Management of hepatitis C in opioid agonist therapy patients of the Swiss canton Aargau within and outside the cohort study.

With regard to HCV elimination in opioid agonist therapy patients by 2030, case finding and regular screening for new and re-infections remain a challenge, especially for non-cohort patients in a decentralised setting. Documentation of the HCV sero- and RNA status of each opioid agonist therapy  patient by the cantonal physician and a yearly HCV screening reminder sent to the opioid agonist therapy prescriber combined with capillary HCV antibody and HCV RNA testing might facilitate the implementation of the FOPH guidelines. Prescription of direct-acting antivirals directly by the opioid agonist therapy prescriber could increase awareness and improve linkage to care.

[Gastric Bypass: Weight Loss with Complications]. / Magenbypass: Abnehmen mit Komplikationen.

Gastric Bypass: Weight Loss with Complications Abstract. Roux-en-Y gastric bypass (RYGBP) is the most often performed bariatric operation worldwide with internal hernia as one of the main long-term complications. To our knowledge, we report the first case of post-ischemic small-bowel strictures observed after a successful operation of an internal hernia after RYGBP. During emergency surgery a Petersen and a Brolin hernia were diagnosed and repaired. The initially ischemic small intestine was recovered. However, a week later the patient presented herself again due to ischemia-induced small-bowel strictures. These were treated successfully by endoscopic balloon dilatation.

Management of hepatitis C in decentralised versus centralised drug substitution programmes and minimally invasive point-of-care tests to close gaps in the HCV cascade.

BACKGROUND: In Switzerland, intravenous drug use accounts for the majority of hepatitis C virus (HCV) infections. Early HCV treatment prevents further transmissions and reduces morbidity and mortality due to decompensated liver cirrhosis and hepatocellular carcinoma. Nevertheless, patients in drug substitution programmes are often insufficiently screened and treated. AIM: The aim was to compare the current state of HCV management in centralised and decentralised drug substitution programmes of the canton Aargau. Objectives were human immunodeficiency virus (HIV) and HCV prevalence, compliance with guidelines and gaps in the HCV cascade, as well as feasibility/acceptance/validity of HIV/HCV rapid tests on finger-prick blood and noninvasive liver fibrosis assessment with Fibroscan®. METHODS: For the cross-sectional study, in June 2013, questionnaires and free rapid tests for HIV (Determine®) and HCV (OraQuick®) that used capillary blood (finger-stick) were sent to 161 physicians providing drug substitution treatment for 631 patients. Free liver fibrosis assessment with Fibroscan® by a member of the study team was offered to all patients. Additionally, patients were directly recruited by the study team in the heroin substitution programme and several addiction clinics visited every 4-6 months, as well as in the Infectious Diseases Outpatient Clinic (questionnaire, rapid tests and Fibroscan® in the same session). RESULTS: Between July 2013 and July 2015, 205 (32.5%) of the 631 patients receiving opioid substitution in the canton Aargau were enrolled, 192 (93.7%) with HIV/HCV rapid tests and 167 (81.5%) with Fibroscan®. Acceptance of Fibroscan® was higher when offered in the same session (94.1 vs 69.2%). Overall, 77.8% had ever used intravenous drugs. HCV seroprevalence was 53.7% (109/203), HCV RNA prevalence 27.8%. Overall, 7.4% (15/202) were HIV infected, all of whom were HCV co-infected and under antiretroviral treatment. Of the 205 patients included, 104 (50.7%) were recruited in a decentralised setting (family practice / pharmacy) and 101 (49.3%) in a centralised setting (heroin programme, addiction clinic, Infectious Diseases Outpatient Clinic). Compliance with guidelines (regular HIV/HCV screening, workup of HCV-positive patients, availability of HAV/HBV serology) was consistently lower in the decentralised setting, characterised by a higher proportion of females, longer median time in the programme, lower percentage of daily attendance, ever-use of intravenous drugs and HIV and HCV infections. We identified several gaps in the HCV cascade: 23.9% (49/205) had never been HCV screened; 18.9% (18/95) of the HCV positive patients had no HCV RNA test. Of the 61 patients developing chronic HCV infection, 19.7% (12) were not HCV genotyped, 52.5% (32) had no liver fibrosis assessment (liver biopsy) and 54.1% (33) never received treatment; 25.0% (7/28) did not achieve a sustained virological response with interferon-based treatment. The 192 HCV rapid tests showed a sensitivity of 90.4% (94/104; 95% confidence interval 84.7-96.1%) and a specificity of 100% (88/88), and provided 14 new HCV diagnoses. Eight of ten patients with a false-negative HCV rapid test were HCV RNA negative (2 unknown). Among the 88.6% (39/44) currently HCV RNA-positive individuals with valid Fibroscan® results, 24 (61.5%) had a liver stiffness <7.5 kPa. Both HIV co-infection and alcohol overconsumption doubled the risk of severe fibrosis/cirrhosis in HCV positive patients. CONCLUSION: In contrast to HIV, HCV transmission among intravenous drug users is still ongoing. The management of hepatitis C in drug substitution patients needs improvement, especially in family practices. Minimally invasive "point-of-care" diagnostics such as the HCV antibody rapid test using capillary blood and mobile Fibroscan® can close some of the gaps in the HCV cascade. HCV RNA determination in capillary blood is still an unmet need. A "one-stop strategy" might improve linkage to care. Restricting the new, highly efficient (90-100% sustained virological response for all genotypes) direct-acting antivirals to patients with at least stage F2 fibrosis withholds treatment from two thirds of the chronically infected and prevents us from reaching the WHO goal of 80% treatment uptake necessary to eliminate hepatitis C by 2030.

The "Suicide Guard Rail": a minimal structural intervention in hospitals reduces suicide jumps.

BACKGROUND: Jumping from heights is a readily available and lethal method of suicide. This study examined the effectiveness of a minimal structural intervention in preventing suicide jumps at a Swiss general teaching hospital. Following a series of suicide jumps out of the hospital's windows, a metal guard rail was installed at each window of the high-rise building. RESULTS: In the 114 months prior to the installation of the metal guard rail, 10 suicides by jumping out of the hospital's windows occurred among 119,269 inpatients. This figure was significantly reduced to 2 fatal incidents among 104,435 inpatients treated during the 78 months immediately following the installation of the rails at the hospital's windows (χ2 = 4.34, df = 1, p = .037). CONCLUSIONS: Even a minimal structural intervention might prevent suicide jumps in a general hospital. Further work is needed to examine the effectiveness of minimal structural interventions in preventing suicide jumps.

Assessment of dynamic contrast enhancement of the small bowel in active Crohn's disease using 3D MR enterography.

PURPOSE: To retrospectively compare the dynamic contrast enhancement of the small bowel segments with and without active Crohn's disease at 3D MR enterography (MRE). MATERIALS AND METHODS: Thirteen patients (five men, eight women; mean age 41.2 years; range 29-56) were imaged on a 1.5-T MR scanner (Sonata, Siemens Medical) with standard MR sequences after having ingested 1000 ml of a 3% mannitol solution. Subsequently, high resolution 3D gradient-echo (volumetric interpolated breath-hold examination=VIBE) data sets were obtained pre-contrast and 20-40s, 60-80s, and 120-140 s after i.v. Gd-DOTA administration (0.2 mmol/kg). Signal enhancement was measured on single slices both in normal and histologically confirmed (12/13) inflamed small bowel wall segments as well as in the aorta, the psoas muscle, and the background to calculate signal-to-noise (SNR) and contrast-to-noise ratios (CNR). RESULTS: Small bowel wall enhancement was significantly higher (p<0.05) in inflamed compared to normal segments at 20-40s (SNR inflamed: 58.7+/-33.8 vs normal: 36.0+/-19.8; p=0.048; CNR inflamed: 34.8+/-23.4 vs normal: 16.3+/-11.2; p=0.017) and at 60-80s (SNR: 60.3+/-25.1 vs 41.9+/-20.0; p=0.049; CNR: 34.9+/-15.1 vs 19.3+/-13.2; p=0.01) after i.v. contrast administration, respectively. Even at 120-140 s CNR was still increased in inflamed segments (33.7+/-16.0 vs 18.1+/-13.2; p=0.04), while differences in SNR did not attain statistical significance (63.0+/-26.2 vs 45.3+/-23.3; p=0.15). CONCLUSION: In active Crohn's disease, histologically confirmed inflamed small bowel wall segments demonstrate a significantly increased early uptake of gadolinium on 3D VIBE sequences compared to normal small bowel segments.

Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease.

PURPOSE: The goal of this study was to compare magnetic resonance enterography (MRE) and video capsule endoscopy (VCE) in suspected small bowel disease. MATERIALS AND METHODS: Nineteen patients with suspected small bowel disease participated in a prospective clinical comparison of MRE versus VCE. Both methods were evaluated separately and in conjunction with respect to a combined diagnostic endpoint based on clinical, laboratory, surgical, and histopathological findings. The Fisher's exact and j tests were used in comparing MRE and VCE. RESULTS: Small bowel pathologies were found in 15 out of 19 patients: Crohn's disease (n= 5), lymphoma (n= 4), lymphangioma (n= 1), adenocarcinoma (n= 1), postradiation enteropathy (n= 1), NSAID-induced enteropathy (n =1), angiodysplasia (n= 1), and small bowel adhesions (n= 1). VCE and MRE separately and in conjunction showed sensitivities of 92.9, 71.4, and 100% and specificities of 80, 60, and 80% (kappa= 0.73 vs. kappa = 0.29; P= 0.31/kappa = 0.85), respectively. In four patients, VCE depicted mucosal pathologies missed by MRE. MRE revealed 19 extraenteric findings in 11 patients as well as small bowel adhesions not detected on VCE (n= 1). CONCLUSION: VCE can readily depict and characterize subtle mucosal lesions missed at MRE, whereas MRE yields additional mural, perienteric, and extraenteric information. Thus, VCE and MRE appear to be complementary methods which, when used in conjunction, may better characterize suspected small bowel disease.

Correlation of Helicobacter pylori virulence genotypes vacA and cagA with histological parameters of gastritis and patient's age.

The histological parameters of Helicobacter pylori (H. pylori) gastritis are dependent on the virulence factor profile of the microbe, which includes the cytotoxins vacA (vacuolating cytotoxin A) and cagA (cytotoxin-associated gene A) as well as the duration of infection. The virulence factor genotypes vacA and cagA were assessed by the line probe reverse hybridization assay INNO-LiPA and correlated with the histological parameters of H. pylori infection, in particular intestinal metaplasia (IM) as well as with the patient's age. A total of 120 patients were analyzed; 47 patients with IM in the antrum and 73 control patients without this alteration. The vacA s1 cagA+ genotype (high virulence) correlated with the presence of antral IM, a more intense acute inflammation in both antrum and corpus and the formation of ulcer. The vacA m1 genotype (high virulence) correlated with a more intense acute inflammation in only the corpus as well as more prominent Russell bodies in the antrum. H. pylori strains with the vacA s2 m2 cagA- genotype (low virulence) were rarely found in these conditions (all P <0.05). No correlation with the virulence status was found for the type and extent of IM, the intensity of chronic inflammation, the formation of lymphoid follicles and the microbial density. Furthermore, patients with IM were 7 years older than their counterparts without (P<0.05). Finally, there was a trend for more virulent vacA s1 m1 cagA+ strains to be found in younger individuals (P>0.05). The virulence genotype of the microbe is an important determinant for the severity of the gastritis and the formation of antral IM. Age is an additional factor for the development of IM.

Assessment of Helicobacter pylori clarithromycin resistance mutations in archival gastric biopsy samples.

AIM: First, to assess the clarithromycin resistance (Cla(R)) rate 1) in patients with persistent Helicobacter pylori (H. pylori) infection after eradication,2) in patients with untreated infection and 3) in patients with successful status post eradication. Second, to evaluate the techniques sequencing and line probe hybridisation INNO-LipA for resolution of uniform and mixed populations in archival gastric biopsy samples. METHODS: The genomic 2142/43 23s rRNA mutations of the 50S ribosomal subunit conferring Cla(R) were detected by PCR-based assays. RESULTS: A total of 130 patients were investigated. Out of 21 patients of a first series with persistent infection after eradication, 19 (90%; CI (95%): 67-99%) exhibited point mutations at position 2142/43. In the second series of untreated patients, primary resistance was observed in 8 out of 93 patients (9%; CI: 4-16%). In a third series of 16 successfully eradicated patients, pure wild type populations (WT; for loci 2142/43) without any minimal mutated part were found (resistance rate 0%; CI: 0-21%). Further, in all 24 biopsies with uniform mutated and in 8 of 11 biopsies with mixed populations the two molecular biological methods yielded concordant results (100%; CI: 86-100% and 73%; CI: 39-94%, respectively). CONCLUSION: In the Baden region of Switzerland, most clarithromycin resistant H. pylori strains harbour mutations at position 2142/43. The primary resistance rate is below 10%. Mixed populations, even with minor mutated part, cannot become successfully eradicated. The two investigated techniques are equally valid for resolution of uniform mutated or mixed H. pylori populations in archival biopsy material.