Hepatitis C among drug users: consensus guidelines on management in general practice

BACKGROUND

Hepatitis C (HCV) is a common cause of morbidity among patients who attend general practitioners (GPs) in Ireland for methadone maintenance treatment.

AIMS

To describe the development and content of guidelines for the management of HCV among current or former opiate users in the Eastern Regional Health Authority area attending GPs for methadone treatment.

METHODS

The guidelines were produced in five stages: identification of key stakeholders; development of evidence-based draft guidelines; discussion of content; determination of 'Delphi'-facilitated consensus and review by a sample of GPs for whom the guidelines would be intended.

RESULTS

The guidelines contain advice for GPs on all aspects of care of patients at risk of HCV, including general and preventative care, care of other bloodborne and hepatotoxic viruses, and the factors to be considered and appropriate evaluation prior to referring a patient for assessment at a hepatology unit.

CONCLUSIONS

GPs have an important role to play in the care of patients at risk of, or infected with, HCV.

Cholestatic pruritus - the role of cutaneous mast cells and nerves

BACKGROUND

The pathogenesis of pruritus in cholestatic liver disease is poorly understood. Cutaneous mast cells and nerves are thought to contribute to pruritus in several dermatological diseases.

AIM

To determine if cutaneous mast cell density, neural density and mast cell-neural interaction are increased in patients with pruritus and cholestatic liver disease.

METHODS

Skin biopsy specimens from (i). patients with pruritus due to cholestatic liver disease (CLDP+; n = 6), (ii). patients with chronic liver disease without pruritus (CLDP-; n = 5), and (iii). healthy controls (n = 6) were studied. Biopsies were dual stained immunohistochemically for mast cells and nerves.

RESULTS

Mast cell density in the control group was not significantly different from that in CLDP+ group or from that in the CLDP- group. Similarly neural density was not significantly different between groups when assessed either in terms of total nerve area, or in terms of the number of neural elements seen. The frequency of mast cell-nerve contact was not significantly different between groups.

CONCLUSIONS

These findings suggest that mast cells, nerves or interaction between the two may not contribute to cholestatic pruritus. Therefore, therapies targeted at cutaneous mast cells or nerves are unlikely to be of benefit.

Telephone reminders to reduce non-attendance rate for endoscopy

Non-attendance at clinics and endoscopy units wastes resources and lengthens waiting lists. In a previous study elsewhere, a substantial proportion of patients claimed to have forgotten their appointment. We therefore assessed the value of telephoning patients a week before their booked day-case endoscopy. An observation period of two months was followed by an intervention period of two months in which patients were contacted by phone and asked if they wished to come for their investigation. A maximum of three separate attempts were made to contact each patient. Patients cancelling the appointment were replaced by others on the reserve list. The non-attendance rate was expressed as the percentage of unused beds. During the observation period 56 patients were admitted and 18 beds were unused. During the intervention period it was possible to contact 73 of 88 patients and 8 of these cancelled. 87 beds were available and 83 patients were admitted. When clerical error, overbooking and failure to replace patients were taken into account, the non-attendance rate declined from 23.3% during the observation period to 5.7% during the intervention period (P<0.05). The intervention seemed more effective in reducing non-attendance in outpatients referrals (0/48) than in general practitioner referrals (5/40).

High morbidity expected from cirrhosis in injecting drug users

Hepatitis C infection commonly complicates injecting drug use. The outcome of end stage liver disease for this cohort in Ireland has not been estimated. (1) to estimate the prevalence of persistent hepatitis C viraemia and distribution of genotypes in a drug using cohort. (2) To measure the frequency of poor prognostic co-factors. (3) To extrapolate the burden of hepatitis C related disease nationally for this route of infection. A cross section survey of attendees at an East Coast Area drug treatment clinic. Of 94 patients studied (63 male), 70 were hepatitis C antibody positive and 39 were PCR positive. 26 had genotype 1 and 11 had genotype 2 or 3. Most displayed factors associated with a poor prognosis: 72% male, 83% problem drinkers and 87% abnormal liver blood tests. Using published data, we extrapolate over 1,214 cases of cirrhosis via this route of infection nationally, leading to approximately 35, 60 and 50 cases of hepatocellular carcinoma, hepatic decompensation and liver related death respectively per annum. A high prevalence of hepatitis C infection in injecting drug users, compounded by a high frequency of poor prognostic co-factors, means a significant burden of disease can be expected from this group.

Telephone reminders to reduce non-attendance rate for endoscopy

Non-attendance at clinics and endoscopy units wastes resources and lengthens waiting lists. In a previous study elsewhere, a substantial proportion of patients claimed to have forgotten their appointment. We therefore assessed the value of telephoning patients a week before their booked day-case endoscopy. An observation period of two months was followed by an intervention period of two months in which patients were contacted by phone and asked if they wished to come for their investigation. A maximum of three separate attempts were made to contact each patient. Patients cancelling the appointment were replaced by others on the reserve list. The non-attendance rate was expressed as the percentage of unused beds. During the observation period 56 patients were admitted and 18 beds were unused. During the intervention period it was possible to contact 73 of 88 patients and 8 of these cancelled. 87 beds were available and 83 patients were admitted. When clerical error, overbooking and failure to replace patients were taken into account, the non-attendance rate declined from 23.3% during the observation period to 5.7% during the intervention period (P<0.05). The intervention seemed more effective in reducing non-attendance in outpatients referrals (0/48) than in general practitioner referrals (5/40).

Both under-nutrition and obesity increase morbidity following liver transplantation

Malnutrition is common in patients awaiting liver transplantation and may contribute to operative and post-operative mortality, although this is controversial. We assessed the pre-operative nutritional status of 87 patients and the impact this had on mortality and morbidity following liver transplantation for chronic liver disease. Thirty six per cent of patients had more than 10% loss of body weight prior to transplantation. Nutritional depletion, considered present if triceps skin fold thickness or mid-arm muscle circumference were < 5th percentile, was present in 17% and 15% of the total group respectively. Patients whose pre-operative body weights were < 90% of their ideal body weight (IBW) had a longer hospital stay (p = 0.001) and required longer post-operative ventilatory support (p = 0.033). This group also required significantly more treatment with intravenous antibiotics (p = 0.001) suggesting an increased incidence of infective complications. Patients who were obese pre-operatively (body mass index > 30Kg/m2) also required a longer period in high dependency (p = 0.0003). No individual nutritional variable correlated with mortality. In the Irish population undergoing liver transplantation, we found a relatively low prevalence of malnutrition in comparison with other studies. Both under- nutrition and obesity significantly affected morbidity and length of hospital stay post-transplant, although no individual nutritional variable predicted survival post transplant.

Ease of access is a principal factor in the frequency of paracetamol overdose

BACKGROUND

In Ireland, 30% of non-fatal overdoses involve paracetamol.

AIMS

To determine how and where patients obtained paracetamol, to assess awareness of toxicity and examine the relationship between dose and suicidal intent.

METHODS

A prospective study of patients admitted following a paracetamol overdose recording their reasons for using paracetamol, their knowledge of its toxicity and their suicidal intent scale (SIS).

RESULTS

Of 100 patients, 66% obtained paracetamol in non-pharmacy outlets, 82% cited ease of availability as the reason, 55% were aware of its toxicity, 31% of liver damage and 68% did not read the warning on packets. The mean number of tablets taken was 51.3 for males and 37.2 for females (p < 0.01). Males presented later than females for medical attention (12.5 versus seven hours [p < 0.02]) and more males than females took alcohol (p < 0.03). The mean SIS score was 14.71 for males and 12.38 for females. There was a significant correlation between the SIS and the amount of paracetamol consumed (r = 0.28; p < 0.01).

CONCLUSION

The majority obtained paracetamol in local shops or at home. Knowledge of toxicity and the need for early antidote was poor. There was a significant relationship between suicidal intent and number of tablets consumed. Limiting availability could reduce number of overdoses.

Severe acute alcoholic hepatitis: an audit of medical treatment

Despite advances in treatment, severe alcoholic hepatitis is still associated with a high mortality rate of 30% to 40%. Nutritional support and steroids in selected patients are believed to improve prognosis. In controlled trials steroids have been beneficial in patients with a discriminant function (DF) value >32 or spontaneous hepatic encephalopathy. The aim of this study was to investigate current practice and outcomes in the treatment of acute alcoholic hepatitis. We retrospectively studied patients admitted to our unit with acute alcoholic hepatitis over a 4 year period. Forty-three patients with acute alcoholic hepatitis were admitted between 1994 and 1997. Overall mortality was 26% (11/43). Only 5 patients were treated with steroids of whom 1 died (mortality 20%). Liver biopsy was available in 19/43 of whom 12/19 (63%) had underlying cirrhosis in addition to alcoholic hepatitis. Mortality was higher in patients with a discriminant function of greater than 32 but not significantly so (32%: 8/25 vs 17%: 3/18 p = 0.31). A discriminant function of greater than 32 and contra-indications to steroid use was the best predictor of mortality (60% 6/10 P = 0.0096) compared to patients not fulfilling these criteria In this study overall mortality was comparable with published reports. Of interest was the relatively low liver biopsy rate and the fact that steroids were used in only a minority of eligible patients. We found that mortality was concentrated in a subgroup of patients with a discriminant function value >32 and contra-indications to steroids. These criteria appear to identify a high-risk subgroup of patients. If confirmed, experimental treatments need to be targeted at this group to improve the overall prognosis of acute alcoholic hepatitis.

Improving prognosis following a first variceal haemorrhage over four decades

BACKGROUND

Variceal bleeding is a frequent cause of death in patients with cirrhosis and portal hypertension. Over the past 40 years a number of new techniques have been introduced to control active variceal haemorrhage. Many randomised controlled trials were performed to evaluate these new therapies. While most have demonstrated efficacy in controlling haemorrhage few showed improved survival.

AIM

The aim of this study was to investigate whether the prognosis for cirrhotic patients following a first variceal haemorrhage has improved over the past four decades.

PATIENTS AND METHODS

A total of 1475 patients included in the control or untreated arms of randomised controlled prophylactic trials for the primary prevention of variceal haemorrhage between 1960 and 2000. Twenty eight eligible randomised controlled studies were included. Over the 40 year period of observation there was a reduction in bleeding related mortality over time from approximately 65% to approximately 40% (p=0.024).

CONCLUSION

This study suggests that there has been a significant reduction in bleeding related mortality in patients with cirrhosis and portal hypertension over the past 40 years.

Tissue cytokine and chemokine expression in inflammatory bowel disease

OBJECTIVE AND DESIGN

This study aimed to determine if mucosal expression of the chemokines IL-8, RANTES and MCP-1 and the pro-inflammatory cytokines TNFalpha and IL-6 are elevated in patients with inflammatory bowel disease.

MATERIALS AND SUBJECTS

Intestinal mucosa samples were obtained at the time of surgical resection, n = 16 from each of the following groups: normal/control, CD and UC.

METHODS

An homogenate was prepared of each tissue sample and cytokines measured by ELISA.

RESULTS

IL-8 was significantly increased in both disease groups compared to controls Similarly, RANTES levels were also significantly increased. MCP-1 levels were increased in both disease groups, this increase was statistically significant in the UC group only. TNFalpha and IL-6 were significantly increased in the CD group only.

CONCLUSIONS

Chemokines, together with key cytokines that promote their release are elevated in mucosal tissues from patients with IBD. It is likely that these chemokines play an important role in the perpetuation of tissue destructive inflammatory processes.

Transjuglar liver biopsy: a review

Transjugular liver biopsy is advocated as the technique of choice for use in those with contraindications to standard transabdominal biopsy. This technique was introduced to our unit in 1995. We audited our experience in performing transjugular liver biopsies over a three year period. Eighty-eight biopsies were performed in seventy-eight patients. We identified no major procedure related complications, despite the presence of coagulopathy and thrombocytopenia in 85% and 47% of cases respectively. Biopsy provided histological diagnosis in 97.7% of cases. Availability of the technique allowed us to perform liver biopsy safely and quickly in patients with both acute and chronic liver problems in whom standard techniques were contraindicated. We conclude that transjugular liver biopsy is a safe and effective technique, invaluable in the investigation and management of patients in a liver diseases referral unit.

Splenomegaly, hypersplenism and coagulation abnormalities in liver disease

Splenomegaly is a frequent finding in patients with liver disease. It is usually asymptomatic but may cause hypersplenism. Thrombocytopenia is the most frequent manifestation of hypersplenism and may contribute to portal hypertension related bleeding. A number of therapies are available for treating thrombocytopenia due to hypersplenism including splenectomy, partial splenectomy, partial splenic embolization, TIPS etc. None is entirely satisfactory. Hypersplenism usually improves following liver transplantation. Therapy with cytokines such as thrombopoietin may offer hope for the future. Patients with liver disease also have abnormalities in coagulation. This is not surprising as all coagulation proteins (except for von willebrand factor vWF) and most inhibitors of coagulation are synthesized in the liver. Genetic or acquired abnormalities of coagulation may predispose to thrombosis of the hepatic or portal veins with significant clinical sequelae. An understanding of the mechanisms involved in coagulation and thrombosis is valuable in choosing from the increasing treatment options available. These include clotting factors, haemeostatic drugs and newer therapies such as recombinant factor VIIa. Splenic artery aneurysms are the most common visceral artery aneurysms in man. Rupture is frequently catastrophic. These aneurysms are being increasingly recognized in liver transplant patients and require treatment before or during transplant surgery.

Severe pain confounds neuropsychological test performance

There is little information on the effect of pain on neuropsychological test performance. We have undertaken this study to explore which tests are affected by pain, the magnitude of these changes, and other confounders of neuropsychological performance in a population of patients having spine surgery. Twenty-four elderly English speaking Caucasian patients (age > 60 years) were enrolled pre-operatively in this Institutional Review Board approved study. Pain scores using an 11-point Numeric Pain Intensity scale and performance on a neuropsychological battery (Controlled Oral Word Association, Rey Complex Figure, Trails A and B) were assessed at two times, before and one day after surgery. Scores were calculated using the standard algorithms and change scores were calculated by subtracting the baseline from follow-up scores. After surgery, performance on the Rey Complex Figure ( r = -0.577, p = 0.004) and Trails Part A (r = 0.527, p = 0.01) declined with increasing post-operative pain scores. Women reported higher pain scores post-operatively than men (p = 0.046), and performed worse than men for change in performance on Trails Part A (p = 0.027). These data suggest that pain can influence performance on certain cognitive tests, and that some gender differences in these effects may occur. Interpretation of performance measures should take into account possible effects of pain, although our understanding of pain effects and ability to predict them in individual people, currently are quite limited.

Delays in administration of acetylcysteine in paracetamol overdose

Despite an effective antidote, paracetamol overdose is a frequent cause of fulminant hepatic failure in Ireland and the United Kingdom. Most treatment failures are due to late presentation but some may be related to delayed treatment in hospital. The aim of this study was to investigate delays in treatment in patients presenting to two large Dublin accident and emergency departments. One hundred and seventy seven admissions were recorded over a two year period. The average patient presented 6-8 hours after the overdose and waited another 1.5 to 2 hours for treatment to commence. Treatment was delayed more than 2 hours after presentation in 24/110 (22%) and more than 4 hours in 10/110 (10%). The majority had no adverse sequelae but four patients required ventilation, one haemofiltration and one died. The patient who died presented 35 hours after overdose. This study suggests that delays in treatment of paracetamol overdose are common. Delays of this magnitude may be clinically important in the small minority of patients with significant liver injury. It is possible that oral administration of n-acetylcysteine may reduce delays in treatment.

A practical guide to the management of oesophageal varices

Bleeding oesophageal varices are a frequent and sometimes fatal complication of portal hypertension. Prompt resuscitation and arrest of haemorrhage are the immediate short term priorities. Vasoactive therapy to reduce portal pressure is administered on presentation. Early endoscopy is necessary to make a definitive diagnosis and initiate appropriate therapy; usually emergency sclerotherapy or banding. After the acute bleeding episode, follow-up therapy is instituted either to obliterate the varices by sclerotherapy or banding, or to chronically lower portal pressure and hence reduce the risk of bleeding pharmacologically; a combination of both strategies may be also used. Active surveillance of those at risk of developing varices is advocated. Long term beta-blocker therapy has been demonstrated to be effective in both the primary prevention of variceal haemorrhage and the prevention of rebleeding in those who have already bled. Despite a multitude of therapeutic regimes and ongoing clinical trials, mortality from this condition remains disappointingly high.

Portal hypertension increases vasoconstrictor responsiveness of rat aorta

We have examined the effects of pre-hepatic portal hypertension on the responsiveness of aorta from Wistar and Sprague-Dawley rats. Rats were made portal hypertensive by creating a calibrated portal vein stenosis, or sham operated. In rat aorta, there was no significant difference between portal hypertensive and sham-operated animals in the contractile potency of KCl, noradrenaline or phenylephrine. In aortas from Wistar rats, the maximum response to KCl (0.71+/-0.12 g) and noradrenaline (1.00+/-0.17 g) but not phenylephrine (0.86+/-0.10 g) in portal hypertensive animals was significantly increased compared with that in sham-operated animals (0.45+/-0.04 g, 0.57+/-0.07 g, 0.71+/-0.05 g respectively). In aortas from Sprague-Dawley rats, the maximum response to KCl (1. 21+/-0.21 g) and phenylephrine (1.54+/-0.30 g) but not noradrenaline (0.93+/-0.09 g) in portal hypertensive animals was significantly increased compared with that in sham-operated animals (0.59+/-0.09 g, 0.76+/-0.11 g, 1.04+/-0.10 g respectively). There was no difference between portal hypertensive and sham-operated Wistar rats in the affinity or maximum number of binding sites for [3H]prazosin to alpha1-adrenoceptors in cardiac ventricular membranes. It is concluded that portal hypertension tends to produce an increase rather than a decrease in the contractile response to vasoconstrictors in aorta from both Wistar and Sprague-Dawley rats. This suggests that the diminished responsiveness to vasoconstrictors reported in portal hypertensive rats in vivo is not due to a diminished responsiveness at the level of the vascular smooth muscle.

Cardiovascular actions of nitric oxide synthase inhibition in the portal hypertensive rat

We have investigated the actions of the nitric oxide synthase inhibitor L-NMMA in the portal hypertensive Wistar rat in vivo. Resting blood pressure in the anaesthetised portal hypertensive rat was 107.8+/-11.0 / 79.2+/-11.7 mmHg (n = 12), which was significantly lower than in sham-operated animals (143.0+/-3.8 / 114.0+/-4.0 mmHg, n = 19; P < 0.01). Cardiac output was significantly higher in portal hypertensive (30.2+/-1.0 ml min(-1) per 100 g, n = 12) than sham-operated animals (23.7+/-2.2 ml min(-1) per 100 g, n = 13; P < 0.01). Intravenous injection of L-NMMA (10 mg kg(-1)) significantly increased systemic blood pressure in both portal hypertensive and sham-operated animals to 123.0+/-15.0 / 93.4+/-14.0 mmHg and 162.1+/-5.7 / 131.6+/-6.0 mmHg, respectively. The magnitude of the changes were similar in both groups. This increase in blood pressure was accompanied by a decrease in cardiac output to 88.5+/-2.8% and 91.5+/-2.4% of control in portal hypertensive and sham-operated animals, respectively (no significant difference). L-NMMA (10 mg kg(-1)) had similar effects on small mesenteric arterial conductance in both portal hypertensive and sham operated animals, reducing conductance to 84.4+/-3.6% (n = 6) and 82.7+/-1.2% (n = 4) of control, respectively. It is concluded that L-NMMA has similar effects in vivo in portal hypertensive as compared with sham-operated rats. Hence, an enhancement of endothelium-derived nitric oxide is not involved in the hyperdynamic state following portal hypertension in the rat.

Effects of the selective cyclooxygenase-2 inhibitor nimesulide on vascular contractions in endothelium-denuded rat aorta

We have examined the effects of the selective cyclooxygenase-2 inhibitor nimesulide and the non-selective cyclooxygenase inhibitor indomethacin on vascular responsiveness of endothelium-denuded rat aorta. Isometric contractions were obtained to the alpha-adrenoceptor agonists phenylephrine (full agonist) and clonidine (partial agonist relative to phenylephrine) and to endothelin-1 and KCl. Maximum contractile responses to the partial agonist clonidine were significantly reduced by nimesulide (10 microM) and by indomethacin (10 microM) to 60.8 +/- 8.5% (n = 8) and 69.0 +/- 9.6% (n = 12) of control, respectively, as compared with the effects of vehicle (99.0 +/- 5.8%; n = 17). The inhibitors had lesser effects against contractions to phenylephrine: nimesulide had no significant effect, whereas indomethacin caused a small but significant reduction in the maximum contraction to phenylephrine to 90.3 +/- 5.0% (n = 12) of control (vehicle: 108.0 +/- 5.2%, n = 15 nimesulide: 111.8 +/- 5.9%, n = 5). Neither nimesulide nor indomethacin had any effect on contractions to endothelin-1 or KCl. These actions differed from the effects of the Ca2+ entry blocker nifedipine, which significantly reduced contractions to clonidine and KCl to a similar extent. The maximum contraction to clonidine was also significantly reduced by the thromboxane receptor antagonist SQ 29548 (1 microM) to 83.4 +/- 6.4% of control (n = 7) (vehicle 115.5 +/- 7.5%, n = 7). It is concluded that the cyclooxygenase inhibitors nimesulide or indomethacin reduce vascular responsiveness to alpha-adrenoceptor agonists in endothelium-denuded rat aorta, presumably by preventing the formation of vasoconstrictor prostaglandins in aortic smooth muscle by cyclooxygenase-2. This reduced vascular responsiveness was most clearly seen with the partial agonist clonidine.