can provide an alternative useful tool for monitoring the disease evolution.

Short duration treatment in genotype 1 chronic hepatitis C patients with rapid virologic response to pegylated interferon plus ribavirin.

BACKGROUND: In patients with chronic hepatitis C, rapid HCV-RNA clearance under treatment might allow shorter treatment duration without modifying the sustained virological response (SVR) rate. This study evaluated the impact of rapid virological response (RVR) in HCV genotype 1b infection management. METHODS: In an open-label trial, 180 patients received standard doses of peginterferon alfa-2a plus ribavirin. Those with undetectable serum HCV-RNA at week 6 (RVR) received 24-week short-course treatment; patients with undetectable HCV-RNA at week 12 (early responders [ER]) received 48-week "standard of care" treatment; patients with positive HCV-RNA at week 12 (non-responders [NR]) stopped the treatment. Study end-point was to determine SVR rate at week 24. RESULTS: The following responses were observed: 24% RVR, 44% ER, 32% NR. Among RVR subjects, HCV-RNA baseline levels and age were significantly lower (P=0.038 and 0.035 respectively) than in non-RVR patients. At follow-up, 91% of RVR and 33% of ER patients achieved SVR. Among those with RVR, patients experiencing post-therapy relapse were older than those who achieved a SVR (P=0.028). CONCLUSIONS: Chronic HCV-1b patients, achieving RVR with a 24-week treatment regimen, attained excellent SVR rates. In a cost-effective therapeutic approach, all HCV-1b patients eligible for therapy may have a short duration therapy on the basis of RVR.