Reengagement strategies for hepatitis C patients lost to follow-up: A randomized clinical trial.

BACKGROUND AND AIMS: To achieve the World Health Organization's goal of eliminating HCV by 2030, reengagement of lost to follow-up cases is mandatory. However, there is lack of evidence concerning the best strategy. Our study evaluated the effectiveness, efficiency, predictive factors, and costs of 2 different strategies. METHODS: We identified patients positive for HCV antibodies without RNA requests from 2005 to 2018. Patients fulfilling trial criteria (NCT04153708) were randomized to (1) phone call or (2) letter of invitation to schedule an appointment, followed by switching strategy. RESULTS: Three hundred forty-five patients among 1167 lost to follow-up were identified. An analysis of the first 270 randomized patients (72% male, 51±13 y) showed a higher contact rate in the mail than in the phone call strategy (84.5% vs. 50.3%). In the intention-to-treat analysis, no differences were found related to appointment attendance (26.5% vs. 28.5%). Regarding efficiency, 3.1 letters and 8 phone calls were needed to successfully link 1 patient (p<0.001) but dropped down to 2.3 phone calls if we only considered the first call attempt (p=0.008). Prior specialist's evaluation and HCV testing in the predirect-acting antiviral era were the only factors associated with no showing up for the appointment. The cost per patient was €621.3 (2.5 quality-adjusted life-years) in the phone call strategy and €611.8 (2.4 quality-adjusted life-years) in the mail letter strategy. CONCLUSIONS: Reengagement of patients with HCV is feasible, and equally effective with similar costs in both strategies. The mail letter was more efficient, except when only 1 phone call was considered. Prior specialist's evaluation and testing in the predirect-acting antiviral era were factors associated with nonattendance to the appointment.

Chronic intermittent hypoxia promotes early intrahepatic endothelial impairment in rats with nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is a progressive disease that ranges from simple steatosis to cirrhosis. Obstructive sleep apnea syndrome (OSAS) and chronic intermittent hypoxia (CIH) are implicated in the pathogenesis of NAFLD. However, the overlapping consequences of CIH on liver sinusoidal endothelial function over time in NAFLD are largely unknown. We explored endothelial dysfunction in a rat model of NAFLD with a high-fat diet exposed to CIH [12 h/day, every 30 s to fractional concentration of oxygen ([Formula: see text] 8%-10%]. The livers were isolated and perfused, and the endothelial function was determined by testing the vasodilation of the liver circulation to increased concentrations of acetylcholine and von Willebrand factor (vWF) and intercellular adhesion molecule 1 (ICAM-1) expression. Phosphorylated endothelial nitric oxide synthase (p-eNOS), cGMP, and oxidative stress were assessed to determine nitric oxide bioavailability. Inflammation and fibrosis were evaluated by transaminases, myeloperoxidase activity, hydroxyproline, and histological evaluation. Hypoxia-inducible factors (HIFs) were studied as a marker of hypoxia and after a second insult with acetaminophen. CIH exposure provoked typical systemic features of OSAS and provoked a decreased response in vasodilation to acetylcholine. This was associated with increased oxidative stress and reduced p-eNOS and cGMP. The microcirculation impairment due to CIH preceded significant hepatic inflammation and fibrotic changes, despite the presence of HIF expression. In conclusion, CIH exacerbates endothelial dysfunction in NAFLD rats associated with increased oxidative stress and reduced nitric oxide bioavailability. This occurs before inflammation and fibrosis establish. Our results suggest that with CIH endothelial dysfunction should be considered an early target.NEW & NOTEWORTHY We believe the findings are of relevance because we demonstrate that chronic intermittent hypoxia further augments impaired hepatic endothelial dysfunction in nonalcoholic fatty liver disease rats. Because obstructive sleep apnea syndrome is associated with systemic endothelial dysfunction in cardiovascular disorders, and chronic intermittent hypoxia is an independent and reversible risk factor for hypertension and coronary artery disease, we hypothesized that this entity may be of potential relevance in the pathophysiology of nonalcoholic fatty liver disease.

Appropriateness of high-priority criteria and safety of endoscopy procedures during the COVID-19 lockdown.

BACKGROUND: During the coronavirus-19 disease (COVID-19) pandemic, gastroenterology guidelines recommended the suspension or reduction of non-urgent endoscopy. We aimed to assess the appropriateness and safety of endoscopic activity during the pandemic first wave lockdown using European Society of Gastrointestinal Endoscopy (ESGE) recommendations. METHODS: We identified scheduled patients from the onset of the lockdown in Spain since March 16, 2020) to April 14, 2020. Daily hospital COVID-19-related burden was also registered. A similar cohort from a period immediately before the lockdown was studied (pre-lockdown cohort) to compare appropriateness. RESULTS: 454 endoscopy procedures were performed during the studied period, comprising a 49.7% reduction compared to the pre-lockdown cohort (n = 913). There was a significant increase in ESGE high-priority indications (62.1% vs. 45.6%, p<0.001) associated with an increase in relevant endoscopic findings (p = 0.006), advanced neoplasia/cancer (p = 0.004) and cancer detection rate (p = 0.010). There were no differences in the rate of admissions or infection among scheduled patients in the lockdown cohort. None of the staff members tested positive for COVID-19 in the 7 days after the adoption of protective measures. CONCLUSION: A prioritized endoscopic activity is not associated with higher contagion after adopting protective measures. In addition, a triage of procedures that follow the ESGE criteria increases the rate of relevant endoscopic findings. These considerations may reduce the impact of the delays of diagnosis after the pandemic.

El paciente tratado de hepatitis C como fuente potencial de derivación de nuevos casos / Hepatitis C-treated patients as a potential source for referral of new cases

Introducción: Los antivirales de acción directa (AAD) representan una oportunidad para la eliminación del virus de la hepatitis C (VHC) por su simplicidad. No obstante, se precisan estrategias dirigidas a diagnosticar nuevos pacientes y a atraer diagnosticados sin evaluación. En este sentido, los pacientes con otras enfermedades virales crónicas que reciben un trato satisfactorio promueven la derivación a consulta de otros pacientes. Nuestro objetivo fue evaluar en qué grado los pacientes que han sido tratados con AAD recomendarían seguimiento y tratamiento a otros pacientes, así como las características de los pacientes que influyen en esta decisión. Pacientes y métodos: Se incluyó a 202 pacientes infectados por VHC tratados con AAD. Se les preguntó sobre conocimiento de otros infectados y deseos de compartir su experiencia, y se realizó encuesta de satisfacción general (cuestionario Baker) y específica de VHC (cuestionario HCVTSat). Además, se registraron variables demográficas, socioeconómicas y de la infección por VHC. Resultados: A pesar de que el 54,4% de los pacientes refería conocer a otros afectados, un 34,2% no estaría totalmente de acuerdo en compartir su experiencia global en consulta. El análisis de satisfacción general y específica mostró que los pacientes que compartirían su experiencia referían una percepción de mayor atención por parte del especialista (4,7±0,4 vs. 4,3±0,6, p=0,001), tenían más información sobre el tratamiento (4,6±0,5 vs. 4,0±0,7, p=0,001) y mayor apoyo social (4,5±0,7 vs. 4,0±0,8, p=0,001). Conclusiones: La percepción por parte del paciente tratado sobre satisfacción general del proceso de atención sanitaria e información de beneficios influye en el grado de recomendación a otros infectados. Se debe prestar atención y mejorar el conocimiento del tratamiento y la percepción de mejora en salud de los pacientes tratados, ya que puede contribuir a aumentar las derivaciones a consulta especializada.(AU)

Introduction: Direct-acting antivirals (DAAs) are an opportunity for hepatitis C virus (HCV) elimination. Strategies are needed to diagnose new patients and to attract those diagnosed without evaluation. Patients with other chronic viral diseases who receive satisfactory treatment promote referral of other patients for evaluation. Our aim was to evaluate whether patients who have been treated with DAAs would recommend follow-up and treatment to other patients as well as the characteristics that influence this decision. Patients and methods: Two-hundred and 2HCV-infected patients treated with DAAs were included. Patients were asked about whether they knew other infected people and their willingness to share their experience. A general satisfaction survey and a specific HCV satisfaction survey were carried out. Demographic, socioeconomic and HCV infection variables were recorded. Results: Despite the fact that 54.4% of the patients reported knowing others infected, 34.2% would not fully agree to share their experience. The analysis of general and specific satisfaction showed that patients who shared their experience mentioned a perception of greater care from the specialist (4.7±0.4 vs. 4.3±0.6, P=.001) and had more information on treatment expectations (4.6±0.5 vs. 4.0±0.7, P=.001) and social support (4.5±0.7 vs. 4.0±0.8, P=.001). Conclusions: The perception by treated patients of general satisfaction with the healthcare process and information about benefits influences the degree of recommendation to other infected people. Knowledge about treatment and perception of improvement in health of treated patients should be enhanced as it can contribute to increasing referrals to specialized consultation.(AU)

Hepatitis C-treated patients as a potential source for referral of new cases. / El paciente tratado de hepatitis C como fuente potencial de derivación de nuevos casos.

INTRODUCTION: Direct-acting antivirals (DAAs) are an opportunity for hepatitis C virus (HCV) elimination. Strategies are needed to diagnose new patients and to attract those diagnosed without evaluation. Patients with other chronic viral diseases who receive satisfactory treatment promote referral of other patients for evaluation. Our aim was to evaluate whether patients who have been treated with DAAs would recommend follow-up and treatment to other patients as well as the characteristics that influence this decision. PATIENTS AND METHODS: Two-hundred and 2HCV-infected patients treated with DAAs were included. Patients were asked about whether they knew other infected people and their willingness to share their experience. A general satisfaction survey and a specific HCV satisfaction survey were carried out. Demographic, socioeconomic and HCV infection variables were recorded. RESULTS: Despite the fact that 54.4% of the patients reported knowing others infected, 34.2% would not fully agree to share their experience. The analysis of general and specific satisfaction showed that patients who shared their experience mentioned a perception of greater care from the specialist (4.7±0.4 vs. 4.3±0.6, P=.001) and had more information on treatment expectations (4.6±0.5 vs. 4.0±0.7, P=.001) and social support (4.5±0.7 vs. 4.0±0.8, P=.001). CONCLUSIONS: The perception by treated patients of general satisfaction with the healthcare process and information about benefits influences the degree of recommendation to other infected people. Knowledge about treatment and perception of improvement in health of treated patients should be enhanced as it can contribute to increasing referrals to specialized consultation.

Telemedicine and decentralized hepatitis C treatment as a strategy to enhance retention in care among people attending drug treatment centres.

BACKGROUND: People attending drug treatment centres have a high burden of hepatitis C virus (HCV) and face barriers to diagnosis and treatment. Dried blood spot (DBS) testing has been proposed to simplify diagnosis, but many patients remain untreated. In this retrospective study, we evaluated the reasons for non-retention in care in an intervention using on-site DBS testing and the effect of telemedicine and decentralized care compared to standard of care among people attending drug treatment centres who were lost to follow-up. METHODS: In a first phase, retention in care, adherence to treatment, and predictive factors in the DBS testing program of patients in drug treatment centres were analyzed and compared to a cohort of patients treated at the hospital outpatient clinic. Subsequently, in a second phase we evaluated in patients lost to follow-up from drug treatment centres the efficacy of one-step testing and telemedicine linked to a decentralized dispensation of HCV treatment or standard of care. RESULTS: Among 512 patients attending drug treatment centres, 467 (91.2%) agreed to be tested and 53.4% (237 patients/444 valid tests) tested positive (46 ± 9 years, 87.3% male) for HCV antibodies. After excluding patients negative for RNA or under surveillance, 178 patients were scheduled to meet with a specialist. Overall, 44 patients did not attend and 25 did not complete the pre-treatment evaluation. The only factor associated with retention in care was patient's knowledge of HCV infection. Treated patients attending drug treatment centres (n = 68) compared to the hospital outpatient clinic cohort (n = 135) had lower rates of treatment adherence. Among the patients who attended drug treatment centres that were lost to follow-up (n = 69), the proportion of patients who completed the program was significantly higher among those assisted by telemedicine than by standard of care (62.5% vs. 24.3%, p = 0.002). CONCLUSION: Although there was a high participation rate in a DBS testing program in drug treatment centres, non-retention in care is a challenge. Importantly, telemedicine linked to a decentralized dispensation of HCV treatment re-engages patients and may be effective for HCV microelimination.

An Enhanced High-Volume Preparation for Colonoscopy Is Not Better Than a Conventional Low-Volume One in Patients at Risk of Poor Bowel Cleansing: A Randomized Controlled Trial.

Objective: We tested the hypothesis that an enhanced bowel preparation strategy (EBS) improves colonic cleansing in patients at high risk for inadequate bowel cleansing (HRI). Methods: This prospective randomized clinical trial included consecutive HRI patients referred for outpatient colonoscopy between February and October 2019. HRI was considered if patients scored >1.225 according to a previously validated bowel-cleansing predictive score. HRI patients were randomized (1:1) to a low-volume conventional bowel cleansing strategy (CBS) (1-day low residue diet (LRD) plus 2 L of polyethylene glycol (PEG) plus ascorbic acid) or to an EBS (3-day LRD plus 10 mg oral bisacodyl plus 4 L PEG). The Boston Bowel Preparation Scale (BBPS) was used to assess the quality of cleanliness. Intention-to-treat (ITT) and per protocol (PP) analyses were performed. A sample size of 130 patients per group was estimated to reach a 15% difference in favor of EBP. Results: A total of 253 HRI patients were included (mean age 69.8 ± 9.5 years, 51.8% women). No statistically significant differences were found in the BBPS scale between the two groups in the ITT analysis (CBS 76.8% vs. EBS 79.7%, P = 0.58) or PP analysis (CBS 78% vs. EBS 84.3%, P = 0.21), risk difference 2.9% (95% CI-7.26 to 39.16) in the ITT analysis, or risk difference 6.3% (95% CI-3.48 to 16.08) in PP analysis. No differences in preparation tolerance, compliance, adverse effects, or colonoscopy findings were found. Conclusion: EBS is not superior to CBS in hard-to-prepare patients. (EUDRACT: 2017-000787-15, NCT03830489). Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03830489.

Sexual behaviour and poor hygiene are related to recent hepatitis a virus community outbreaks

OBJECTIVES: there has been a global increase in the incidence of hepatitis A infection. The aim of this study was to examine the characteristics of the increase in our region and the degree of adherence to the recommended hygienic measures after discharge from hospital. METHODS: demographic, clinical and biochemical variables were collected from patients with acute hepatitis A in our health area. The patients were grouped as follows: January 2010 to December 2016 (historical cohort) and January 2017 to October 2017 (recent cohort). A phylogenetic analysis was also performed in the recent cohort. One month after discharge, bacterial growth was evaluated by a culture of the dominant hand imprint and were compared with a control group. RESULTS: a total of 110 cases were registered with a median age of 36.3 years (range 3-89) and 77.3 % were male. The incidence was 0.82/100,000 inhabitants/year and 22.75/100,000 inhabitants/year in the historical and recent cohorts, respectively. Patients in the recent cohort were more frequently male (52.6 % vs. 82.4 %, p = 0.008) and younger (51.7 [3-89] vs. 33.4 [4-74] years, p < 0.001). In addition, 63.8 % of the recent cohort were men who had sex with other men and had unsafe sexual practices (37.5 %). Phylogenetic analysis showed a predominance of genotype A and a high frequency of the VRD 521-2016 sequence. A higher growth of enterobacteria was observed in patients with hepatitis A compared to the control group (7.3 % vs. 1.2 %, p = 0.005), despite specific hygienic measures given at discharge. CONCLUSIONS: a recent outbreak of hepatitis A in our area was related with gender, younger age and sexual practices. Hepatitis A infected subjects showed a poor adherence to hygienic measures. Our data suggests the need for policies that encourage preventive actions, particularly vaccination in this high-risk group

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Sexual behaviour and poor hygiene are related to recent hepatitis a virus community outbreaks.

OBJECTIVES: there has been a global increase in the incidence of hepatitis A infection. The aim of this study was to examine the characteristics of the increase in our region and the degree of adherence to the recommended hygienic measures after discharge from hospital. METHODS: demographic, clinical and biochemical variables were collected from patients with acute hepatitis A in our health area. The patients were grouped as follows: January 2010 to December 2016 (historical cohort) and January 2017 to October 2017 (recent cohort). A phylogenetic analysis was also performed in the recent cohort. One month after discharge, bacterial growth was evaluated by a culture of the dominant hand imprint and were compared with a control group. RESULTS: a total of 110 cases were registered with a median age of 36.3 years (range 3-89) and 77.3 % were male. The incidence was 0.82/100,000 inhabitants/year and 22.75/100,000 inhabitants/year in the historical and recent cohorts, respectively. Patients in the recent cohort were more frequently male (52.6 % vs. 82.4 %, p = 0.008) and younger (51.7 [3-89] vs. 33.4 [4-74] years, p < 0.001). In addition, 63.8 % of the recent cohort were men who had sex with other men and had unsafe sexual practices (37.5 %). Phylogenetic analysis showed a predominance of genotype A and a high frequency of the VRD 521-2016 sequence. A higher growth of enterobacteria was observed in patients with hepatitis A compared to the control group (7.3 % vs. 1.2 %, p = 0.005), despite specific hygienic measures given at discharge. CONCLUSIONS: a recent outbreak of hepatitis A in our area was related with gender, younger age and sexual practices. Hepatitis A infected subjects showed a poor adherence to hygienic measures. Our data suggests the need for policies that encourage preventive actions, particularly vaccination in this high-risk group.