Addressing the challenges of chronic viral infections and addiction in prisons: the PRODEPIST study.

OBJECTIVES: In 2010 only 30.9%, of the Puy-de-Dome prison detainees were screened for human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV). Our goal was then to promote these assesments, as well as to identify addictive behaviour using FAGERSTROM, Cannabis Abuse Screening Test and CAGE tests, diagnose fibrosis by means of Fibrometer or Fibroscan in hepatic virus carriers and heavy drinkers, and perform HBV vaccinations. SETTING: This prospective study of adult detainees in the prisons of Puy-de-Dome, France, took place from June 2012 to December 2013. RESULTS: Of the 702 incarcerated individuals, 396(56.4%) were screened and 357(50.9%) enrolled. HIV prevalence was 0.3%, HCV 4.7% and HBV 0.6%. While 234/294(79.6%) smokers and 115/145(79.3%) cannabis users were screened for dependence, excessive alcohol consumption was tested for in 91/179(50.8%) cases. Fibrosis was screened for in 75/80(93.7%) individuals selected with 16.0% presenting with moderate to severe fibrosis, 4/9(44.4%) HCV carriers and 8/65(12.3%) excessive alcohol consumers. HBV vaccination was given to 81/149(54.4%) individuals with no serological markers. A total of nine HIV tests were conducted at the 57 discharge consultations, involving 215 detainees being released, all of which were negative. CONCLUSION: The promotion of these evaluations proved beneficial, although viral screening could be achieved for only approaching half of the detainees, as could alcohol consumption assessment and HBV vaccination for those concerned. Fibrosis screening revealed lesions in HCV carriers yet also in heavy drinkers, who are typically less likely to be assessed. Consultations and HIV screening on release were found to be rarely possible.

A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy.

BACKGROUND: Endoscopist-administered propofol sedation for colonoscopy has not been compared to anaesthetist-administered deep sedation in clinical trials. Our aim was to compare patients' satisfaction and safety during these two sedation modalities. METHODS: 90 adult patients undergoing colonoscopy were randomized into Group A, Endoscopist-administered propofol sedation and Group B, anaesthetist-administered deep sedation. Group A patients received an initial dose of 30-50 mg of intravenous propofol; additional doses were injected by the endoscopist using a pre-programmed pump. Global satisfaction was measured on a 0-100 mm visual analogue scale. RESULTS: The average satisfaction scores after examination completion amongst group were not statistically different (90.8 mm for Group A vs. 89 mm for Group B). Group A patients expressed more frequently a good level of satisfaction (95% vs. 75%; p=0.03) and willingness to undergo further colonoscopies under the same conditions (95% vs. 79%; p=0.02). Total duration time and procedural difficulty did not differ between the groups. Group A received a lower total propofol dose than Group B (94 mg vs. 260 mg) and experienced fewer side-effects (16 vs. 3, respectively; p < 0.008). CONCLUSION: Endoscopist-administered propofol sedation for colonoscopy offered a better level of satisfaction and fewer side-effects than anaesthetist-administered deep sedation.

Non-invasive assessment of liver fibrosis progression in hepatitis C patients retreated for 96 weeks with antiviral therapy: a randomized study.

BACKGROUND: The efficacy of a maintenance therapy in non-responder patients with chronic hepatitis C has been essentially evaluated by histological semiquantitative scores. AIM: The aim was to evaluate the efficiency of 2 years of treatment with peginterferon alpha-2a vs alpha-tocopherol in these patients by histology, morphometry and blood markers of fibrosis. METHOD: Hundred and five HCV patients with a Metavir fibrosis score > or = 2 were randomized to receive peginterferon alpha-2a 180 microg/week (PEG) (n=55) or alpha-tocopherol (TOCO) 1000 mg/day (n=50) for 96 weeks. The primary endpoint was improvement or stabilization of the Metavir fibrosis score by biopsy performed at week 96. Secondary endpoints included a quantitative assessment of fibrosis by morphometry and changes in blood markers of fibrosis. RESULTS: There was no difference at baseline between PEG and TOCO according to the metavir (83.3 vs 86.8%, P=0.751) stage. The median fibrosis rate, measured with morphometry was 2.72 and 2.86% at day 0, and 3.66 and 2.82% at week 96, in the PEG and TOCO groups (P=0.90) respectively. However, the percentage of patients with metavir activity grade improvement was significantly higher in the PEG group vs the TOCO group (52.8 vs 23.7%, P=0.016). Non-invasive markers analysis did not show any significant change in both groups. CONCLUSION: Long-term therapy with peginterferon alpha-2a did not reduce liver fibrosis degree assessed by morphometry and blood tests as compared with alpha-tocopherol. Blood tests could be useful to assess liver fibrosis changes in clinical trials.

Comparison of outcome in patients with cirrhosis and ascites following treatment with albumin or a synthetic colloid: a randomised controlled pilot trail.

BACKGROUND: The question of which colloid (albumin or synthetic colloids) used for plasma expansion following paracentesis or other complications requiring fluid loading in patients with cirrhosis remains controversial. AIMS: To compare outcome and hospital-related cost in patients with cirrhosis treated with 20% human albumin with those treated with a synthetic colloid (3.5% polygeline). METHODS: The primary end point was occurrence of a first liver-related complication. RESULTS: When the trial was prematurely discontinued because of safety concerns about bovine-derived products, 30 patients were assigned to receive albumin and 38 were assigned to receive a synthetic colloid. Sixty-three patients were included for ascites removal by paracentesis and five patients for ascites removal by paracentesis and renal impairment. The median time to first liver-related complication was not significantly longer in the albumin group (20 vs. 7 days). However, the total number of liver-related complications adjusted to a 100-day period was significantly lower in the albumin group. The median hospital cost for a 30-day period was significantly lower in the albumin group (1915 euros vs. 4612 euros). CONCLUSIONS: In patients with cirrhosis and ascites, human albumin appears to be more effective in preventing liver-related complications than synthetic colloid. This may be associated with decreased hospital costs.

[Iron overload and chronic liver diseases]. / Surcharges en fer et maladies chroniques du foie.

Several liver diseases can be associated with liver iron overload: alcohol liver disease, non alcoholic fatty liver disease, chronic viral hepatitis and porphyria cutanea tarda. These diseases are frequently associated with abnormal iron tests but iron overload is infrequent. Hyperferritinemia in these patients can be explained by cellular necrosis, synthesis increase, inflammation and iron overload. Research of C282Y mutation should be performed in patients who stopped alcohol for at least 1 or 2 weeks and transferrin saturation > 45%. Several studies are conducted to explore the mechanisms of iron overload and the role of iron in hepatic fibrogenesis and carcinogenesis. These studies will help to better define the role of venesection and iron chelators in patients with chronic liver diseases.

Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study.

BACKGROUND: In France, general anesthesia is given to more than 90% of patients undergoing colonoscopy although in several countries sedation is limited to intolerant patients. This study was carried out to determine whether Patient-Controlled Sedation (PCS) could provide a lighter sedation than general anesthesia adapted to the patient's individual requirement. METHODS: Patients aged from 18 to 80 scheduled for elective colonoscopy were prospectively randomized to receive either standard sedation (control group) or patient-controlled-sedation (PCS). In the control group, patients received a continuous infusion of propofol. Patients in the PCS group were connected to an infusion pump containing propofol and self-administered 20-mg boluses as often as they required. An anesthetist was present throughout the procedure. Patient satisfaction measured on a visual analog scale four hours after colonoscopy was the main outcome criterion. RESULTS: From December 2002 to September 2003, 402 patients underwent elective colonoscopy, 173 of them were eligible and were asked to participate in the study. Seventy-two gave their informed consent and were prospectively randomized. The patients' mean satisfaction scores were not statistically different between the two groups: 84.7 mm (PCS group) vs. 91.5 mm (control group); P = 0.24. Mean doses of propofol (60 mg vs. 248 mg; P <0.001), depth of sedation and time before discharge (1.75 hours vs. 4.45 hours) were significantly lower for patients in the PCS group; nine of them (25.7%) did not use the pump and had total colonoscopy without sedation. There were no statistically significant differences between the two groups regarding total duration of colonoscopy (19.4 min (PCS) vs. 18 min (control)) difficulty and therapeutic procedures (biopsy or polypectomy). Two weeks after the procedure, 96.5% of patients in the PCS group were willing to repeat the examination under the same conditions vs. 72.5% of patients in the control group (P = 0.03). CONCLUSIONS: Our results demonstrate that need of sedation is widely overestimated in France. A subset of our patients is willing to consider colonoscopy without general anesthesia. For them, PCS with propofol is an effective and very well accepted form of sedation.

Histological response in patients treated by interferon plus ribavirin for hepatitis C virus-related severe fibrosis.

BACKGROUND: Studies of viral hepatitis C have suggested that fibrosis can regress, at least in patients with sustained virological response. A recent study suggested that cirrhosis was reversible in sustained and non-virological responders. AIM: To study fibrosis progression rate and cirrhosis reversion in patients treated for severe fibrosis with interferon or interferon + ribavirin. PATIENTS AND METHODS: Ninety-nine patients were treated with interferon + ribavirin and 64 with interferon. The Metavir fibrosis score and the semiquantitative fibrosis score (SFS) were used to assess fibrosis. RESULTS: In sustained responders, fibrosis progression rate decreased from 0.26 Metavir unit (interquartile range: 0.19-0.34) to -0.67 (-0.67 to 0) (P < 0.0001) and from 0.81 SFS unit (0.48-1.13) to -1.33 (-3.67 to 0) (P < 0.0001). In non-responders, fibrosis progression rate decreased from 0.25 Metavir unit (0.17-0.33) before treatment to 0 (0-0) during treatment (P = 0.002) and from 0.63 SFS unit (0.49-1.12) to 0 (-2.67-1.33) (P = 0.18). Six out of 18 (33%) sustained virological responders and four of 43 (9%) non-responders regressed from cirrhosis (F4) to severe fibrosis (F3) (P = 0.058). No patient with cirrhosis had a decrease of Metavir fibrosis score of 2 points. CONCLUSION: Interferon can slow fibrosis progression in sustained virological responders with severe fibrosis. In patients with a non-virological response and treated for 12 months the fibrosis progression rate was nil, meaning that only fibrosis stabilization could be obtained in these patients. Then, longer treatment duration (3-4 years) could be evaluated in non-virological responders.

[Medical practices and expectations of general practitioners in relation to hepatitis C virus infection in the Auvergne region]. / Pratiques et attentes des médecins généralistes en matière d'hépatite C dans la région Auvergne.

AIMS: To determine the medical practices and expectations of general practitioners concerning screening and management of hepatitis C in the Auvergne region. METHODS: A survey was sent by mail to 250 general practitioners. They were then contacted by telephone interviews. RESULTS: 94% of general practitioners answered the survey. Each physician diagnosed an average of 0.6 new cases of hepatitis C in 1999, and had a mean of 3.2 patients with HCV in their practice. Screening was performed by 91% of general practitioners if there was a history of blood transfusion, by 87% if there was a history of intravenous drug use, by 92% in case of increased serum amino transferase levels. Screening was less frequent in case of household contact and was only performed by 68% general practitioners or of asthenia by 52% of general practitioners. Liver biopsy seems to be the main obstacle for the management of hepatitis C patients which is due to a refusal of liver biopsy by the patient according to 55% of general practitioners, a fear of complications according to 25% of general practitioners. Sixty percent of general practitioners considered that liver biopsy was performed in less than 50% of patients with hepatitis C. Fifty three percent of general practitioner thought that hepatitis C network could be useful for increasing their knowledge. CONCLUSIONS: Liver biopsy refusal by the patient restricts the management and therapy of patients with hepatitis C infection. Increase formation still requisite by 60 percent of general practitioner.

[Radiofrequency ablation of hepatocellular carcinoma in patients with cirrhosis]. / Traitement par radiofréquence des carcinomes hépatocellulaires sur cirrhose.

UNLABELLED: Radiofrequency is an effective therapeutic modality for patients with hepatocellular carcinoma. However few data are available with regard to the complication rate, the feasibility and long term survival. AIMS: To assess the response rate and complications of radiofrequency in cirrhotic patients with hepatocellular carcinoma. PATIENTS AND METHODS: Eighteen patients were enrolled. Each nodule was treated subcutaneously. Treatment response was assessed by computed tomography performed at 24 hours in 10 patients and every 3 months in all patients. Necrosis of the tumor was considered complete when hypodensity without enhanced contrast. RESULTS: Thirty hepatocellular carcinoma nodules with a mean tumor size of 30 mm; 15<30 mm and 15 >=30 mm, were treated by 1.3 radiofrequency sessions. Complete necrosis was achieved in 89%, greater for nodules<30 mm (100%) than for nodules >=30mm (80%). After a median follow up of 10.6 months, survival rate was 50%. Death was related to tumor involvement in 28%, to cirrhosis complications in 17% and to non liver-related disease in 5%. Three major treatment-related complications occurred (10%): subcapsular hematoma, sustained severe pain and peritoneal dissemination. All three complications were related to subcapsular location. CONCLUSION: Radiofrequency may be considered as an alternative treatment to percutaneous ethanol injection for hepatocellular carcinoma; however, subcapsular location has to be excluded when considering the observed morbidity. Prospective studies are warranted to evaluate the efficacy and morbidity of this treatment in hepatocellular carcinoma.