High prevalence of fatty liver and its association with metabolic syndrome among rural adults with chronic hepatitis C: Implications for primary healthcare

BACKGROUND

Chronic hepatitis C (CHC) virus infection is a global health concern that is associated with significant liver-related morbidity and mortality. Owing to the inflammatory pathway, CHC can causefatty liver, liver cirrhosis, and liver cancer and is associated with cardiometabolic diseases, such as hypertension and diabetes. Fatty liver is associated with metabolic disorders, cardiovascular diseases, diabetes, and liver cancer. Hence, the early detection of fatty liver through noninvasive screening in adults with CHC is important in primary healthcare settings. This study aimed to explore the prevalence of fatty liver and its association with metabolic syndrome amongrural adults with CHC.

METHODS

This was a series of cohort studies related to the elimination of the CHC burden around the western coastal Yunlin County, Taiwan, between August 2018 and July 2021. A cross-sectional study was conducted after hepatitis C virus RNA confirmation in a hepatitis C- endemic area. A gastrointestinal physician or radiologist assessed fatty liver by ultrasonography. Fatty liver was classified into four grades: normal, mild, moderate, and severe. Three liver enzyme biomarkers were identified. According to the Taiwan national standard, metabolic syndrome was defined based on the presence of three or more of the five abnormal biomarkers, including increased waist circumference, elevated blood pressure, elevated fasting blood glucose level, elevated triglyceride level, and low high-density lipoprotein cholesterol level.

RESULTS

A total of 256 rural adults with CHC were enrolled. The mean age of the participants was 67.5 (standard deviation = 11.8) years, with a low educational level. High prevalence of fatty liver (79%), central obesity (54.3%), elevated blood pressure (55.5%),elevated fasting blood glucose (FBG) level (44.9%), and metabolic syndrome (37.9%) were observed.The results showed that adults with CHC with moderate to severe fatty liver were significantly associated with an increased risk of increased waist circumference (P < 0.001), increased blood pressure (P < 0.001), low high-density lipoprotein cholesterol level (P < 0.05), and elevated liver enzyme biomarker levels (all P < 0.05) after adjusting for age, sex, and educational level. Furthermore, adults with CHC with moderate to severe fatty liver were significantly associated with a greater risk of metabolic syndrome (odds ratio = 2.85, 95% confidence interval = 1.66 to 4.92).

CONCLUSIONS

The findings demonstrate a high prevalence of fatty liver in rural adults with CHC, which is significantly associated with obesity, metabolic syndrome, and elevated liver biomarker levels. Clinicians and primary healthcare providers must encourage patients with CHC to receive antiviral therapy combined with weight loss management and lifestyle modification, allowing general improvements in their liver and cardiometabolic health.

Pangenotypic direct-acting antiviral agents for mixed genotype hepatitis C infection: A real-world effectiveness analysis

BACKGROUND

Pangenotypic direct-acting antiviral agents (DAAs) glecaprevir/pibrentasvir (GLE/PIB) and sofosbuvir/velpatasvir (SOF/VEL) are effective against all hepatitis C virus (HCV) genotype infections. However, data on pangenotypic DAA treatment for mixed genotype HCV infection are sparse.

METHODS

This is a retrospective, single site cohort study analyzing all patients with mixed HCV genotype infections treated with GLE/PIB or SOF/VEL from August 2018 to August 2020 in Chiayi Chang Gung Memorial Hospital, Taiwan. The primary study endpoint was sustained virologic response (SVR) 12 weeks after treatment cessation. We also reported adverse events (AEs).

RESULTS

A total of 108 patients with mixed infections of any two or three genotypes of 1a, 1b, 2, 3, and 6 received pangenotypic DAAs during the study period. A total of 67 patients received GLE/PIB and 41 received SOF/VEL. The evaluable population analysis revealed SVR rates of 94% (63/67) and 95.1% (39/41) for GLE/PIB and SOF/VEL therapy, respectively, and the per-protocol analysis revealed an SVR of 100% for both regimens. Four patients in the GLE/PIB group and two patients in the SOF/VEL were lost to follow-up. The most common AEs for GLE/PIB versus SOF/VEL therapy included pruritus (14.9% vs 2.4%), fatigue (6.0% vs 7.3%), abdominal discomfort (4.5% vs 7.3%), and acid reflux (3.0% vs 4.9%). DAA-related significant laboratory abnormalities occurred in three patients with > 1.5 × elevated bilirubin level in the GLE/PIB group. None of the above AEs resulted in DAA discontinuation.

CONCLUSIONS

Pangenotypic DAAs are well tolerated by and yield high SVR rates in patients with mixed genotype HCV infection.

Village-to-village screening for hepatitis B and C using quantitative HBsAg and anti-HCV testing with reflex HCV core antigen tests in the remote communities of a resource-rich setting: a population-based prospective cohort study

OBJECTIVES

Community-based screening for hepatitis B virus (HBV) and hepatitis C virus (HCV) is essential for hepatitis elimination. This study attempted to increase screening accessibility and efficacy by using alternative tools.

DESIGN

Population-based prospective cohort study.

SETTING

Hepatitis elimination program at Yunlin County, Taiwan.

PARTICIPANTS

All 4552 individuals participated in 60 screening sessions of a community-based HBV and HCV screening project in five rural townships with approximately 95 000 inhabitants in central-western Taiwan.

INTERVENTIONS

To increase accessibility, 60 outreach screening sessions were conducted in 41 disseminative sites. Quantitative HBV surface antigen (qHBsAg) and anti-HCV testing with reflex HCV core antigen (HCV Ag) tests were employed as alternative screening tools.

MAIN OUTCOME MEASURES

Calculate village-specific prevalence of HBsAg, anti-HCV and HCV Ag and establish patient allocation strategies according to levels of qHBsAg HCV Ag and alanine aminotransferase (ALT).

RESULTS

Of 4552 participants, 553, 697 and 290 were positive for HBsAg, anti-HCV and HCV Ag, respectively; 75 of them had both HBsAg and anti-HCV positivity. The average (range) number of participants in each screening session was 98 (31-150). The prevalence rates (range) of HBsAg, anti-HCV and HCV Ag were 12.1% (4.3%-19.4%), 15.3% (2.6%-52.3%) and 6.4% (0%-30.2%), respectively. The HCV Ag positivity rate among anti-HCV-positive participants was 42% (0%-100%). Using cut-off values of >200 IU/mL for qHBsAg, >3 fmol/L for HCV Ag and >40 IU/mL for ALT as criteria for patient referral, we noted an 80.2% reduction in referral burden. Three villages had high anti-HCV prevalences of 52.3%, 53.8% and 63.4% with corresponding viraemic prevalences of 23.2%, 30.1% and 22% and thus constituted newly identified HCV-hyperendemic villages.

CONCLUSION

Outreach hepatitis screening increases accessibility for residents in rural communities. Screening HBV and HCV through qHBsAg and HCV Ag tests provides information concerning viral activities, which might be conducive to precise patient allocation in remote communities.

Usefulness of quantitative hepatitis B surface antigen testing in hepatitis B community-based screening

BACKGROUND/PURPOSE

Low viral load (LVL) of hepatitis B virus (HBV) is a predictor of chronic HBV infection. However, the usefulness of quantitative hepatitis B surface antigen (qHBsAg) in predicting LVL in community-based screening has not been well studied. We aimed to measure the prevalence of LVL in HBV carriers and validate the efficacy of qHBsAg in predicting LVL.

METHODS

This community-based screening study was conducted in Taiwan. HBV DNA was assayed in HBsAg carriers. Participants were randomized to training and validation sets to determine the ability of qHBsAg to predict LVL. Receiver operating characteristic curves were used to identify the best cutoff values in the training set.

RESULTS

Among the 2919 participants, 359 (12.2%) were HBsAg carriers. There were 132 and 137 carriers in the training and validation sets, respectively. Significant correlations were found between qHBsAg and HBV DNA in both training and validation sets. Thirty and 29 participants with qHBsAg <8 IU/mL in the training and validation sets, respectively, had LVL. Using 8 IU/mL as the cutoff, negative predictive value (NPV) of qHBsAg for HBV DNA levels >2000 IU/mL was 100%. The best cutoff level of qHBsAg to predict HBV LVL was 200 IU/mL, with a sensitivity, specificity, and accuracy of 75.0%, 76.1%, and 75.8%, respectively, in the training set. The positive predictive value and NPV were 70.0% and 77.9%, respectively, in the validation set.

CONCLUSION

Approximately 60% of HBsAg carriers had HBV LVL, and qHBsAg <8 IU/mL accurately predicts LVL. This quantitative test provides additional information for community-based screening.

Real-world effectiveness of glecaprevir/pibrentasvir and ledipasvir/sofosbuvir for mixed genotype hepatitis C infection: A multicenter pooled analysis in Taiwan

Data on direct-acting antiviral agent (DAA) treatment for mixed genotype hepatitis C virus (HCV) infection are scant. This study examined the effectiveness of glecaprevir/pibrentasvir (GLE/PIB) and ledipasvir/sofosbuvir (LDV/SOF) for mixed HCV genotype infection in a real-world setting in Taiwan. We analysed the data from all patients with mixed HCV genotype infections treated with GLE/PIB or LDV/SOF from 2017 to 2019 in three Chang Gung Memorial Hospitals in Taiwan. The primary treatment outcome was sustained virologic response 12 weeks after treatment cessation (SVR12). Adverse events (AEs) were also evaluated. A total of 5190 HCV patients received DAA treatment during this time period. Among them, 116 patients (2.2%) had mixed infections of any 2 or 3 genotypes of 1a, 1b, 2, 3 and 6. Fifty-four patients received GLE/PIB and 62 received LDV/SOF. SVR12 rates for LDV/SOF vs GLE/PIB therapy were 96.6% (56/58) vs 100% (51/51) by the per-protocol analysis and 90.3% (56/62) vs 94.4% (51/54) by the evaluable population analysis. Two patients with 1b + 6 and 1b + 2 genotype infections in the LDV/SOF group had relapse. Evaluating the GLE/PIB vs LDV/SOF groups for the most common AEs revealed pruritus (16.7% vs 4.8%), abdominal discomfort (5.6% vs 8%) and fatigue (5.6% vs 4.8%). One patient with AE-related treatment discontinuation presented with liver decompensation after 4-week GLE/PIB therapy. DAA-related significant laboratory abnormalities occurred in two patients with >3× elevated bilirubin level in the GLE/PIB group. GLE/PIB and LDV/SOF are well tolerated and achieve high SVR12 rates for patients with mixed HCV genotype infection.

The effectiveness of an oral hygiene program combined with health-promoting counseling for rural adults with cardiometabolic risks: A quasi-experimental design

AIM

The aim of this study was to explore the effectiveness of an oral hygiene program combined with home-phone health promoting counseling for rural adults with metabolic syndrome.

BACKGROUND

Metabolic syndrome is an important risk factor for cardiometabolic diseases. Evidence indicates that the poor oral hygiene and unhealthy lifestyles are closely related to metabolic syndrome.

METHODS

A prospective quasi-experimental design involved a total of 136 community adults, with metabolic syndrome living in two rural townships, were clustered and conveniently assigned to intervention and control group between June 2017 and December 2018. The primary outcome was the change in cardiometabolic biomarkers. The secondary outcome comprised changes in the health-promoting behaviors. The intervention effect was assessed using a generalized estimating equation model.

RESULTS

There were 80 and 56 participants in the intervention and control group, respectively. The mean age was 56 years and ranged from 33 to 70 years. The intervention group exhibited a greater improvement in body mass index (P < 0.01), waist circumference (P < 0.05), body fat percentage (P < 0.05), triglyceride level (P < 0.05), use of dental floss (P < 0.05), regular tooth scaling (P < 0.05), physical activity (P < 0.001), and total score of health-promoting behaviors (P < 0.001) than the control group.

CONCLUSION

This study supports the use of an oral hygiene program combined with home-phone counseling, which offers more advantages than its counterpart. Considering the global epidemic of cardiometabolic diseases, this is a community health nursing model worth to replicate and evaluate. Further study should consider innovative strategies to improve the awareness and adoption of a healthy lifestyle in residents with cardiometabolic risks.

Liver Health Literacy and Health Status Among Adults With Hepatitis C: Implications for the Nursing Profession as Part of the 2030 Global Elimination Goal

PURPOSE

To explore the prevalence of hepatitis C virus (HCV) infection as well as the levels of liver health literacy and association with the health status of people with HCV through the nurse-led community health development goal of global elimination.

METHODS

A community-based, cross-sectional study was conducted between July 2018 and June 2019 in coastal Western Yunlin County, Taiwan. This study was conducted at five townships, and serum HCV antibody (anti-HCV) screening was used for the identification of potentially infected people by a collaborating local hospital.

RESULTS

Of the 1,963 adults from rural areas enrolled in this study, 321 (16.4%) were anti-HCV positive, 237 (73.8%) reported that they were unaware of their HCV positivity, and none of them were provided information on direct-acting antiviral agent therapy. The levels of anti-HCV positivity were higher among female patients (p < .05), elderly people (p < .001), those with a low education level (p < .001), and those from the Sihu Township within Yunlin County (p < .001). Participants with anti-HCV positivity tended to have lower intakes of vegetables (p < .01) and fruit (p < .05), a greater number of comorbidities (p < .05), as well as a greater incidence of abnormal liver (p < .001) and renal function (p < .001) compared to those with anti-HCV negativity. Multivariable linear regression analysis showed that the presence of HCV infection and a greater number of metabolic syndrome components were associated with poor liver and renal function.

CONCLUSIONS

These findings showed a high prevalence of HCV infection among adults living in rural areas, who had low literacy levels on hepatitis, unhealthy lifestyles, and abnormal liver and renal function.

CLINICAL RELEVANCE

Clinicians and primary healthcare providers should initiate efforts to increase the levels of liver health literacy by increasing the accessibility to infection confirmation tests and reducing the number of barriers to the reception of antiviral treatment.

Comparison of Compliance and Efficacy of Pegylated Interferon α-2a and α-2b in Adults with Chronic Hepatitis C

This study compares treatment completion rates and outcomes in hepatitis C virus (HCV) patients between those aged <60 and ≥60 years receiving pegylated interferon (PEG-IFN) α-2a or α-2b combined with ribavirin. No significant differences were found in treatment completion rates and virological responses between age-stratified patients or between genotype-stratified patients receiving PEG-IFN α-2a versus PEG-IFN α-2b. Significantly more patients ≥60 years of receiving PEG-IFN α-2b exhibited an early virological response compared to those receiving PEG-IFN α-2a (P = 0.002); for patients <60 years of age, treatment outcomes were similar between the 2 groups. More liver fibrosis was observed in patients with HCV of genotype 1 than in those with genotypes 2 or 3. Mean changes in pre- and post-treatment fibrosis variables (bilirubin, platelet count, liver enzymes, FIB-4, and APRI) in HCV genotype 1 patients were greater in those receiving PEG-IFN α-2b than in those receiving PEG-IFN α-2a. Significant differences were not observed between age- and HCV genotype-stratified patients receiving PEG-IFN α-2a and -α-2b, but α-2b appears to have a modest efficacy advantage over α-2b, particularly in male HCV patients ≥60 years of age.

Association between hepatitis C virus infection and osteoporotic fracture risk among postmenopausal women: a cross-sectional investigation in Taiwan

PURPOSE

Early low bone mass is a risk factor for osteoporotic fractures associated with multiple factors, including menopause and chronic liver diseases. Hepatitis C virus (HCV) also plays a major role in chronic liver disease and has many extrahepatic consequences, such as decreased bone mineral density (BMD). This study aimed to examine the hypothesis that HCV seropositivity is independently associated with menopausal BMD loss.

METHODS

This community-based, cross-sectional study was based in two rural townships in Yunlin County, Taiwan. A total of 636 menopausal women aged 45-80 years who underwent annual health checks were included. Viral markers of HCV, dual-energy X-ray absorptiometry and fracture risk assessment tool (FRAX) scores were measured. Logistic regression analysis was performed to assess the association between various predictors and the presence of low BMD.

RESULTS

The participants (median age: 65 years) had a HCV seropositivity rate of 32.2%. BMD was significantly lower in the HCV-seropositive participants in different anatomic locations than in the seronegative individuals (lumbar spine: -1.5 vs -1.1; total hip: -0.9 vs -0.6; femoral neck: -1.2 vs -1.0; p<0.05). HCV-seropositive subjects had higher rates of major osteoporotic fractures (11.3%±7.6%vs 9.0±6.8%; p<0.001) and hip fractures (3.4%±4.7%vs 2.3±4.9%; p=0.006) and a higher risk of lower BMD (osteopenia and osteoporosis) based on a multivariable regression analysis (adjusted OR: 1.8; 95% CI 1.16 to 2.81; p=0.009).

CONCLUSIONS

HCV infection may be an independent risk factor for menopausal BMD loss and fractures predicted by FRAX.

Effects of gender and age on prevalence of cholelithiasis in patients with chronic HCV infection: A community-based cross-sectional study in an HCV-hyperendemic area

This study investigated the effects of age and gender on the prevalence of cholelithiasis in patients with chronic HCV infection.Demographic and clinical data of 8489 subjects (3671 males, 4818 females; mean age 47.5 years) receiving township-wide health examinations between September 2012 and August 2013 were analyzed. The main endpoint was prevalence of cholelithiasis. Risk factors (age, gender, body mass index, concomitant diseases, lifestyle, laboratory parameters, and HCV status) were evaluated. Univariate and multivariate logistic regression analyses were performed to identify associations between cholelithiasis and variables.Cholelithiasis was more prevalent among HCV subjects than non-HCV subjects (females: 8.1% vs 4.2%; males: 9.1% vs 3.9%; both P < .001); rates ranged from 5.6% to 8.3% in females and 4.7% to 10.6% in males. HCV status and age were associated with cholelithiasis occurrence (OR = 2.17 for HCV vs non-HCV; OR = 2.44, 3.54 for age 45-55, and >55 vs <45 years; all P < .05). Multivariate analysis showed a significant association between cholelithiasis and age/sex interaction terms (OR = 0.517 for age >55 vs <45 for sex; P = .011). Cholelithiasis prevalence was significantly associated between age and sex interaction terms but not anymore if considering positive HCV status. All noninvasive tests for liver fibrosis were associated with cholelithiasis but only fibrosis-4 index was significantly associated (OR = 1.28, P = .019).Age, gender, and HCV infection are associated with increased risk and prevalence of cholelithiasis. After age of 55 years, cholelithiasis is more prevalent among HCV-positive males than females. Females of age 55 and more may be protected against cholelithiasis as sex hormones decrease.

Add-on neurological benefits of antiviral therapy in HCV patients with chronic kidney disease - a nationwide cohort study

Background

Hepatitis C virus (HCV)-infected patients with chronic kidney disease (CKD) have rarely been studied because they rarely accept interferon-based therapy (IBT) and have been difficult to follow up. We investigated long-term outcomes of IBT on the population.

Methods

This population-based cohort study used the Taiwan National Health Insurance Research Database as its data source. HCV patients diagnosed with CKD between Jan. 1, 2003, and Dec. 31, 2013, were selected. They were then divided into two groups based on whether they had undergone IBT. All-cause mortality, acute myocardial infarction (AMI), ischemic stroke (IS), hemorrhagic stroke, and new-onset dialysis were evaluated using a Cox proportional hazard regression analysis after propensity score matching.

Results

We enrolled 9872 HCV patients with CKD: 1684 patients in the treated cohort and 8188 patients in the untreated cohort. The annual incidence of all-cause mortality (19.00 vs. 42.89 events per 1000 person-years; p < 0.001) and the incidences of hemorrhagic stroke (1.21 vs. 4.19 events per 1000 person-years; p = 0.006) were lower in the treated cohort. New-onset dialysis was also lower in the treated cohort (aHR: 0.31; 95% CI: 0.20–0.48; p < 0.001).

Conclusion

Antiviral therapy might provide protective benefits on all-cause mortality, hemorrhagic stroke, and new-onset dialysis in HCV-infected patients with CKD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0653-2) contains supplementary material, which is available to authorized users.

Prevalence, discomfort and self-relief behaviours of painful diabetic neuropathy in Taiwan: a cross-sectional study

OBJECTIVES

To explore the prevalence, discomfort, and self-relief behaviours of painful diabetic neuropathy (PDN) among rural community residents with type 2 diabetes.

DESIGN

A community-based, cross-sectional study.

SETTING

This study was part of a longitudinal cohort study of a nurse-led health promotion programme for preventing foot ulceration in Chiayi County, Taiwan.

PARTICIPANTS

Six hundred and twenty-eight community adults with type 2 diabetes participated in this study.

OUTCOME MEASURES

Parameters assessed included peripheral neuropathy, peripheral vasculopathy, glycaemic control and metabolic biomarkers. Statistical analyses included descriptive statistics and a multivariate logistic regression model.

RESULTS

About 30.6% of participants (192/628) had PDN. Factors associated with PDN included an abnormal ankle brachial index (ABI; OR=3.4; 95% CI 1.9 to 6.2; p<0.001), Michigan neuropathy screening index (OR=1.69; 95% CI 1.0 to 2.6; p=0.021), triglyceride level (OR=1.61; 95% CI 1.0 to 2.4; p=0.036) and being female (OR=1.68; 95% CI 1.1 to 2.4; p=0.022). PDN was characterised by uncomfortable feelings of prickling, stinging or burning pain and inexplicable dullness around the base or dorsal areas of the feet, but received little attention or treatment from primary healthcare providers.

CONCLUSIONS

A high prevalence of PDN was found in rural community residents with type 2 diabetes and the healthcare workers provided little attention to, or treatment of, discomfort. It is important to identify high-risk groups with PDN early in order to prevent foot ulceration and reduce the incidence of amputation of the extremities. It is also urgent to develop appropriate treatment and self-relief behaviours to halt or reverse the progression of PDN for this population living in rural areas.

Factors associated with having less than 20 natural teeth in rural adults: a cross-sectional study

BACKGROUND

Some systematic reviews have consistently indicated a positive link between Metabolic syndrome, impairedfasting glucose, all-cause or circulatory disease-related mortality, general health, periodontitis, and toothloss. This study was to examine the prevalence of number of remaining teeth <20 and associated risk factors among adults in a rural area of Taiwan.

METHODS

A community-based, cross-sectional study was conducted in southwestern coastal Taiwan in 2013; 6680 residents aged 20-64 years were studied. Oral hygiene, substance use, dietary habits, and metabolic syndrome were explored as potential risk factors for number of remaining teeth <20 using logistic regression analysis.

RESULTS

The mean number of remaining teeth was 24.6 (SD = 7.4), and 16.3 % (n = 1085) of the participants had number of remaining teeth <20. Men had significantly less frequent use of dental floss, unhealthy dietary habits, more substance use and metabolic syndrome than did women (p <0.001). However, women tended to have fewer teeth than men (p <0.001). After adjusting for potential confounders, older age (odds ratio [OR] = 4.56, 95 % confidence interval [CI]: 3.74-5.55), female (OR = 1.88, 95 % CI: 1.56-2.25), less education (OR = 2.40, 95 % CI: 1.90-3.02), infrequent use of dental floss (OR = 1.94, 95 % CI: 1.66-2.27), substance use (OR = 1.32, 95 % CI: 1.09-1.59), and number of metabolic syndrome components (OR = 1.10, 95 % CI: 1.04-1.16) were independently associated with a higher risk of number of remaining teeth <20.

CONCLUSIONS

Number of remaining teeth <20 was highly prevalent among rural adults. In addition to unmodifiable factors, infrequent use of dental floss, substance use, and metabolic syndrome were risk factors associated with tooth loss.