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.

A slowdown of hepatitis C diagnosis in high-prevalence groups and with decentralized diagnostic strategies during the COVID-19 pandemic.

INTRODUCTION: the COVID-19 pandemic has had a major impact on hepatitis C virus (HCV) diagnosis by hindering the path to elimination. Albeit, in an uneven manner, depending on the risk group and diagnostic strategy. METHODS: the requests of antibodies/RNA by venipuncture at hospitals and Primary Care centers (centralized) and via venipuncture or dried blood spot tests at prison and drug treatment centers referred for central processing (integrated decentralized) were recorded for one year, before and after the onset of the COVID-19 health crisis. RESULTS: a total of 20,600 tests (51 % male, 47.9 ± 1 5.8 years) were recorded. Among them, 96.5 % of the cases came from centralized and 3.5 % from decentralized settings, with an active infection rate of 0.2 % and 2.3 % (p < 0.001), respectively. There was a 31.3 % decrease in the number of requests during the pandemic compared to the pre-pandemic period, which was more pronounced in the decentralized than centralized diagnosis setting (60 vs 30 %, p < 0.001). In addition, there was a 31.5 % decline in screening and 18.2 % decrease in the diagnosis of new cases of active infection, with a statistically significant decrease in decentralized compared to centralized diagnosis. CONCLUSIONS: during the COVID-19 pandemic, a decline in HCV diagnostic effort was observed, especially in decentralized strategies, with a higher prevalence of infection. Our results suggest a diagnostic delay that will prevent Spain from reaching the elimination target in 2023. Therefore, the reactivation of strategies, particularly targeting the priority groups, is urgently required.

Mayor ralentización en el diagnóstico de la hepatitis C en estrategias descentralizas y en grupos de alta prevalencia durante la pandemia por COVID-19 / A slowdown of hepatitis C diagnosis in high-prevalence groups and with decentralized diagnostic strategies during the COVID-19 pandemic

Introducción: la pandemia por COVID-19 ha tenido una importante repercusión en el diagnóstico del virus de la hepatitis C (VHC) obstaculizando el camino hacia su eliminación,aunque es probable que de forma desigual según la estrategia diagnóstica y el grupo de riesgo.Métodos: se registraron las solicitudes de anticuerpos/ARNpor venopunción en hospital y Atención Primaria (centralizado) y mediante venopunción o test de gota de sangre seca enprisión y centros de drogodependencias remitidos para procesamiento central (descentralizado integrado) durante un añoantes y después del inicio de la alerta sanitaria por COVID-19.Resultados: se registró un total de 20.600 determinaciones(51 % varones, 47,9 ± 15,8 años) realizadas el 96,5 % deforma centralizada y el 3,5 % de forma descentralizada,con una tasa de infección activa del 0,2 % y el 2,3 %(p < 0,001), respectivamente. Durante el periodo de pandemia, comparado con el de prepandemia, hubo un descensoen el número de determinaciones del 31,3 %, que fue mayor en diagnóstico descentralizado comparado con centralizado (60 vs. 30 %, p < 0,001). Además, se contabilizó undescenso en el cribado del 31,5 % y en el diagnóstico denuevos casos de infección activa, del 18,2 %, con mayordescenso en el diagnóstico descentralizado comparado concentralizado.Conclusiones: durante la pandemia por COVID-19 se ha objetivado un descenso en el esfuerzo diagnóstico del VHC,especialmente en estrategias descentralizadas y con mayorprevalencia de infección. Estos resultados sugieren un retraso diagnóstico que dificultará alcanzar la meta de eliminación en nuestro país en 2023, por lo que urge reactivarestrategias principalmente en grupos prioritarios. (AU)

Hepatitis C virus infection screening reduces mortality and is cost-effective independently of the intervention test

Introduction: chronic infection due to hepatitis C virus (HCV)is frequently asymptomatic even in advanced stages of liverdisease. Implementation of a screening program based ondifferent HCV tests may enable an earlier diagnosis of HCVliver disease and subsequent application of highly effectivetreatment.Patients and methods: a Markov model which comparesthree different screening strategies for hepatitis C versus noscreening in low-risk prevalence (general population) andhigh-risk prevalence population (people who inject drugs orprison population) was designed, taking into account age atthe start of screening and participation. The three strategieswere: a) serological detection of antibodies against the HCV;b) dried blood spot test (DBS) to detect antibodies againstHCV; and c) detection of ribonucleic acid (RNA) from HCV.Quality-adjusted life-years (QALY) were taken as a measurement of effectiveness. The incremental cost-effectivenessratio (ICER) was calculated and a deterministic and probabilistic sensitivity analysis was performed.Results: all three screening strategies were found to becost-effective, with an ICER of €13,633, €12,015 and €12,328/QALY for antiHCV, DBS-antiHCV and DBS-RNA HCV, respectively. There was a decrease in mortality due to liver disease in comparison to no screening for antiHCV (40.7 % and52 %), DBS-antiHCV (45 % and 80 %) and DBS-RNA HCV (45.2 % and 80 %) for low-prevalence and high-prevalencepopulations, respectively.Conclusion: all test interventions for HCV screening arecost-effective for the early detection of HCV infection, alsoachieving a reduction in mortality. Thus, implementationof screening programs for HCV should not be halted by decisions on monetary policy. (AU)

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.

Retrieval and treatment of patients with primary biliary cholangitis who are lost in the health system.

INTRODUCTION: hepatitis C patients loss to follow-up in the health care system has been shown to have negative consequences. This study aimed to investigate this issue as regards primary biliary cholangitis. METHODS: the databases (immunology, biochemistry, clinical reports, drug dispensation, appointments) of 4 reference hospitals in Spain (serving a population of 1,450,000 inhabitants) were analyzed. The diagnosis of primary biliary cholangitis was based on an antimitochondrial antibody titer ≥ 1:80, chronically elevated alkaline phosphatase, and the absence of other liver disease. Patients were classified as lost in the absence of reports indicating a diagnosis, specific medical follow-up, and/or treatment with bile salts. RESULTS: a total of 1372 patients with antimitochondrial antibody titers ≥ 1:80 were included between January 2010 and June 2019. A total of 697 (50.8 %) were classified as having primary biliary cholangitis, and 100 patients (14.3 %; 95 % CI: 11.8-17.2) were identified as lost. Of these, 30 were contacted and retrieved. The median age was 70 years, 93 % were female, median alkaline phosphatase was 185 IU/L, 10 % had pruritus, and 27 % had a transient elastography value > 9.5 kPa. The disease was confirmed and ursodeoxycholic acid was started in all 30 patients. Death was liver-related in 6 of the 100 patients classified as lost. CONCLUSION: up to 14.3 % of patients (1 out of 7) with a definitive diagnosis of primary biliary cholangitis remain undiagnosed, thus preventing monitoring and treatment. More than a quarter are at risk of advanced liver disease and its complications. Patients lost in the system must be identified and retrieved, and searching hospital databases is a suitable approach to meet this goal.

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.

Hepatitis C virus media coverage favorably impacts on antibody testing in the non-interferon era.

BACKGROUND: In the non-interferon era, many patients still remain untested for hepatitis C virus (HCV) infection. Our aim was to determine if media coverage, number and type of news, can influence the rate of HCV testing. METHODS: For each calendar year we searched from national, regional and local newspapers for articles published related to HCV between 2001 and 2013 (interferon era) and 2014-2018 (non-interferon era) and the HCV tests performed. Demographics, provider data and test result were collected from patients tested. RESULTS: During the studied period, 21 913 press articles were found, and we identified a total of 293 226 HCV tests. A total of 9778 HCV tests from 5237 patients tested positive (1.88%). An inverse correlation was found between media coverage and the number of HCV tests during the interferon era (r2 = -0.558, P = 0.024), where news concerning epidemiology and burden of the disease were more frequent. By contrast, in the non-interferon era a strong correlation was observed (r2 = 0.900, P = 0.019), where news related to treatment prevailed. CONCLUSION: Our results show that media coverage on HCV fluctuate so the type of news. It remains to be prospectively evaluated if well designed publicity campaigns about the benefits of HCV screening and treatment influences on HCV testing.

Evaluación de la precisión diagnóstica del sistema Cobas 6800 para la detección de los niveles de viremia del virus de la hepatitis C a partir de muestras de gotas de sangre seca en papel de filtro / Diagnostic test accuracy of the cobas 6800 system for detection of hepatitis c virus viraemia levels from dried blood spots

INTRODUCCIÓN: La infección por el virus de la hepatitis C (VHC) es curable en la mayoría de los casos tratados, siendo actualmente una prioridad diagnosticar a todos los infectados. Para ello se necesitan, especialmente en poblaciones de difícil diagnóstico, métodos diagnósticos simples, como es el uso de muestras de gotas de sangre seca (GSS), como alternativa a la extracción de sangre mediante venopunción. Como paso previo para poder implantarlo como método diagnóstico de detección de pacientes con VHC dentro del Sistema Nacional de Salud se precisa evaluar la precisión diagnóstica en equipos de uso hospitalario habitual. METODOLOGÍA: Se evaluaron in vitro y en ensayo de campo muestras de GSS tras ser procesadas en el equipo Cobas 6800, estableciendo una correlación con el resultado obtenido con sangre completa. Se realizaron pruebas de correlación y de variabilidad intraensayo de la determinación con sangre completa y GSS para cuantificar la carga viral del VHC. RESULTADOS: En muestras de sangre completa, con una carga viral ≥ 3 log10UI/ml, se detectó viremia en todos los casos cuando se utilizaron eluciones de 2 gotas (94 detecciones de 95 eluciones de círculos). El rendimiento con 2 gotas fue menor en muestras con < 3 log 10UI/ml (7/20). La correlación entre la viremia determinada con sangre completa y con GSS fue excelente (máximo con 2 gotas, r2 = 0,906; p < 0,001), con un coeficiente de variación del 0,05%. En práctica clínica habitual con muestras de pacientes analizados (n = 61) se obtuvo igualmente una excelente precisión diagnóstica. CONCLUSIÓN: La determinación de la carga viral mediante GSS, procesando al menos 2 gotas, es un método fiable para el diagnóstico de infección por el VHC. La estandarización del método es factible en nuestro equipo Cobas 6800 local, y nuestros resultados respaldan la incorporación de esta herramienta diagnóstica al Sistema Nacional de Salud para facilitar planes de microeliminación

INTRODUCTION: Because hepatitis C virus (HCV) infection is curable in the majority of cases, the diagnosis of all infected patients has become a priority. In difficult-to-diagnose populations, simpler diagnostic methods are required such as the use of dried blood spots (DBS) as an alternative to blood drawn by venipuncture (VP). Before being able to include it as a HCV diagnostic detection method within the Spanish National Health System, the diagnostic accuracy of standard hospital equipment must be evaluated. METHODOLOGY: DBS samples were evaluated in vitro and in a field test after being processed in the Cobas 6800 system, establishing a correlation with the result by VP. Performance with different viral loads and intra-assay variability was compared. RESULTS: In samples with a viral load of>3 log10IU/ml, viraemia was detected in all cases when at least two blood spot elutions were used (94 detections out of 95 spot elutions). The performance with 2 spots was lower in samples with<3 log10IU/ml (7/20). Correlation between VP and DBS viraemia was excellent (maximum with 2 spots, r2=0.906, P<.001) with a coefficient of variation of 0.05%. In routine clinical practice with specimens from screened subjects (n=61), excellent diagnostic accuracy was also observed. CONCLUSION: Viral load detection using DBS of at least two spots is a reliable method for HCV diagnosis. The standardisation of the method is feasible and our results support the incorporation of this diagnostic tool in Spain's Public Health System

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.

Mutations in TRIM63 cause an autosomal-recessive form of hypertrophic cardiomyopathy.

OBJECTIVE: Up to 50% of patients with hypertrophic cardiomyopathy (HCM) show no disease-causing variants in genetic studies. TRIM63 has been suggested as a candidate gene for the development of cardiomyopathies, although evidence for a causative role in HCM is limited. We sought to investigate the relationship between rare variants in TRIM63 and the development of HCM. METHODS: TRIM63 was sequenced by next generation sequencing in 4867 index cases with a clinical diagnosis of HCM and in 3628 probands with other cardiomyopathies. Additionally, 3136 index cases with familial cardiovascular diseases other than cardiomyopathy (mainly channelopathies and aortic diseases) were used as controls. RESULTS: Sixteen index cases with rare homozygous or compound heterozygous variants in TRIM63 (15 HCM and one restrictive cardiomyopathy) were included. No homozygous or compound heterozygous were identified in the control population. Familial evaluation showed that only homozygous and compound heterozygous had signs of disease, whereas all heterozygous family members were healthy. The mean age at diagnosis was 35 years (range 15-69). Fifty per cent of patients had concentric left ventricular hypertrophy (LVH) and 45% were asymptomatic at the moment of the first examination. Significant degrees of late gadolinium enhancement were detected in 80% of affected individuals, and 20% of patients had left ventricular (LV) systolic dysfunction. Fifty per cent had non-sustained ventricular tachycardia. Twenty per cent of patients suffered an adverse cerebrovascular event (20%). CONCLUSION: TRIM63 appears to be an uncommon cause of HCM inherited in an autosomal-recessive manner and associated with concentric LVH and a high rate of LV dysfunction.

Patients with suboptimal hepatitis B virus diagnostic characterization are at risk of liver fibrosis progression.

BACKGROUND: Many patients with chronic hepatitis B virus infection remain infradiagnosed and untreated. In a national health system with unrestricted access to treatment, our aims were to assess the level of compliance with clinical guidelines and the characteristics and risk of fibrosis progression in patients with suboptimal diagnosis. METHODS: In a cohort of patients with positive hepatitis B surface antigen from January 2011 to December 2013, data were registered to assess characteristics and compliance with guidelines. For assessing the risk of liver fibrosis, positive hepatitis B surface antigen patients from January 2008 to December 2013 were grouped depending on DNA request. Liver fibrosis was estimated by serological scores. RESULTS: Of 41 158 subjects with hepatitis B surface antigen request, 351 (0.9%) tested positive, and DNA was not available from 110 patients (66.4% male, mean 42.4 ± 14.5 years) after a median of 25.6 months (range 12.0-43.5). Most of these patients (76%) were assessed by primary care. Half of the patients (47.2%) showed hypertransaminasemia, at least significant fibrosis, or both conditions. After long follow-up (mean 90.1 ± 45.2 months), these patients had a higher risk of achieving at least significant fibrosis during follow-up (log-rank 8.73; P = 0.003). CONCLUSION: In more than one-third of patients with positive hepatitis B surface antigen, DNA was not requested despite showing hypertransaminasemia and significant fibrosis. Patients without DNA request are at high risk of liver fibrosis progression. Thus, educational measures and other strategies are necessary, especially targeting primary care, to improve access to treatment.

Risk of liver fibrosis progression in patients with suboptimal diagnosis of hepatitis C virus infection.

OBJECTIVE: Many hepatitis C virus (HCV)-infected patients have a suboptimal diagnosis. Particularly, the characteristics and risk of fibrosis progression of HCV antibody-positive patients without RNA testing are unknown. METHODS: Patients with a positive HCV antibody performed during 2005-2007 were classified based on RNA request and result until January 2017. Fibrosis was estimated with serologic scores. RESULTS: Of the 38 246 HCV tests performed, 791 (2.01%) patients tested positive. At the end of the follow-up (median 128.6 months, range 109.8-145.9), 49.43% (n = 391) of the subjects did not have RNA testing, 13.02% (n = 103) had undetectable RNA, and 37.55% (n = 297) had detectable RNA. After excluding patients without data for AST to platelet ratio index calculation (n = 334), patients without RNA testing (n = 122) compared with RNA undetectable (n = 92) were more frequently men (68.9 versus 46.7%), alcohol (52.6 versus 38.2%) and drug (53.0 versus 39.1%) users, lacking social support (50.4 versus 29.3%), and showed higher basal fibrosis. Patients without RNA testing had a significantly higher increase in the percentage of patients with ≥F2 (P = 0.035) and cirrhosis (P = 0.022). The relative risk for ≥F2 and cirrhosis in patients without RNA testing was 3.03 [95% confidence interval (CI): 1.54-5.98] and 4.31 (95% CI: 1.42-13.10), respectively. Non-RNA request was an independent predictor factor for progression to cirrhosis. CONCLUSION: In our cohort, patients with positive HCV antibody without RNA testing were more likely to be people at risk of social exclusion with an increased risk of fibrosis progression, because non-RNA request was a predictor for cirrhosis. Therefore, we urge support measures and strategies to link to care these difficult-to-treat populations.

Diagnostic test accuracy of the cobas 6800 system for detection of hepatitis c virus viraemia levels from dried blood spots. / Evaluación de la precisión diagnóstica del sistema Cobas 6800 para la detección de los niveles de viremia del virus de la hepatitis C a partir de muestras de gotas de sangre seca en papel de filtro.

INTRODUCTION: Because hepatitis C virus (HCV) infection is curable in the majority of cases, the diagnosis of all infected patients has become a priority. In difficult-to-diagnose populations, simpler diagnostic methods are required such as the use of dried blood spots (DBS) as an alternative to blood drawn by venipuncture (VP). Before being able to include it as a HCV diagnostic detection method within the Spanish National Health System, the diagnostic accuracy of standard hospital equipment must be evaluated. METHODOLOGY: DBS samples were evaluated in vitro and in a field test after being processed in the Cobas 6800 system, establishing a correlation with the result by VP. Performance with different viral loads and intra-assay variability was compared. RESULTS: In samples with a viral load of>3 log10IU/ml, viraemia was detected in all cases when at least two blood spot elutions were used (94 detections out of 95 spot elutions). The performance with 2 spots was lower in samples with<3 log10IU/ml (7/20). Correlation between VP and DBS viraemia was excellent (maximum with 2 spots, r2=0.906, P<.001) with a coefficient of variation of 0.05%. In routine clinical practice with specimens from screened subjects (n=61), excellent diagnostic accuracy was also observed. CONCLUSION: Viral load detection using DBS of at least two spots is a reliable method for HCV diagnosis. The standardisation of the method is feasible and our results support the incorporation of this diagnostic tool in Spain's Public Health System.

Rare Variants in 48 Genes Account for 42% of Cases of Epilepsy With or Without Neurodevelopmental Delay in 246 Pediatric Patients.

In order to characterize the genetic architecture of epilepsy in a pediatric population from the Iberian Peninsula (including the Canary Islands), we conducted targeted exome sequencing of 246 patients with infantile-onset seizures with or without neurodevelopmental delay. We detected 107 variants in 48 different genes, which were implicated in neuronal excitability, neurodevelopment, synaptic transmission, and metabolic pathways. In 104 cases (42%) we detected variant(s) that we classified as pathogenic or likely pathogenic. Of the 48 mutated genes, 32 were dominant, 8 recessive and 8 X-linked. Of the patients for whom family studies could be performed and in whom pathogenic variants were identified in dominant or X-linked genes, 82% carried de novo mutations. The involvement of small copy number variations (CNVs) is 9%. The use of progressively updated custom panels with high mean vertical coverage enabled establishment of a definitive diagnosis in a large proportion of cases (42%) and detection of CNVs (even duplications) with high fidelity. In 10.5% of patients we detected associations that are pending confirmation via functional and/or familial studies. Our findings had important consequences for the clinical management of the probands, since a large proportion of the cohort had been clinically misdiagnosed, and their families were subsequently able to avail of genetic counseling. In some cases, a more appropriate treatment was selected for the patient in question, or an inappropriate treatment discontinued. Our findings suggest the existence of modifier genes that may explain the incomplete penetrance of some epilepsy-related genes. We discuss possible reasons for non-diagnosis and future research directions. Further studies will be required to uncover the roles of structural variants, epimutations, and oligogenic inheritance in epilepsy, thereby providing a more complete molecular picture of this disease. In summary, given the broad phenotypic spectrum of most epilepsy-related genes, efficient genomic tools like the targeted exome sequencing panel described here are essential for early diagnosis and treatment, and should be implemented as first-tier diagnostic tools for children with epilepsy without a clear etiologic basis.

Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert.

The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0 months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.

Role of copy number variants in sudden cardiac death and related diseases: genetic analysis and translation into clinical practice.

Several studies have identified copy number variants (CNVs) as responsible for cardiac diseases associated with sudden cardiac death (SCD), but very few exhaustive analyses in large cohorts of patients have been performed, and they have been generally focused on a specific SCD-related disease. The aim of the present study was to screen for CNVs the most prevalent genes associated with SCD in a large cohort of patients who suffered sudden unexplained death or had an inherited cardiac disease (cardiomyopathy or channelopathy). A total of 1765 European patients were analyzed with a homemade algorithm for the assessment of CNVs using high-throughput sequencing data. Thirty-six CNVs were identified (2%), and most of them appeared to have a pathogenic role. The frequency of CNVs among cases of sudden unexplained death, patients with a cardiomyopathy or a channelopathy was 1.4% (8/587), 2.3% (20/874), and 2.6% (8/304), respectively. Detection rates were particularly high for arrhythmogenic cardiomyopathy (5.1%), long QT syndrome (4.7%), and dilated cardiomyopathy (4.4%). As such large genomic rearrangements underlie a non-neglectable portion of cases, we consider that their analysis should be performed as part of the routine genetic testing of sudden unexpected death cases and patients with SCD-related diseases.

Clinical and genetic features of 13 Spanish patients with KCNQ2 mutations.

The KCNQ2 gene codifies a subunit of the voltage-gated potassium M channel underlying the neuronal M-current. Classically, mutations in this gene have been associated with benign familial neonatal seizures, however, in recent years KCNQ2 mutations have been reported associated to early-onset epileptic encephalopathy. In this work, detailed familiar, clinical and genetic data were collected for 13 KCNQ2-positive patients revealed among a cohort of 80 epileptic pediatric probands from Spain who were analyzed through a targeted next-generation sequencing assay for 155 epilepsy-associated genes. This work shows for the first time the association between KCNQ2 mutations and startle attacks in 38% of patients, which opens the possibility to define electroclinical phenotypes associated to KCNQ2 mutations. It also demonstrates that KCNQ2 mutations contribute to an important percentage of Spanish patients with epilepsy. The study confirm the high genetic heterogeneity of this gene with 13 different mutations found, 10 of them novel and the better outcome of patients treated with sodium channel blockers.

Contribution of Cyclooxygenase End Products and Oxidative Stress to Intrahepatic Endothelial Dysfunction in Early Non-Alcoholic Fatty Liver Disease.

INTRODUCTION: Metabolic syndrome induces endothelial dysfunction, a surrogate marker of cardiovascular disease. In parallel, metabolic syndrome is frequently associated with non-alcoholic fatty liver disease (NAFLD), which may progress to cirrhosis. The aim of the present study was to evaluate intrahepatic endothelial dysfunction related to cyclooxygenase end products and oxidative stress as possible mechanisms involved in the pathophysiology of NAFLD. MATERIALS AND METHODS: Sprague-Dawley rats were fed standard diet (control-diet, CD) or high-fat-diet (HFD) for 6 weeks. Metabolic syndrome was assessed by recording arterial pressure, lipids, glycemia and rat body weight. Splanchnic hemodynamics were measured, and endothelial dysfunction was evaluated using concentration-effect curves to acetylcholine. Response was assessed with either vehicle, L-NG-Nitroarginine (L-NNA), indomethacin, tempol, or a thromboxane receptor antagonist, SQ 29548. We quantified inflammation, fibrosis, oxidative stress, nitric oxide (NO) bioavailability and thromboxane B2 levels. RESULTS: HFD rats exhibited metabolic syndrome together with the presence of NAFLD. Compared to control-diet livers, HFD livers showed increased hepatic vascular resistance unrelated to inflammation or fibrosis, but with decreased NO activity and increased oxidative stress. Endothelial dysfunction was observed in HFD livers compared with CD rats and improved after cyclooxygenase inhibition or tempol pre-incubation. However, pre-incubation with SQ 29548 did not modify acetylcholine response. CONCLUSIONS: Our study provides evidence that endothelial dysfunction at an early stage of NAFLD is associated with reduced NO bioavailability together with increased cyclooxygenase end products and oxidative stress, which suggests that both pathways are involved in the pathophysiology and may be worth exploring as therapeutic targets to prevent progression of the disease.