Screening for hepatitis C in a general adult population in a low-prevalence area: the Tromsø study.

BACKGROUND: Chronic hepatitis C virus (HCV) infection can progress to cirrhosis and end-stage liver disease in a substantial proportion of patients. The infection is frequently asymptomatic, leaving many infected individuals unaware of the diagnosis until complications occur. This advocates the screening of healthy individuals. The aim of this study was to estimate the prevalence of HCV infection in the general adult population of the municipality of Tromsø, Norway, and to evaluate the efficiency of such an approach in a presumed low-prevalence area. METHODS: The study was part of the seventh survey of the Tromsø Study (Tromsø 7) in 2015-2016. Sera from 20,946 individuals aged 40 years and older were analysed for antibodies to HCV (anti-HCV). A positive anti-HCV test was followed up with a new blood test for HCV RNA, and the result of any previous laboratory HCV data were recorded. Samples positive for anti-HCV and negative for HCV RNA were tested with a recombinant immunoblot assay. All HCV RNA positive individuals were offered clinical evaluation. RESULTS: Among 20,946 participants, HCV RNA was detected in 33 (0.2%; 95% CI: 0.1-0.3), of whom 13 (39.4%; 95% CI: 22.7-56.1) were unaware of their infection. The anti-HCV test was confirmed positive in 134 individuals (0.6%; 95% CI: 0.5-0.7) with the highest prevalence in the age group 50-59 years. Current or treatment-recovered chronic HCV-infection was found in 85 individuals (0.4%; 95% CI: 0.3-0.5) and was associated with an unfavorable psychosocial profile. CONCLUSION: In this population-based study, the prevalence of viraemic HCV infection was 0.2%. A substantial proportion (39%) of persons with viraemic disease was not aware of their infectious status, which suggests that the current screening strategy of individuals with high risk of infection may be an inadequate approach to identify chronic HCV infection hidden in the general population.

Future complications of chronic hepatitis C in a low-risk area: projections from the hepatitis c study in Northern Norway.

BACKGROUND: Hepatitis C (HCV) infection causes an asymptomatic chronic hepatitis in most affected individuals, which often remains undetected until cirrhosis and cirrhosis-related complications occur. Screening of high-risk subjects in Northern Norway has revealed a relatively low prevalence in the general population (0.24%). Despite this, late complications of HCV infection are increasing. Our object was to estimate the future prevalence and complications of chronic HCV infection in the period 2013-2050 in a low-risk area. METHODS: We have entered available data into a prognostic Markov model to project future complications to HCV infection. RESULTS: The model extrapolates the prevalence in the present cohort of HCV-infected individuals, and assumes a stable low incidence in the projection period. We predict an almost three-fold increase in the incidence of cirrhosis (68 per 100,000), of decompensated cirrhosis (21 per 100,000) and of hepatocellular carcinoma (4 per 100,000) by 2050, as well as a six-fold increase in the cumulated number of deaths from HCV-related liver disease (170 per 100,000 inhabitants). All estimates are made assuming an unchanged treatment coverage of approximately 15%. The estimated numbers can be reduced by approximately 50% for cirrhosis, and by approximately one third for the other endpoints if treatment coverage is raised to 50%. CONCLUSION: These projections from a low-prevalence area indicate a substantial rise in HCV-related morbidity and mortality in the coming years. The global HCV epidemic is of great concern and increased treatment coverage is necessary to reduce the burden of the disease.

Total and cause-specific mortality rates in a prospective study of community-acquired hepatitis C virus infection in northern Norway.

Knowledge of the natural course and especially the total and cause-specific mortality of community-acquired chronic HCV infection is limited. The aims of our study were to determine the total and cause-specific mortality in patients infected with chronic hepatitis C in a community-based setting in northern Norway. This prospective cohort study included 1010 HCV-positive patients diagnosed with recombinant immunoblot assay between 1 January 1990 and 1 January 2000, with a median observation time from diagnosis to follow-up of 7 years. Data were collected from medical records in the period between 1 January 2004 and 30 June 2006. Time and cause of death were ascertained from the Norwegian Causes of Death Register. Age-adjusted death rates and standardised mortality ratios (SMRs) were compared with those of the general Norwegian population. In total, 122 deaths were recorded. The Kaplan-Meier estimate of survival was 88% at 14 years. The SMR in the cohort relative to the general population was 6.66. Most of the excess deaths in both genders were because of liver-related causes, those associated with a drug-using lifestyle and suicide. The statistically significant increase in SMRs ranged from 4.2 for death by cancer in women to 64.6 for liver disease in women. There was no statistically significant increase in SMRs from cardiovascular disease in either gender or from cancer in men. In conclusion, our study shows that the death rate in patients infected with hepatitis C is 6.66 times higher than in the general Norwegian population.

Cidofovir inhibits polyomavirus BK replication in human renal tubular cells downstream of viral early gene expression.

The human polyomavirus BK (BKV) causes nephropathy and hemorrhagic cystitis in kidney and bone marrow transplant patients, respectively. The anti-viral cidofovir (CDV) has been used in small case series but the effects on BKV replication are unclear, since polyomaviruses do not encode viral DNA polymerases. We investigated the effects of CDV on BKV(Dunlop) replication in primary human renal proximal tubule epithelial cells (RPTECs). CDV inhibited the generation of viral progeny in a dose-dependent manner yielding a 90% reduction at 40 microg/mL. Early steps such as receptor binding and entry seemed unaffected. Initial large T-antigen transcription and expression were also unaffected, but subsequent intra-cellular BKV DNA replication was reduced by >90%. Late viral mRNA and corresponding protein levels were also 90% reduced. In uninfected RPTECs, CDV 40 microg/mL reduced cellular DNA replication and metabolic activity by 7% and 11% in BrdU and WST-1 assays, respectively. BKV infection increased DNA replication to 142% and metabolic activity to 116%, respectively, which were reduced by CDV 40 microg/mL to levels of uninfected untreated RPTECs. Our results show that CDV inhibits BKV DNA replication downstream of large T-antigen expression and involves significant host cell toxicity. This should be considered in current treatment and drug development.

Modulation of blood cell activation by four commonly used anticoagulants.

In the past years, our group has made several observations suggesting that blood cells behave differently and when stimulated, release different levels of cytokines, depending on which anticoagulant the blood has been drawn into. The aim of this study was therefore to compare the effect of the four anticoagulants EDTA, citrate, heparin and hirudin on monocyte, neutrophil (PMN), and platelet function in human whole blood. Human whole blood was employed as an ex vivo model of cytokine production and protein secretion, and lipopolysaccharide (LPS) induced tissue factor (TF) activity in monocytes and LPS induced tumor necrosis factor alpha (TNF alpha) release were chosen as parameters of monocyte activation. Platelet factor 4 (PF4) secretion and LPS induced lactoferrin release were chosen as parameters of platelet and PMN activation, respectively. When human whole blood was stimulated with 5 ng/ml LPS for 2 h, TF activity in monocytes isolated from EDTA blood was found to be 2.9 mU/10(6) cells, whereas TF activity in monocytes isolated from citrated, heparinized and hirudinized blood was 14.7, 24.7 and 28.5 mU/10(6) cells, respectively. TNF alpha concentrations in platelet poor plasma (PPP) isolated from whole blood stimulated with 5 ng/ml LPS for 2 h was increased with 200, 400 and 350% in citrated, heparinized and hirudinized blood respectively, as compared to EDTA blood. Next, the effect of the anticoagulant on PMN secretion was measured. PPP isolated from whole blood incubated with 5 ng/ml LPS for 90 min contained 1170 ng/ml (EDTA blood), 2880 ng/ml (citrated blood), 4220 ng/ml (heparinized blood), and 5520 ng/ml lactoferrin (hirudinized blood). When studying the platelet parameter PF4, whole blood was incubated without any stimuli for 60 min, and we found that heparin PPP contained 1180 ng/ml PF4, while hirudin PPP contained 469 ng/ml, citrate PPP 440 ng/ml, and EDTA PPP 217 ng/ml PF4, respectively. Finally, the low molecular weight heparin compound Fragmin had no enhancing effect on PF4 levels in whole blood. It is concluded that the anticoagulant used in in vitro experiments has a large influence on the parameters measured.

Early response in neonatal septicemia. The effect of Escherichia coli, Streptococcus agalactiae and tumor necrosis factor on the generation of lactoferrin.

Using an in vitro model, we report the early effect of Escherichia coli (E. coli), Streptococcus agalactiea (group B streptococci, GBS) and recombinant tumor necrosis factor alpha (TNF) on the release of lactoferrin (LF) and the generation of interleukin-1 (IL-1) due to E. coli, using heparinized whole blood from healthy full-term newborns. We wanted to find a dose response relationship between lactoferrin generation on the one hand and the amount of E. coli, GBS and TNF on the other hand. In a final concentration of 10(7) per ml both bacteria increased the release of LF significantly. The response to E. coli was immediate and mg/l +/- 0.29 mg/l, E. coli 1.83 mg/l +/- 0.76 mg/l, p less than 0.001). GBS was a less potent stimulant than E. coli and the response was only apparent after 20 minutes (mean +/- S.D.: 1.06 mg/l +/- 0.49 mg/l, p less than 0.01). TNF in a concentration of 10000 pg/ml as well as 1000 pg/ml increased the release of LF significantly (after 20 minutes mean +/- S.D.: 1.09 mg/l +/- 0.42 mg/l and 0.97 mg/l +/- 0.36 mg/l, respectively), whereas a concentration of 100 pg/ml had no effect. Whole blood incubated with different preparations of LF for 20 minutes did not increase the generation of LF significantly. No significant changes in IL-1 levels were observed. Lactoferrin had bacteriostatic but no bactericidal effect on GBS and Streptococcus mutans.

Early response in septicemia in newborns and their mothers. Effect of Escherichia coli, Streptococcus agalactiae and tumor necrosis factor on lactoferrin release and the generation of tissue thromboplastin.

Using a whole blood in vitro model, we have investigated the effect of Escherichia coli (E. coli), Streptococcus agalactiae (group B streptococci, GBS) and tumor necrosis factor alpha (TNF) on the generation of lactoferrin (LF), interleukin-1 beta (IL-1) and tissue thromboplastin (TPL) in healthy newborns at term and their mothers. E. coli (at a final concentration of 10(7)/ml) significantly increased the release of LF in whole blood from newborns after 20 as well as 60 min stimulation, and in samples from their mothers after 60 min stimulation. A significant increase in the release of LF was observed in both newborns and their mothers after 20 and 60 min stimulation with TNF (at a final concentration of 1000 pg/ml). A combination of TNF/E. coli or TNF/GBS never gave any significant additional stimulatory effect. After stimulation with E. coli or GBS (both at a final concentration of 10(7)/ml) for 60 min a significant increase in production of TNF and TPL was observed in newborns. In newborns a significant increase in production of TNF and TPL was observed also after 20 min stimulation with E. coli. TNF (at a final concentration of 1000 pg/ml) significantly increased the generation of TPL after 20 and 60 min stimulation in both groups. There was a tendency for a greater release of LF and generation of TNF and TPL in samples from newborns compared with their mothers, but the differences were not statistically significant. E. coli, GBS and TNF had no significant effect on the production of IL-1.

Lactoferrin and cyclic lactoferricin inhibit the entry of human cytomegalovirus into human fibroblasts.

Lactoferrin is mainly produced by polymorphonuclear leukocytes and has been demonstrated in mammalian milk and external secretions. Lactoferrin is an iron-binding, multifunctional protein and may play an important role in immune regulation and in defense mechanisms against bacteria, fungi and viruses. Lactoferricin is a potent antimicrobial peptide generated from the N-terminal part of lactoferrin by pepsin cleavage. We demonstrate that lactoferrins from different species and its N-terminal peptide lactoferricin (particularly the cyclic form) inhibit expression of early and late antigens, as well as production of infectious viral progeny during human cytomegalovirus (HCMV) infection in vitro. Iron-saturated lactoferrin did not affect HCMV antigen expression. Heparin had the same effects as iron-depleted lactoferrin. Yet, mixtures of lactoferrin and heparin did not inhibit HCMV multiplication i.e. lactoferrin and heparin seemed to mutually block each other's antiviral activities. HCMV-infected cells exposed to lactoferrin and cyclic lactoferricin contained less intracellular virus than unexposed cells. The antiviral activity of cyclic lactoferricin was more than seven-fold weaker than that of the maternal molecule. Lactoferrin and cyclic lactoferricin prevented HCMV entrance into the host cell.

Dopamine-beta-hydroxylase activity in serum following acute myocardial infarction: an evaluation of this parameter for routine use as an index of sympathetic activity.

Dopamine-beta-hydroxylase activity was measured in sera from 114 normal males and from 11 patients on the 1st, 2nd, 3rd, 5th and 10th day following acute myocardial infarction. A significant elevation of dopamine-beta-hydroxylase levels (P less than 0.001) was found during the first two days after infarction when compared with the 10th-day values. Only a few activities were above the reference range. Temporary elevations of glucose and glycerol levels were also found. Assay of serum dopamine-beta-hydroxylase may be a useful parameter of sympathetic activity in longitudinal studies in which each individual is used as his own reference.

The latency of serum acute phase proteins in meningococcal septicemia, with special emphasis on lactoferrin.

Serum lactoferrin concentrations were elevated in almost all children with meningococcal septicemia, in whom the disease had been clinically apparent for less than 18 hours, while the concentrations were normal or only moderately elevated in patients who had had the disease longer before being admitted. Concentrations of C-reactive protein (CRP) were markedly elevated, even with a time lapse of less than six hours, making this the most suitable parameter for the early diagnosis of severe meningococcal infection. Following an operative injury on children the lactoferrin concentrations changed very little. More than six hours after an operation, however, a marked increase in CRP-values was observed, possibly indicating differentiation of this response from that of bacterial infection. The concomitant study of serum alpha 1-antitrypsin, alpha 1-antichymotrypsin, orosomucoid and haptoglobin did not uncover results of great significance with regard to early changes.

Laboratory diagnosis of respiratory diseases: PCR versus serology.

We present a comparison between serology and genetic detection of three bacterial pathogens causing lower respiratory tract infection (LRI). We evaluated serology and PCR for the detection of Mycoplasma pneumoniae, Bordetella pertussis and Chlamydia pneumoniae from 1712 nasopharyngeal and serum samples. For 856 nasopharyngeal samples, average PCR time was 7.2 days, the parallel serum samples was 13 days. Automated extraction of nucleic acids reduces average PCR time to 6.7 days.

A rapid chemokine response of macrophage inflammatory protein (MIP)-1α, MIP-1ß and the regulated on activation, normal T expressed and secreted chemokine is associated with a sustained virological response in the treatment of chronic hepatitis C.

The role of chemokines in chronic hepatitis C virus (HCV) infection is not fully understood. The present study aimed to characterize the baseline serum concentrations and the initial ß-chemokine response to treatment with interferon-α and ribavirin with respect to the final clinical outcome of virological response to treatment. Serum concentrations of alanine aminotransferase (ALT) and of the CC subfamily chemokines [macrophage inflammatory protein (MIP)-1α, MIP-1ß, monocyte chemoattractant protein (MCP)-1 and the regulated on activation, normal T expressed and secreted (RANTES) chemokine] were measured in patients with chronic HCV infection and in healthy individuals. Necroinflammation and fibrosis were scored in liver biopsies. Treatment outcomes were classified as with or without a sustained virological response after a full-course treatment according to the genotypes. The main treatment group consisted of 72 patients with chronic hepatitis C, whereas 24-h blood samples were available for 42 patients. Increased baseline levels of all CC chemokines were found in the two responder groups compared to the healthy controls, although significant levels were reached only for MIP-1α and MCP-1. No correlation was observed between chemokine levels and serum ALT levels, any histological necroinflammatory parameters, or the fibrosis grade. After 24 h of treatment, increases in MIP-1α, MIP-1ß and RANTES levels were exclusively observed in the group with sustained virological response. MCP-1 was also significantly increased after 24 h in both responder groups, although no differences were observed between the two responder groups. In conclusion, an early MIP-1α, MIP-1ß, and RANTES response may predict a sustained response to virological treatment.

HPV mRNA test in women with minor cervical lesions: experience of the University Hospital of North Norway.

In the Norwegian Cervical Cancer Screening Programme tests for detection of human papillomavirus (HPV) are used to triage women with minor cytological cervical lesions. The material in this study comprises samples from 1798 women in the period 2006-2008. The HPV test was performed according to the guidelines of the Norwegian Cancer Registry. The HPV mRNA test (PreTect HPV-Proofer) detects and types 5 high-risk genotypes (16, 18, 31, 33 and 45). The HPV mRNA results were compared to cytology and then biopsy up to December 2009. Women with minor cytological cervical lesions and negative HPV test were followed with a new PAP smear after 12 months. A total of 327 women (18%) were HPV mRNA positive. Of the 1798 women with minor cytological lesions, 232 women (13%) had moderate dysplasia, severe dysplasia or cancer and 144 women (8%) had severe dysplasia or cancer in biopsy. 57% of the women with a positive HPV mRNA test had moderate dysplasia, severe dysplasia or cancer. 37% had severe dysplasia or cancer. The sensitivity of the HPV mRNA test to detect moderate dysplasia, severe dysplasia or cancer was 81%. The specificity for moderate dysplasia, severe dysplasia or cancer was 91%. The negative predictive value (NPV) of the HPV mRNA test for moderate dysplasia, severe dysplasia or cancer was 97%. Of 11 women with cervical cancer, 10 were positive for HPV type 16 or 18. The HPV mRNA test seems more suitable than HPV DNA tests to triage women with minor cytological cervical lesions due to its higher specificity.

Chlamydophila pneumoniae diagnostics: importance of methodology in relation to timing of sampling.

The diagnostic impact of PCR-based detection was compared to single-serum IgM antibody measurement and IgG antibody seroconversion during an outbreak of Chlamydophila pneumoniae in a military community. Nasopharyngeal swabs for PCR-based detection, and serum, were obtained from 127 conscripts during the outbreak. Serum, drawn many months before the outbreak, provided the baseline antibody status. C. pneumoniae IgM and IgG antibodies were assayed using microimmunofluorescence (MIF), enzyme immunoassay (EIA) and recombinant ELISA (rELISA). Two reference standard tests were applied: (i) C. pneumoniae PCR; and (ii) assay of C. pneumoniae IgM antibodies, defined as positive if >or=2 IgM antibody assays (i.e. rELISA with MIF and/or EIA) were positive. In 33 subjects, of whom two tested negative according to IgM antibody assays and IgG seroconversion, C. pneumoniae DNA was detected by PCR. The sensitivities were 79%, 85%, 88% and 68%, respectively, and the specificities were 86%, 84%, 78% and 93%, respectively, for MIF IgM, EIA IgM, rELISA IgM and PCR. In two subjects, acute infection was diagnosed on the basis of IgG antibody seroconversion alone. The sensitivity of PCR detection was lower than that of any IgM antibody assay. This may be explained by the late sampling, or clearance of the organism following antibiotic treatment. The results of assay evaluation studies are affected not only by the choice of reference standard tests, but also by the timing of sampling for the different test principles used. On the basis of these findings, a combination of nasopharyngeal swabbing for PCR detection and specific single-serum IgM measurement is recommended in cases of acute respiratory C. pneumoniae infection.

Serum beta-2-microglobulin in healthy children.

Acquired immunodeficiency syndrome (AIDS) is an increasing problem in the pediatric population. Beta-2-microglobulin is part of the HLA structure, being especially abundant in the lymphoid cells and the most useful nonspecific indicium of AIDS. Serum beta-2-microglobulin assayed in 271 healthy children had a geometric mean of 1.398 mg/L and a 5-95 percentile interval of 0.925-2.202 mg/L; thus, values above 2.202 mg/L may be indicative of active disease.

Plasma exchange in the treatment of severe, childhood onset systemic lupus erythematosus.

Plasma exchange was used in the treatment of a 10-year-old girl with acute systemic lupus erythematosus. The patient was in a life-threatening condition, and treatment with high dose corticosteroids did not control the disease. The patient's condition improved dramatically during the second day of plasma exchange therapy. It also appeared to have a long-lasting effect in combination with immunosuppressive drugs. This is, to our knowledge, the first report of plasma exchange in a child with systemic lupus erythematosus.

Antibodies to meningococci in children with meningococcal disease.

Sera from 33 children with and 84 without meningococcal disease were examined for antimeningococcal IgG and IgM antibodies using an ELISA test. The meningococcal patients had a significantly higher prevalence of specific IgG antibodies (p = 0.0014), and also higher prevalence of IgM antibodies (p = 0.08; NS) than other children. These results indicate that the patients had been immunologically stimulated for some time before admission. The meningococcal patients who died had lower prevalence of specific IgM antibodies than the surviving patients, but the difference was not significant (p = 0.16). A significant increase of or high level of antimeningococcal antibodies was found in 11/12 patients examined, the last one had high levels already at admission. This type of ELISA test should therefore be helpful in the diagnosis of meningococcal disease when blood or CSF cultures are negative.

Lactoferrin as an indicator of septicemia and endotoxemia in pigs.

The levels of plasma lactoferrin (LF) in response to endotoxin and Escherichia coli infusions in piglets were studied to obtain exact time relation of plasma LF increase in relation to start of endotoxin and E. coli infusions. A new enzyme-linked immunoassay of swine LF is presented. 13 piglets had a 10-fold rapid increase of plasma LF concentrations after 0.25 mg/kg endotoxin intravenous infusion. The initial rise was 3.4 mg/l/h. 14 piglets, receiving 1 x 10(11) E. coli intravenously, showed a higher increase of plasma LF concentrations, amounting to 6-9 mg/l/h. Thus, plasma LF was an early marker of septicemia and endotoxemia.