This document summarizes epidemiology and the natural history of hepatitis C virus (HCV) infection. It discusses the prevalence of HCV worldwide and in France, declining from 575,000 cases in 1994 to an estimated 270,000 cases in 2014. Risk factors for infection include blood transfusions before 1991, intravenous drug use, and occupational exposure for healthcare workers. The progression of liver fibrosis is influenced by factors like age, sex, alcohol consumption and HCV genotype. Large cohort studies have modeled fibrosis progression rates and identified rapid, intermediate and slow progressors. Non-invasive markers now help estimate fibrosis stages.
Los sistemas de pago en Internet incluyen cajeros electrónicos y dinero electrónico anónimo e identificado. PayPal permite la transferencia de dinero entre usuarios con correo electrónico como una alternativa a cheques o giros postales, cobrando un porcentaje por procesar pagos en comercio electrónico. Xoom permite enviar dinero a más de 45 países desde una computadora usando PayPal, tarjetas de crédito o fondos bancarios en EE.UU.
FibroTest and ActiTest provide accurate non-invasive assessment of fibrosis and activity in patients with chronic hepatitis B. Studies involving over 3,300 hepatitis B patients found FibroTest had standardized accuracy of 0.84 for fibrosis staging compared to 0.90 for liver biopsy. Analysis of discordant cases found biopsy failure accounted for at least half of discrepancies compared to biomarker results. The biomarkers also demonstrated ability to monitor treatment response and predict clinical outcomes in hepatitis B.
This document discusses hepatitis and travel risks. It provides statistics on the incidence of hepatitis A per 100,000 travellers to developing countries. The four main types of travellers are identified. Hepatitis A is summarized as being transmitted via the fecal-oral route and having no chronic phase. Vaccines for hepatitis A are inactivated whole virus vaccines and are highly immunogenic for both adults and children.
This document discusses diagnostic methods for genital tuberculosis. It covers direct visualization techniques like culture as well as non-culture methods like nucleic acid amplification tests. It notes that conventional culture methods using Lowenstein Jensen media are slow, taking 8 weeks for results. Newer liquid culture systems like MGIT and BacT/Alert allow for faster diagnosis within 1-4 weeks. Molecular tests like PCR and line probe assays can also rapidly detect Mycobacterium tuberculosis and determine drug resistance directly from clinical samples. The document emphasizes using a diagnostic algorithm that combines smear, culture and non-culture tests to improve definitive diagnosis of genital TB.
1) Liver carcinoma, specifically hepatocellular carcinoma (HCC), is a primary tumor of the liver that usually arises in a cirrhotic liver.
2) The main risk factors for HCC are chronic hepatitis B and C infections, which can lead to cirrhosis. Other risk factors include alcoholism and aflatoxin exposure.
3) HCC is often asymptomatic in early stages but can present with abdominal pain or a palpable mass. Diagnosis involves imaging like ultrasound or CT along with blood markers like alpha-fetoprotein.
Galati V. Quali sono i principali tipi di infezione? E come si manifestano? A...Gianfranco Tammaro
The document discusses the main types of hospital-acquired infections, including their most common locations such as the urinary tract, surgical sites, and lungs. It also examines the typical causative pathogens of ventilator-associated pneumonia and hospital-acquired pneumonia, which often involve drug-resistant bacteria like Pseudomonas aeruginosa and Acinetobacter species. The timing and risk factors for different types of hospital-acquired infections are also reviewed.
Presentazione a cura del Dottor Claudio Puoti - "HOT TOPICS IN GASTROENTEROLOGIA - I TUMORI DELL'APPARATO DIGERENTE: cosa è cambiato e cosa bisogna sapere" - Roma 10/11/2018
Los sistemas de pago en Internet incluyen cajeros electrónicos y dinero electrónico anónimo e identificado. PayPal permite la transferencia de dinero entre usuarios con correo electrónico como una alternativa a cheques o giros postales, cobrando un porcentaje por procesar pagos en comercio electrónico. Xoom permite enviar dinero a más de 45 países desde una computadora usando PayPal, tarjetas de crédito o fondos bancarios en EE.UU.
FibroTest and ActiTest provide accurate non-invasive assessment of fibrosis and activity in patients with chronic hepatitis B. Studies involving over 3,300 hepatitis B patients found FibroTest had standardized accuracy of 0.84 for fibrosis staging compared to 0.90 for liver biopsy. Analysis of discordant cases found biopsy failure accounted for at least half of discrepancies compared to biomarker results. The biomarkers also demonstrated ability to monitor treatment response and predict clinical outcomes in hepatitis B.
This document discusses hepatitis and travel risks. It provides statistics on the incidence of hepatitis A per 100,000 travellers to developing countries. The four main types of travellers are identified. Hepatitis A is summarized as being transmitted via the fecal-oral route and having no chronic phase. Vaccines for hepatitis A are inactivated whole virus vaccines and are highly immunogenic for both adults and children.
This document discusses diagnostic methods for genital tuberculosis. It covers direct visualization techniques like culture as well as non-culture methods like nucleic acid amplification tests. It notes that conventional culture methods using Lowenstein Jensen media are slow, taking 8 weeks for results. Newer liquid culture systems like MGIT and BacT/Alert allow for faster diagnosis within 1-4 weeks. Molecular tests like PCR and line probe assays can also rapidly detect Mycobacterium tuberculosis and determine drug resistance directly from clinical samples. The document emphasizes using a diagnostic algorithm that combines smear, culture and non-culture tests to improve definitive diagnosis of genital TB.
1) Liver carcinoma, specifically hepatocellular carcinoma (HCC), is a primary tumor of the liver that usually arises in a cirrhotic liver.
2) The main risk factors for HCC are chronic hepatitis B and C infections, which can lead to cirrhosis. Other risk factors include alcoholism and aflatoxin exposure.
3) HCC is often asymptomatic in early stages but can present with abdominal pain or a palpable mass. Diagnosis involves imaging like ultrasound or CT along with blood markers like alpha-fetoprotein.
Galati V. Quali sono i principali tipi di infezione? E come si manifestano? A...Gianfranco Tammaro
The document discusses the main types of hospital-acquired infections, including their most common locations such as the urinary tract, surgical sites, and lungs. It also examines the typical causative pathogens of ventilator-associated pneumonia and hospital-acquired pneumonia, which often involve drug-resistant bacteria like Pseudomonas aeruginosa and Acinetobacter species. The timing and risk factors for different types of hospital-acquired infections are also reviewed.
Presentazione a cura del Dottor Claudio Puoti - "HOT TOPICS IN GASTROENTEROLOGIA - I TUMORI DELL'APPARATO DIGERENTE: cosa è cambiato e cosa bisogna sapere" - Roma 10/11/2018
Biomarkers can provide non-invasive estimates of liver fibrosis to address the large number of undiagnosed cases. Liver biopsy has limitations as a gold standard due to sampling error and inter-observer variability. New methods show that biopsy has a "gray zone" for intermediate fibrosis stages, while biomarkers like FibroTest have a smaller gray zone and similar diagnostic accuracy to biopsy. Guidelines now recommend the use of validated biomarkers and elastography to diagnose liver fibrosis given biopsy's limitations.
This document discusses the long-term benefits of antiviral treatment for hepatitis B. It provides information on different phases of hepatitis B infection and when treatment is indicated. It also summarizes the approved antiviral drugs for treating chronic hepatitis B, including nucleoside analogs, nucleotide analogs, and cytokines. The document discusses the differences in lifecycles and mechanisms of HIV, HBV, and HCV. It then reviews the efficacy and resistance profiles of different antiviral drugs over time, highlighting the low resistance of tenofovir.
This document discusses treatment of hepatitis B and long-term benefits. It begins by outlining the different phases of hepatitis B infection and when treatment is indicated. The goals of treatment are virological suppression, normalization of liver enzymes, prevention of disease progression, and seroconversion from HBeAg to anti-HBe and from HBsAg to anti-HBs. Approved antiviral drugs for hepatitis B include lamivudine, entecavir, telbivudine, adefovir, tenofovir, interferon alfa, and pegylated interferon alfa-2a. Combination therapies and management of resistance are also discussed.
This document discusses hepatitis C recurrence after liver transplantation. It notes that hepatitis C recurrence is a major issue, accounting for two-thirds of graft loss. Five years post-transplant, 30% of patients have cirrhosis of the graft. The document examines factors that influence recurrence like fibrosis stage and viral load at one year post-transplant. It also discusses using antiviral treatment before and after transplant to improve outcomes.
This document discusses optimal strategies for preventing hepatitis B virus (HBV) recurrence after liver transplantation. It reviews evidence that combination prophylaxis with hepatitis B immunoglobulin (HBIG) and nucleoside/nucleotide analogues (NUCs) is most effective at preventing early HBV reinfection. For long-term prophylaxis, low-dose HBIG or HBIG discontinuation combined with lifelong NUC therapy may be sufficient for patients at low risk of recurrence. Factors such as HBV DNA level pre-transplant, hepatocellular carcinoma, and HBV/HIV coinfection increase risk of recurrence and require continued HBIG plus NUC prophylaxis.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Biomarkers can provide non-invasive estimates of liver fibrosis to address the large number of undiagnosed cases. Liver biopsy has limitations as a gold standard due to sampling error and inter-observer variability. New methods show that biopsy has a "gray zone" for intermediate fibrosis stages, while biomarkers like FibroTest have a smaller gray zone and similar diagnostic accuracy to biopsy. Guidelines now recommend the use of validated biomarkers and elastography to diagnose liver fibrosis given biopsy's limitations.
This document discusses the long-term benefits of antiviral treatment for hepatitis B. It provides information on different phases of hepatitis B infection and when treatment is indicated. It also summarizes the approved antiviral drugs for treating chronic hepatitis B, including nucleoside analogs, nucleotide analogs, and cytokines. The document discusses the differences in lifecycles and mechanisms of HIV, HBV, and HCV. It then reviews the efficacy and resistance profiles of different antiviral drugs over time, highlighting the low resistance of tenofovir.
This document discusses treatment of hepatitis B and long-term benefits. It begins by outlining the different phases of hepatitis B infection and when treatment is indicated. The goals of treatment are virological suppression, normalization of liver enzymes, prevention of disease progression, and seroconversion from HBeAg to anti-HBe and from HBsAg to anti-HBs. Approved antiviral drugs for hepatitis B include lamivudine, entecavir, telbivudine, adefovir, tenofovir, interferon alfa, and pegylated interferon alfa-2a. Combination therapies and management of resistance are also discussed.
This document discusses hepatitis C recurrence after liver transplantation. It notes that hepatitis C recurrence is a major issue, accounting for two-thirds of graft loss. Five years post-transplant, 30% of patients have cirrhosis of the graft. The document examines factors that influence recurrence like fibrosis stage and viral load at one year post-transplant. It also discusses using antiviral treatment before and after transplant to improve outcomes.
This document discusses optimal strategies for preventing hepatitis B virus (HBV) recurrence after liver transplantation. It reviews evidence that combination prophylaxis with hepatitis B immunoglobulin (HBIG) and nucleoside/nucleotide analogues (NUCs) is most effective at preventing early HBV reinfection. For long-term prophylaxis, low-dose HBIG or HBIG discontinuation combined with lifelong NUC therapy may be sufficient for patients at low risk of recurrence. Factors such as HBV DNA level pre-transplant, hepatocellular carcinoma, and HBV/HIV coinfection increase risk of recurrence and require continued HBIG plus NUC prophylaxis.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
1. 16 janv. 2009
Epidémiologie et histoire naturelle de l’hépatite virale C
DU 2009
Thierry Poynard
Groupe Hospitalier Pitié Salpêtrière
LiverCenter
2. 16 janv. 2009
Plan
• Natures
• Prévalence
• Facteurs de contamination
• Facteurs de gravité: vitesse de progression de la fibrose
2
3. 16 janv. 2009
Différentes natures de l’ Hépatite C
• Historique
• Emotionnelle
• Rationnelle
• Economique
3
4.
5. 16 janv. 2009
Case 1: Mlle Koretz-Seef née Optimiste
• 85 ans
• Transfusée âge de 10 ans
• HIV négative
• Pas d’alcool
• Pas de diabète
• A0 F1
5
6. 16 janv. 2009
Case 2: Mr Pitié-Salpêtrière
né Pessimiste
• Mort à 40 ans
• Hémophile infecté à l’âge de 30 ans
• HIV positif
• Alcool 60g par jour
• Diabétique
• A3 F4, Carcinome Hépatocellulaire
6
7. 16 janv. 2009
HCV Infection
A virologic and fibrotic disease
F4
Cancer
8. 16 janv. 2009
Prevalence of extra-hepatic manifestations
60
Fatigue
Arthralgia
Paresthesia
45
Myalgia
Pruritus
Sicca syndrom
30 Hypertension
Diabetes
Raynaud
Thyroiditis
15
Psoriasis
0
HCV n=1614 Control n=412
Cacoub, et al Arthritis Rheum 1999
Poynard, et al J Viral Hepatitis 2001
9. 16 janv. 2009
Plan
• Natures
• Prévalence: Monde, France
• Facteurs de contamination
• Facteurs de gravité: vitesse de progression de la fibrose
9
10. Fibrotic Liver
Disease
F0
F1
F2
F3
F4
Hemorrhage Liver failure Cancer
Poynard Lancet 1997
11. 16 janv. 2009
Population at risk of liver fibrosis, cirrhosis and
hepatocellular carcinoma (Millions)
No advanced fibrosis Advanced fibrosis
Insulin resistance
Alcool consumption
Hepatitis B
Hepatitis C
Hemochromatosis
0 150 300 450 600
11
15. J.F. Perz et al. / Journal of Hepatology 45 (2006) 529–538
a CIRRHOSIS b HEPATOCELLULAR CARCINOMA
Europe
AMRO-B/D EURO-A
SEARO-D SEARO-B
HBV HBV
AMRO-A AMRO-B/D
HCV HCV
EURO-A AMRO-A
SEARO-B AFRO-D/E
EURO-B/C EURO-B/C
AFRO-D/E EMRO-B
EMRO-B EMRO-D
SEARO-D
WPRO-A
Chine WPRO-B
WPRO-B
WPRO-A
EMRO-D
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 10
Fig. 1. Estimates of the attributable fractions of cirrhosis and hepatocellular carcinoma due to infection with HBV or HCV, by region.
HCC were attributable to HBV and HCV. Regional cohort [106]. Therefore, implementation of this stra
estimates of the alcohol-attributable fractions were also which represents the most effective way of preve
consistent with our estimates. Reported alcohol-attrib- 2006
Perz J Hepatol
chronic HBV infection and related end stage liver
utable fractions were generally high where viral hepati- ease, is far from complete [107,108]. Other key pri
27. 16 janv. 2009
Où sont passés les 200.000 entre 1994 et 2004 ?
• Variabilité échantillonage ?
• 1994: n=6.283 20-59 ans
• 2004: n=14.416 18-80 ans
• Morts ? 4.000/an= 40.000 OK pour PCR
• Traités (et Guéris) ?: 13.000/an (20à60%)
27
28.
29. 16 janv. 2009
Plan
• Natures
• Prévalence
• Facteurs de contamination
• Facteurs de gravité: vitesse de progression de la fibrose
29
30. 16 janv. 2009
Dépistage: Discussion
• IVDU: 70%
• Non transfusés Non IVDU: 28%
• Elargir dépistage
30
31. 16 janv. 2009
Risque élevé: Exposition au sang
• Transfusion avant 1991
• Hémophiles transplantés, hémodialysés, gammaglobulines, chimiotherapies
• Injection drogue intra-veineuse
• Personnel de santé avec accidents d’exposition au sang
• Enfants nés mère infectée HCV surtout si coinfection HIV
31
32. 16 janv. 2009
Risque modéré: Exposition au sang
• Comportement sexuel à risque
• Infection herpes simplex 2
• Cocaine et paille
• Médical: chirurgie, endoscopie, dents ...
• Para-médical: acupuncture, sclérose...
• Autres: tatouage, piercing, bagarre...
32
34. 16 janv. 2009
Plan
• Natures
• Prévalence
• Facteurs de contamination
• Facteurs de gravité: vitesse de progression de la fibrose
34
35. 16 janv. 2009
HCV and Fibrosis: Stellate, Inflammatory and Apoptotic Cells
Feld Hepatology 2006
36. 16 janv. 2009
HCV proteins and Fibrosis,
Inflammation, Steatosis, Apoptosis
Shuppan Cell Death Differ 2003
37. 16 janv. 2009
Survival of truth in HCV natural history
• 1980-1990: Necrosis biopsy, ALT
• Chronic persistent or active
• 1990-2000: Fibrosis biopsy
• Scheuer, Knodell-Ishak, METAVIR
• 2000-2010: Non invasive markers
• FibroTest, FibroScan…
37
38. HBV vaccination
Fibrotic Liver
No sex
Disease
No alcohol
No sugar
F0
No fat
No drug F1
FibroTest
F2
F3 Screening
Treatment
F4
Hemorrhage Liver failure Cancer
Poynard Lancet 1997
40. 16 janv. 2009
Fibrosis progression estimates : Methods
• Fibrosis estimate:
• « Observed »: 2 biopsies,
• « Estimated »: 1 biopsy,
• Time estimate:
• Between biopsies: short, bias, small sample
• Time of infection to biopsy: variability
• Age at biopsy = age at infection + infection duration
• Type of association between time and fibrosis:
• Linear, exponential…
• Markov transition
• Time dependent : hazard function
40
41. 16 janv. 2009
Dynamic Concept: Fibrosis progression rate
Stage Fibrosis
Rapid fibroser
METAVIR
4
Intermediate fibroser
3
2
1
Slow fibroser
0
0 10 20 30 40 50
Duration in years
Poynard et al Lancet 1997
42. 16 janv. 2009
Stage Fibrosis
METAVIR Male, > 40y, > 50 g alcohol
4
3
2
Female, < 40y, < 50 g
1
0
0 10 20 30 40 50
Duration in years
Poynard et al Lancet 1997
43. 2313 patients
31-40
n=348
>50 n=149
41-50 n=211
21-30
n=851
<21 n=754
Poynard T et al. J Hepatol 2001
45. 16 janv. 2009
Factors associated with fibrosis progression in HCV
Sure Not associated
Not sure
• Fibrosis stage • Last viral load
• Inflammation
• Age (Duration)
• Genotype non-3
• Hemochromatosis hH
• Alcohol >50g/d
• Mode of infection
• Cigarette, Cannabis
• HIV
• Alcohol <50g/d
• CD4 <200/ml
• HBV
• Male
• Transplantation
• Necrosis
• Genotype 3
• BMI, Steatosis,Diabetes,
• Schistosomiasis
Poynard et al Lancet 2003, EASL 2004
46. 16 janv. 2009
Expression of liver steatosis in HCV infection and pattern of response to interferon
Liver steatosis in a patient genotype 3 with recurrent hepatitis C after transplantation
Before therapy Response Relapse
Rubbia-Brandt et al, J Hepatol 2001
47. 16 janv. 2009
Effect of HCV Treatment on Steatosis
Genotype Non-3
Before After
80
60
40
20
0
Sustained Responders n=461 Non Responders n=439
Poynard et al Hepatology, 2003
48. 16 janv. 2009
Effect of HCV Treatment on Steatosis
Genotype 3
Before After
100
Viral Steatosis
75
50
25
0
Sustained Responders n=113 Non Responders n=21
Poynard et al Hepatology, 2003
49. 16 janv. 2009
Patients are seen 15 years after Infection
« Qui a fibrosé fibrosera »
« Who had fibrosed will fibrose »
Poynard circa 1990
49
50. 16 janv. 2009
Risk of errors : Florilege (2)
• Good estimates with good quality biopsy
• ALT is very useful for clinician to predict fibrosis progression
Ghany Gastroenterology 2003
51. 16 janv. 2009
Risk of errors : Florilege (1)
• Fibrosis progression is
• Linear
• Roughly linear
• Roughly linear by decades
• Roughly linear by decades with progressive acceleration after 40 years of age
• Roughly linear by decades with progressive acceleration after 40 years of age
despite competitive risks (Gastroenterology 2005)
51
52. 16 janv. 2009
Annual cost of Hepatitis C: US $
• No complications 110
• Ascites refractory 18 730
• Variceal bleeding 19 127
• Encephalopathy 12 278
• HCC 32 995
• Transplantation 108 650
Wong et al. Am J Public Health 2001
52
53. FibroTest!
First Line!
Reference Center
FibroScan for!
Confirmation !
Biopsy!
If discordances!
54. 16 janv. 2009
Résumé (1): Histoire naturelle de la fibrose
• Grossière linéarité par décades avec une accélération progressive après 40
ans
• Confirmation
• du rôle majeur de l ’âge
• de l’alcool > 50 g
• de l’insulino-résistance (diabète, surpoids, stéatose)
• HIV
• Absence d ’association
• Mode de contamination, génotype non-3, dernière charge virale
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55. 16 janv. 2009
Résumé (2): Mortalité
• Tueur lent et silencieux
• Deux sujets contaminés sur trois exposés à un risque majeur
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56. 16 janv. 2009
Résumé (3): Hépatite C en France
• 220.000 contaminés
• 4.000 morts / an (en augmentation)
• 50 % détectés
• 25 % traités
• Le traitement guérit plus de 50% des sujets et freine la progression de la
maladie chez les autres
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57. 16 janv. 2009
Conclusion:
Dépister mieux et traiter plus