Hepatitis B prevention, diagnosis, treatment and care: a review

Hepatitis B virus (HBV) infection is a major cause of morbidity and mortality worldwide. Chronic hepatitis B (CHB) infection is associated with an increased risk of cirrhosis, hepatic decompensation and hepatocellular carcinoma (HCC). The likelihood of developing CHB is related to the age at which infection is acquired; the risk being lowest in adults and >90% in neonates whose mothers are hepatitis B e antigen positive. Treatment of CHB infection aims to clear HBV DNA and prevent the development of complications. There are currently seven drugs available for the treatment of CHB: five nucleos(t)ide analogues and two interferon-based therapies. Long-term treatment is often required, and the decision to treat is based on clinical assessment including the phase of CHB infection and the presence and extent of liver damage. A safe and effective HBV vaccine has been available since the early 1980s. Vaccination plays a central role in HBV prevention strategies worldwide, and a decline in the incidence and prevalence of HBV infection following the introduction of universal HBV vaccination programmes has been observed in many countries including the USA and parts of South East Asia and Europe. Post-exposure prophylaxis (PEP) with HBV vaccine +/- hepatitis B immunoglobulin is highly effective in preventing mother to child transmission and in preventing transmission following sharps injuries, sexual contact and other exposures to infected blood and body fluids. Transmission of HBV in the health care setting has become an increasingly rare event in developed nations. However, it remains a significant risk in developing countries reflecting the higher prevalence of CHB, limited access to HBV vaccination and PEP and a lack of adherence to standard infection control precautions.     

Coronary artery stents in the treatment of ischaemic heart disease: a rapid and systematic review

BACKGROUND: Coronary artery stents are prosthetic linings inserted into coronary arteries via a catheter to widen the artery and increase blood flow to ischaemic heart muscle. They are used in the treatment of ischaemic heart disease (IHD). IHD is a major cause of morbidity and mortality (123,000 deaths per annum) in the UK and a major cost to the NHS. Clinical effects of IHD include subacute manifestations (stable and unstable angina) and acute manifestations (particularly myocardial infarction [MI]). Treatment includes attention to risk factors, drug therapy, percutaneous invasive interventions (PCIs) (including percutaneous transluminal coronary angioplasty [PTCA] and stents) and coronary artery bypass graft surgery (CABG). In the last decade there has been a steady and significant increase in the rate of PCIs for IHD. In the UK, rates per million population increased from 174 in 1991 to 437 in 1998. Stents are now used in about 70% of PCIs. Data from the rest of Europe suggest there is potential for PCI and stent rates to increase considerably. In the UK there is evidence of under-provision and inequity of access to revascularisation procedures. OBJECTIVES: The following questions were addressed. 1. What are the effects and effectiveness of elective stent insertion versus PTCA in subacute IHD, particularly stable angina and unstable angina? 2. What are the effects and effectiveness of elective stent insertion versus CABG in subacute IHD, particularly stable angina and unstable angina? 3. What are the effects and effectiveness of elective stent insertion versus PTCA in acute MI (AMI)? 4. What are best estimates of UK cost for elective stent insertion, PTCA and CABG in the circumstances of review questions 1 to 3? 5. What are best estimates of cost-effectiveness and cost-utility for elective stent insertion relative to PTCA or CABG in the circumstances of review questions 1 to 3? METHODS: A systematic review addressing the objectives was undertaken. DATA SOURCES: A search was made for RCTs comparing stents (inserted during a PTCA procedure) with PTCA alone or with CABG in any manifestation of IHD. The search strategy covered the period from 1990 to November 1999 and included searches of electronic databases (MEDLINE, EMBASE, BIDS ISI, The Cochrane Library), Internet sites, and hand-searches of cardiology conference abstracts and 1999 issues of cardiology journals. Lead researchers and local clinical experts were contacted. Manufacturers' submissions to the National Institute for Clinical Excellence were searched. The search strategy was expanded to look for relevant economic analyses and information to inform the economic model (including searching MEDLINE, the NHS Economic Evaluation Database and the Database of Abstracts of Reviews of Effectiveness). Searches focused on research that reported costs and quality of life data associated with IHD and interventional cardiology. STUDY SELECTION: For the review of clinical effectiveness, inclusion criteria were: (i) RCT design; (ii) study population comprising adults with IHD in native or graft vessels (including patients with subacute IHD or AMI); (iii) procedure involving elective insertion of coronary artery stents; (iv) elective PTCA (including PTCA with provisional stenting) or CABG as comparator; (v) outcomes defined as one or more of: combined event rate (or event-free survival), death, MI, angina, target vessel revascularisation, CABG, repeat PTCA, angiographic outcomes; (vi) trials that had closed and reported results for all or almost all recruited patients. For the economic evaluation, studies of adults with IHD were included if they were of the following types: studies reporting UK costs; comparative economic evaluation combining both costs and outcomes; economic evaluations reporting costs and outcomes separately for the years 1998 and 1999 (to ensure current practice was included).(ABSTRACT TRUNCATED)     

Creutzfeldt-Jakob disease: diagnosis, incidence, prevention and treatment

Creutzfeldt-Jakob disease (CJD) is a rare, neurodegenerative disorder belonging to the spongiform encephalopathies. A variant form (vCJD) is most likely the result of infection with the agent that causes bovine spongiform encephalopathy (BSE). Diagnostic information can be obtained by EEG, testing cerebrospinal fluid for the presence of the 14-3-3 protein, MRI, brain biopsy, tonsil biopsy, and postmortem brain examination. Some tests, such as MRI and postmortem brain examination, can be used to distinguish between CJD and vCJD. Pathological prions in a tonsil biopsy are only found with vCJD. In the Netherlands, there are four known cases of iatrogenic CJD. On the basis of certain exposure to BSE via the food chain, cases of vCJD are also to be expected. Chloropromazine and mepacrine are known to inhibit the formation of pathological prion conformations, but clinical trials have not yet been carried out.     

Liver fibrosis: pathophysiology, diagnosis and treatment

The extracellular matrix deposition in the liver parenchyma is a major component of cirrhosis. A great deal of knowledge has been gathered in the past two decades regarding the regulation and dynamics of fibrogenesis, and based on these advances, a review is delivered on the pathophysiology, diagnosis and therapy of liver fibrosis. The key event in fibrogenesis is the activation of hepatic stellate cells, and in its mechanism, inflammation, oxidative stress, steatosis, cytokines, growth factors, enzymes and enzyme inhibitors play a pivotal role. The phenotypic response of activated stellate cells comprises proliferation, fibrogenesis, contractility, loss of vitamin A and matrix degradation. In the diagnosis of liver fibrosis, besides liver biopsy--as "golden standard"--recently non-invasive methods, such as imaging techniques, and mainly serum fibrosis markers and indices have widely been studied. Experimental and clinical data have proved the reversibility of fibrosis, and suggested that an effective antifibrotic treatment in the future may serve even for the prevention of cirrhosis.     

Nosocomial diarrhea: a review of pathophysiology, etiology, and treatment strategies

Diarrhea is a frequent complication among hospitalized patients. Nosocomial diarrhea is generally diagnosed as increased frequency and decreased consistency of stools developing after 72 hours of hospitalization. The causes of nosocomial diarrhea may be infectious or noninfectious. Noninfectious etiologies occur most commonly, and are often adverse effects of medications or enteral nutrition therapies. Infectious etiologies are most concerning and include Clostridium difficile and norovirus. Patients with nosocomial diarrhea should be placed in isolation with contact precautions in place until the presence of C difficile infection is determined. Irrespective of etiology, diarrhea can cause serious complications in hospitalized patients, including malnutrition, hemodynamic instability, metabolic acidosis, and potentially fatal pseudomembranous colitis. This article reviews nosocomial diarrhea, including its pathophysiology, infectious and noninfectious causes, and treatment strategies based on identified cause.     

Gastroesophageal reflux disease in adults: pathophysiology, diagnosis, and management.

Gastroesophageal reflux disease (GERD) refers to symptoms or tissue damage that result from gastroesophageal reflux. Reflux esophagitis is a subset of GERD and implies the presence of esophageal inflammation, ie, esophageal erosions that are visible endoscopically, or nonerosive inflammation that can be documented by biopsies. Heartburn is the most common and specific symptom of GERD. In some patients, chest pain or respiratory symptoms may be the only presenting signs. In patients aged < 50 years with uncomplicated GERD, empiric therapy (typically with antacids or an H2-receptor antagonist) is appropriate. For older patients, those with complications, and those whose symptoms do not respond to empiric therapy, endoscopic evaluation is indicated. Many patients will improve with standard twice-daily dosing of an H2-receptor antagonist. However, GERD is generally more resistant to antisecretory pharmacologic therapy than is peptic ulcer disease. Those patients who fail to respond to standard dosing of an H2-receptor antagonist may get relief from high-dose H2-receptor antagonists or omeprazole therapy.     

Coronary artery calcification by computed tomography in epidemiologic research and cardiovascular disease prevention

Both American and European guidelines recommend coronary artery calcification (CAC) as a tool for screening asymptomatic individuals at intermediate risk for coronary heart disease (CHD). These recommendations are based on epidemiologic studies mostly in the United States. We review (1) the use of CAC in primary prevention of CHD in the United States, (2) epidemiologic studies of CAC in asymptomatic adults outside of the United States, and (3) international epidemiologic studies of CAC. This review will not consider clinical studies of CAC among patients or symptomatic individuals. US studies have shown that CAC is a strong independent predictor of CHD in both sexes among middle-aged and old age groups, various ethnic groups, and individuals with and without diabetes and that CAC plays an important role in reclassifying individuals from intermediate to high risk. Studies in Europe support these conclusions. The Electron-Beam Tomography, Risk Factor Assessment Among Japanese and US Men in the Post-World-War-II birth cohort (ERA JUMP) Study is the first international study to compare subclinical atherosclerosis, including CAC among Japanese, Japanese Americans, Koreans, and whites. It showed that as compared with whites, Japanese had lower levels of atherosclerosis, whereas Japanese Americans had similar or higher levels. CAC is being increasingly used as a screening tool for asymptomatic individuals in Europe and the United States. CAC is a powerful research tool, because it enables us to describe differences in atherosclerotic burden across populations. Such research could identify factors responsible for differences among populations, which may improve CHD prevention.     

Leishmaniasis: progress in diagnosis, treatment and prevention

Visceral leishmaniasis ranks second after malaria in the top 10 fatal parasitic diseases worldwide. Treatment is effective, but most patients live in developing countries where even basic health care is unavailable. Economic factors hamper a targeted approach, which should include the following: preventing transmission by distributing bednets; developing diagnostic tools that can be used in the field without a laboratory; developing new and affordable drugs; and evaluating different drug combinations and treatment schedules that may prevent the development of resistance, as has been done in tuberculosis, HIV and malaria.     

Coronary heart disease in women

Summary The results presented above indicate that the risk factors associated with the development of coronary heart disease in women are not that different than those identified for men. It is encouraging to note that while the prevalence of hypertension in women has not changed over that past twenty years, the proportion of treated hypertensive women has increased dramatically and the proportion with controlled blood pressure has doubled since 1960. It is also encouraging to note that the number of adult women who smoke cigarettes has decreased since 1960, but the number of young girls who smoke has increased at an alarming rate. It has been noted by researchers that among women who smoke, the number of cigarettes smoked per day has increased from the 1950s to the present. From the Framingham data it can be seen that womens' serum cholesterol level increases substantially with age and women should take steps to eat a healthy low-saturated fat, low cholesterol diet in order to maintain a low blood cholesterol level.It has been shown from the Framingham Study data that although the same risk factors operate in men and women, the standard risk factors do not explain the marked differences in morbidity and mortality from heart disease between the two sexes. We must continue to study the epidimiology and biology of coronary heart disease in women both to better understand the disease process in women and to understand the large sex differential for CHD in most westernized countries.

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Koronare Herzkrankheiten bei Frauen

Zusammenfassung Die Risikofaktoren der koronaren Herzkrankheit bei Frauen sind nicht wesentlich verschieden von denen bei Männern.Während sich die Hypertonieprävalenz bei Frauen in den letzten 20 Jahren nicht verändert hat, hat der Anteil der behandelten Hypertonikerinnen dramatisch zugenommen und der Anteil mit kontrollierten Blutdruckwerten hat sich seit 1960 verdoppelt. Die Zahl der erwachsenen Frauen, die Zigaretten rauchen, hat seit 1960 abgenommen, aber die Zahl der jungen Mädchen, die rauchen, hat sehr stark zugenommen. Unter den Raucherinnen hat die Zahl der pro Tag gerauchten Zigaretten von 1950 bis heute zugenommen. Aus der Framingham-Studie wird ersichtlich, dass die Serumcholesterinspiegel bei Frauen mit dem Alter stark zunehmen. Frauen sollten Nahrungsmittel mit einem niedrigen Gehalt an gesättigten Fetten und Cholesterin zu sich nehmen, um einen niedrigen Blutcholesterinspiegel zu erreichen.Die Daten der Framingham-Studie haben gezeigt, dass bei Männern und Frauen dieselben klassischen Risikofaktoren wirksam sind. Allerdings können die klassischen Risikofaktoren nicht die ausgeprägten Unterschiede in der Morbidität und Mortalität an koronarer Herzkrankheit zwischen beiden Geschlechtern erklären. Wir müssen weiterhin die Epidemiologie und Biologie der koronaren Herzkrankheit bei Frauen studieren, um den Krankheitsprozess bei Frauen besser zu verstehen und den grossen Unterschied in der Häufigkeit der Erkankung zwischen Männern und Frauen in den meisten westlichen Ländern besser erklären zu können.

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Maladies coronariennes chez les femmes

Résumé Alors que la prévalence de l'hypertension chez les femmes n'a guère changé durant les 20 dernières années, la proportion d'hypertensives traitées a augmenté considérablement, de même que celle des patients dont l'hypertension est contrÔlée (la proportion a doublé depuis 1960). Le nombre de femmes adultes fumant la cigarette a diminué, mais le nombre de jeunes fumeuses a fortement augmenté. Parmi les fumeuses, le nombre moyen de cigarettes par jour a augmenté depuis 1950. L'étude de Framingham a montré que le taux sanguin de cholestérol augmente avec l'âge des femmes. Elles devraient consommer des aliments contenant moins de graisses animales saturées, de faÇon à diminuer les taux sanguins de cholestérol. Les données de Framingham ont montré que les mêmes facteurs de risques agissent chez les femmes et les hommes. Ce sont les différences de prévalence de ces facteurs entre les sexes qui expliquent les différences de mortalité et de morbidité liées aux maladies coronaires. Il faut étudier plus à fond l'épidémiologie et la biologie de ces maladies chez les femmes, de faÇon à mieux comprendre les processus à l'uvre dans l'apparition de la maladie.