Hepatitis C reinfection after sustained virological response.

BACKGROUND & AIMS: On-going risk behaviour can lead to hepatitis C virus (HCV) reinfection following successful treatment. We aimed to assess the incidence of persistent HCV reinfection in a population of people who inject drugs (PWID) who had achieved sustained virological response (SVR) seven years earlier. METHODS: In 2004-2006 we conducted a multicentre treatment trial comprising HCV genotype 2 or 3 patients in Sweden, Norway and Denmark (NORTH-C). Six months of abstinence from injecting drug use (IDU) was required before treatment. All Norwegian patients who had obtained SVR (n=161) were eligible for participation in this long-term follow-up study assessing virological and behavioural characteristics. RESULTS: Follow-up data were available in 138 of 161 (86%) individuals. Persistent reinfection was identified in 10 of 94 (11%) individuals with a history of IDU prior to treatment (incidence rate 1.7/100 person-years (PY); 95% CI 0.8-3.1) and in 10 of 37 (27%) individuals who had relapsed to IDU after treatment (incidence rate 4.9/100 PY; 95% CI 2.3-8.9). Although relapse to IDU perfectly predicted reinfection, no baseline factor was associated with reinfection. Relapse to IDU was associated with age <30 years (vs. ⩾40 years) at treatment (adjusted odds ratio [aOR] 7.03; 95% CI 1.78-27.8) and low education level (aOR 3.64; 95% CI 1.44-9.18). CONCLUSIONS: Over time, persistent HCV reinfection was common among individuals who had relapsed to IDU after treatment. Reinfection should be systematically addressed and prevented when providing HCV care for PWID.

"Drop in" gastroscopy outpatient clinic--experience after 9 months.

BACKGROUND: Logistics handling referrals for gastroscopy may be more time consuming than the examination itself. For the patient, "drop in" gastroscopy may reduce uncertainty, inadequate therapy and time off work. METHODS: After an 8-9 month run-in period we asked patients, hospital staff and GPs to fill in a questionnaire to evaluate their experience with "drop in" gastroscopy and gastroscopy by appointment, respectively. The diagnostic gain was evaluated. RESULTS: 112 patients had "drop in" gastroscopy and 101 gastroscopy by appointment. The number of "drop in" patients varied between 3 and 12 per day (mean 6.5). Mean time from first GP consultation to gastroscopy was 3.6 weeks in the "drop in" group and 14 weeks in the appointment group. The half-yearly number of outpatient gastroscopies increased from 696 before introducing "drop in" to 1022 after (47% increase) and the proportion of examinations with pathological findings increased from 42% to 58%. Patients and GPs expressed great satisfaction with "drop in". Hospital staff also acclaimed although it caused more unpredictable working days with no additional staff. CONCLUSIONS: "Drop in" gastroscopy was introduced without increase in staff. The observed increase in gastroscopies was paralleled by a similar increase in pathological findings without any apparent disadvantages for other groups of patients. This should legitimise "drop in" outpatient gastroscopies, but it requires meticulous observation of possible unwanted effects when implemented.

Colonoscope with a sub-distal hyper-flaccid segment for improved insertion at colonoscopy: a randomized study.

BACKGROUND: In sharp bends, particularly in the colonic flexures, the axial pushing force conveyed to the distal actively bending tip of the endoscope may cause impaction rather than progression. It is hypothesized that colonoscopes with a very flaccid segment immediately proximal to the distal bending tip might reduce this problem. MATERIAL AND METHODS: Two prototype colonoscopes with a flaccid passively bending segment (either progressively graded or ungraded flaccidity) positioned immediately proximal to the distal actively bending tip was evaluated in a single-blinded randomized study. The primary end-point was patients' evaluation of pain. RESULTS: Altogether, 400 patients were randomized 1:1 to examination with a prototype (60 patients to endoscope with graded flaccidity; 141 to the endoscope with ungraded flaccidity) or a standard colonoscope. The groups were similar regarding age, sex and previous abdominal surgery. Severe pain was reported by 7% of patients in the prototype and 18% in the standard group (p = 0.001). There was a trend toward shorter cecal intubation time in the prototype group (mean 14.1 min, 95% CI 12.8-15.3) compared to the standard group (mean 15.5 min, 95% CI 14.3-16.7) (p = 0.12) and similar intubation rates (89% and 85%, respectively). Results for first (ungraded flaccidity) and second (graded flaccidity) generation prototypes collectively were similar to the second generation separately. CONCLUSIONS: The concept of an endoscope with a hyper-flaccid segment may facilitate negotiation of sharp bends and reduce pain without compromising cecal intubation rate or intubation time.

Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy.

OBJECTIVE: Use of magnetic endoscope imaging (MEI) during colonoscopy has the potential to ease caecal intubation and patient discomfort and to reduce dependence on sedation and/or analgesics (SAs). However, pain reduction by using MEI has not been demonstrated so far, probably because of the liberal use of SAs. The aim of the present study was to evaluate the effect of MEI on caecal intubation and patient pain during unsedated colonoscopy performed by experienced and inexperienced colonoscopists. MATERIAL AND METHODS: A consecutive series of outpatients referred for colonoscopy were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Patients agreeing to SAs being given only on demand were included in the study. End-points were caecal intubation and pain, the latter to be graded by category on a form to be completed on the day after the examination. RESULTS: The proportion of colonoscopies performed without SAs was similar when comparing imager and standard groups and experienced with inexperienced colonoscopists; altogether 367(88%) out of 419 colonoscopies. The caecal intubation rate was higher in the imager group (190/212 (90%)) than in the standard group (153/207(74%)) (p<0.001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of MEI was shown only when performed by experienced colonoscopists, with severe pain in 10/137 patients (7.3%) in the imager group and 21/132 patients (16%) in the standard group (p=0.03). CONCLUSIONS: In colonoscopy without the routine use of SAs, MEI significantly improves the caecum intubation rate and reduces pain during the procedure.