Community-Based Assessment and Treatment of Hepatitis C Virus-Related Liver Disease, Injecting Drug and Alcohol Use Amongst People Who Are Homeless: A Systematic Review and Meta-Analysis.

BACKGROUND/AIMS: We performed a systematic review and meta-analysis addressing community-based assessment and treatment of hepatitis C virus (HCV)-related liver disease, injecting drug use (IDU) and alcohol use amongst people who are homeless (PWAH). METHODS: Using systematic review methodology, databases were searched (MEDLINE/EMBASE/CINAHL) for studies combining PWAH, HCV-related liver disease and community assessment until December 2019. Studies with a sample size ≥ 30, with PWAH constituting at least 30% of the cohort were included and a quality assessment performed. Pooled estimates of key indicators were analysed using meta-analysis. RESULTS: We identified 39 studies (n = 13,918), 37 categorised as poor quality (Newcastle-Ottawa Scale). Prevalence of homelessness ranged between 30%-100% (37 studies). Eight studies provided all of the following: HCV screening, alcohol/substance use/liver fibrosis assessment and HCV treatment. No study provided interventions for alcohol use, with two providing opioid substitution treatment. Alcohol use prevalence (24 studies) was 4%-97%, being 59% (95% CI 20%-92%) in four studies that included only PWAH. Recent IDU prevalence (16 studies) was 7%-73%, being 21% (95% CI 17%-26%) in four studies that included only PWAH. HCV seroprevalence (25 studies) was 2.5% - 58%; in 13 studies that included only PWAH, this was 20% (95% CI 12%-30%). Prevalence of F4 fibrosis (nine studies) was 6%-28%, being 7% and 16% in two studies that included only PWAH. Direct acting antiviral-based intention-to-treat sustained virological response (SVR) rates (five studies) were 82%-92%, being 92% in the one study that included only PWAH. In the only two randomised controlled trials (RCT) identified, community-based interventions (mental health/peer mentor) significantly increased linkage to care (p = 0.04), HCV treatment (p = 0.005) and SVR rates (p = 0.018). CONCLUSION: The burden from alcohol/IDU and HCV, and consequently liver disease in PWAH needs addressing. RCT trials assessing community-based interventions to improve liver health in PWAH are needed.

Factors associated with thiopurine non-adherence in patients with inflammatory bowel disease.

BACKGROUND: Medication non-adherence seems to be a particular problem in younger patients with inflammatory bowel disease (IBD) and has a negative impact on disease outcome. AIMS: To assess whether non-adherence, defined using thiopurine metabolite levels, is more common in young adults attending a transition clinic than adults with IBD and whether psychological co-morbidity is a contributing factor. We also determined the usefulness of the Modified Morisky 8-item Adherence Scale (MMAS-8) to detect non-adherence. METHODS: Seventy young adults [51% (36) male] and 74 [62% (46) male] adults were included. Psychological co-morbidity was assessed using the Hospital Anxiety Depression Scale (HADS) and self-reported adherence using the MMAS-8. RESULTS: Twelve percent (18/144) of the patients were non-adherent. Multivariate analysis [OR, (95% CI), P value] confirmed that being young adult [6.1 (1.7-22.5), 0.001], of lower socio-economic status [1.1 (1.0-1.1), <0.01] and reporting higher HADS-D scores [1.2 (1.0-1.4), 0.01] were associated with non-adherence. Receiver operator curve analysis of MMAS-8 scores gave an area under the curve (95% CI) of 0.85 (0.77-0.92), (P < 0.0001): using a cut-off of <6, the MMAS-8 score has a sensitivity of 94% and a specificity of 64% to predict thiopurine non-adherence. Non-adherence was associated with escalation in therapy, hospital admission and surgeries in the subsequent 6 months of follow up. CONCLUSIONS: Non-adherence to thiopurines is more common in young adults with inflammatory bowel disease, and is associated with lower socio-economic status and depression. The high negative predictive value of MMAS-8 scores <6 suggests that it could be a useful screen for thiopurine non-adherence.

Familial adenomatous polyposis: clinical presentation, detection and surveillance.

Colorectal cancer (CRC) is a leading cause of cancer related death in the western countries. It remains an important health problem, often under-diagnosed. The symptoms can appear very late and about 25% of the patients are diagnosed at metastatic stage. Familial adenomatous polyposis (FAP) is an inherited colorectal cancer syndrome, characterized by the early onset of hundred to thousands of adenomatous polyps in the colon and rectum. Left untreated, there is a nearly 100% cumulative risk of progression to CRC by the age of 35-40 years, as well as an increased risk of various other malignancies. CRC can be prevented by the identification of the high risk population and by the timely implementation of rigid screening programs which will lead to special medico-surgical interventions.

Concordance of risk factors in female spouses of male patients with coronary heart disease.

PURPOSE: Shared environment may put marital partners at increased risk for coronary heart disease (CHD). In this study, the authors examined the degree of concordance of risk factors between men with CHD (n = 177) and their spouses, and described the risk profiles of both patients and spouses. Risk factors examined were smoking, hypertension, obesity, cholesterol level, diet, and exercise. METHODS: Data were collected 2 months after the cardiac event using the Behavioral Risk Factor Surveillance System tool. Concordance between patient and spouse pairs was evaluated using Pearson correlation coefficients (r) for continuous data and phi coefficients (phi) for nominal data. RESULTS: Significant concordance was found between patient and spouse pairs for body mass index, history of smoking, current smoking status, frequency of exercise, miles per exercise session, and the amount of fat and fiber in the diet. There was no significant spousal concordance in relation to the diagnosis of hypertension, systolic and diastolic blood pressure (BP), cholesterol level, history of high cholesterol, current exercise program, duration of exercise, and amount of salt in the diet. Thus, although the physiological indicators of risk (e.g., BP) were not significantly related among marital partners, behavioral indicators of risk (e.g., smoking) were significantly related. CONCLUSIONS: The findings suggested that shared lifestyles of marital partners may result in greater risk of CHD for female partners of men with CHD. Furthermore, lifestyle interventions that specifically target the marital partners as a unit may be more efficacious than individual patient education strategies.

Failure of exhalation during ventilation with the Dräger Oxylog 2000 ventilator.

We describe three cases in which there was failure of exhalation during mechanical ventilation with the Dräger Oxylog 2000 ventilator. Two potential mechanisms for this failure were identified, and were then experimentally reproduced on a test lung. First, a manufacturing fault in the silicone diaphragm in the ventilation valve was discovered. When a small hole in the diaphragm was incompletely perforated, a possible flap valve was formed, limiting exhalation. Second, failure of the one-way rubber disc valve to seat properly in its housing also prevented exhalation. These two previously unreported modes of ventilator failure have been identified. Careful checking of the ventilator circuit before each use is required.

Trypanosoma brucei rhodesiense: enhancement of infection rates in the tsetse fly, Glossina morsitans, by feeding artificial bloodmeal mixtures.

Low mature salivary gland (SG) infection rates (6%) in less than 24-hour-old flies fed on blood containing bloodform trypanosomes can be significantly enhanced by feeding flies an artificial mixture containing procyclic forms in a red cell: culture medium mixture (procyclic mixture, SG rate = 21.0%). However, enhancement is not solely a function of the use of procyclic forms since blood forms fed to flies in the same red cell: culture medium mixture produce SG rates (15.4%) intermediate to those of blood forms in blood and procyclic mixtures. Use of these artificial mixtures produces a similar result in 24- to 48-hour-old flies and also tends to equalize their infection rates with those found in less than 24-hour-old flies. The possible relationships between the different infection rates observed and digestive proteinases in the tsetse fly are discussed.

African sleeping sickness: new evidence that mature tsetse flies (Glossina morsitans) can become potent vectors.

Starved mature male tsetse flies (21 to 25 days old) are capable of developing salivary gland (SG) infections of Trypanosoma brucei rhodesiense at rates nearly comparable to teneral males less than 24 hours old when given an infective meal containing parasites, horse red cells and culture medium. Although the over-all SG infection rate for mature males starved for three, four or five days before infection was about half that for teneral males less than 48 hours old (8.0% v. 15.6%), males starved for four days developed infection rates (12.3%) that were comparable to those of teneral flies less than 24 hours old (11.8%). It is suggested that the acquisition of infection by mature flies should be considered when evaluating factors contributing either to maintenance of endemic infections or perhaps even epidemic infections of human sleeping sickness.

Some phenomena associated with the development of Trypanosoma brucei rhodesiense infections in the tsetse fly, Glossina morsitans.

Immature salivary gland (SG) infections averaging 10(3) parasites per fly can apparently develop into mature gland infections averaging 10(5) parasites per fly in as little as 4 days. Frequently flies which extrude parasites in their saliva prove to have no parasites in the SG, but often show trypanosomes in the esophagus, cibarial pump, and proboscis. In some instances, SG infections have cleared, resulting in a loss of infectivity. Results of studying numbers of parasites regurgitated upon feeding or probing have shown that number to be highly variable and not necessarily related either to previous feeding status or the total number of parasites in the glands. Cloning of metacyclics in mice has been achieved, indicating that the minimum effective dose is one parasite. To date, no infections in mice have resulted from inoculation of extraglandular parasites. Histological and dissection studies support both the classical route and an alternate route of infection development in flies. No SG-infected flies have been found which did not also have proventricular and anterior and posterior midgut (AMG and PMG) infections. Although the AMG is where the heaviest MG infections occur, the PMG seems to support the last survivors in a moribund MG infection. No parasites have been found in the hindgut.