Changes to the national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs between 2013 and 2016: a cross-sectional survey of 34 European countries

Background: Hepatitis C virus (HCV) infection is the leading cause of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC) worldwide. In Europe, people who inject drugs (PWID) represent the majority of HCV infections, but are often excluded from treatment. The aim of this study was to report on national HCV strategies, action plans and guidelines in European countries that include HCV treatment for the general population as well as for PWID. Data on access to direct-acting antivirals (DAAs) were also collected. Methods: In 2016, 38 non-governmental organisations, universities and public health institutions that work with PWID in 34 European countries were invited to complete a 16-item online survey about current national HCV treatment policies and guidelines. Data from 2016 were compared to those from 2013 for 33 European countries, and time trends are presented. Differences in the data were analysed. Data from 2016 on general access to DAAs in PWID are presented separately. Results: The response rate was 100%. Fourteen countries (42%) reported having a national HCV strategy covering HCV treatment; 12 of these addressed HCV treatment for PWID. Respondents from ten countries (29%) reported having a national HCV action plan. PWID were specifically included in seven of them. Twenty-nine countries (85%) reported having national HCV treatment guidelines. PWID were specifically included in 23 (79%) of them. Compared to 2013, respondents reported that an additional seven countries (25%) had national strategies, an additional eight countries (29%) had action plans and an additional six countries (19%) had HCV treatment guidelines. However, PWID were not included in two, four and six of those countries, respectively. DAAs were reported to be available in 91% of the study countries, with restrictions reported in 71% of them. Conclusion: Respondents reported that fewer than half of the European countries in this study had a national HCV strategy and/or action plan, with even fewer including PWID. However, when compared to 2013, the number of such countries had slightly increased. Although PWID are often addressed in clinical guidelines, strategic action is needed to increase access to HCV treatment for this group and the situation should be regularly monitored

The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Objective: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. Methods: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. Results: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm 2, 1.4% in 171 patients with a JBA 4 to 8 mm2, 3.2% in 46 patients with a JBA 8 to 10 mm2, and 5% in 198 patients with a JBA >10 mm2 (P <.001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm2, 4-8 mm2, >8 mm2) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. Conclusions: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation

Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification

Background The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods This was a prospective, multicenter, cohort study of patients undergoing medical intervention for vascular disease. Hazard ratios for ICA stenosis, clinical features, and plaque texture features associated with ipsilateral cerebrovascular or retinal ischemic (CORI) events were calculated using proportional hazards models. Results A total of 1121 patients with 50% to 99% asymptomatic ICA stenosis in relation to the bulb (European Carotid Surgery Trial [ECST] method) were followed-up for 6 to 96 months (mean, 48). A total of 130 ipsilateral CORI events occurred. Severity of stenosis, age, systolic blood pressure, increased serum creatinine, smoking history of more than 10 pack-years, history of contralateral transient ischemic attacks (TIAs) or stroke, low grayscale median (GSM), increased plaque area, plaque types 1, 2, and 3, and the presence of discrete white areas (DWAs) without acoustic shadowing were associated with increased risk. Receiver operating characteristic (ROC) curves were constructed for predicted risk versus observed CORI events as a measure of model validity. The areas under the ROC curves for a model of stenosis alone, a model of stenosis combined with clinical features and a model of stenosis combined with clinical, and plaque features were 0.59 (95% confidence interval [CI] 0.54-0.64), 0.66 (0.62-0.72), and 0.82 (0.78-0.86), respectively. In the last model, stenosis, history of contralateral TIAs or stroke, GSM, plaque area, and DWAs were independent predictors of ipsilateral CORI events. Combinations of these could stratify patients into different levels of risk for ipsilateral CORI and stroke, with predicted risk close to observed risk. Of the 923 patients with <70% stenosis, the predicted cumulative 5-year stroke rate was <5% in 495, 5% to 9.9% in 202, 10% to 19.9% in 142, and <20% in 84 patients. Conclusion Cerebrovascular risk stratification is possible using a combination of clinical and ultrasonic plaque features. These findings need to be validated in additional prospective studies of patients receiving optimal medical intervention alone. Copyright © 2010 by the Society for Vascular Surgery

Carotid arteries in central retinal vessel occlusion as assessed by Doppler ultrasound.

Doppler ultrasound was used to detect possible flow changes in the carotid arteries of patients with central retinal artery and vein occlusion. Twenty-three patients with central retinal artery occlusion (mean age 56, SD 11, years) were examined 4 to 48 months after the development of the occlusion and compared with age and sex matched control subjects with no history of any disease known to be associated with pathological changes in carotid vessels. Significant stenosis or occlusion of one or more carotid arteries was discovered in eight patients with retinal artery occlusion, while the ultrasonic findings were normal in all the controls (p less than 0.005). Blood flow was evaluated by the same method in 16 patients with central retinal vein occlusion (mean age 57, SD 9, years) six to 48 months after the event. A control group was chosen according to the same criteria as in previous comparison. Pathological ultrasonic findings were observed neither in the patients with retinal vein occlusion nor in the control group. The results suggested a possible aetiological relation between pathological changes in the carotid arteries and occlusion of the central retinal artery, but not occlusion of the central retinal vein

Changes to the national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs between 2013 and 2016: a cross-sectional survey of 34 European countries

Background: Hepatitis C virus (HCV) infection is the leading cause of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC) worldwide. In Europe, people who inject drugs (PWID) represent the majority of HCV infections, but are often excluded from treatment. The aim of this study was to report on national HCV strategies, action plans and guidelines in European countries that include HCV treatment for the general population as well as for PWID. Data on access to direct-acting antivirals (DAAs) were also collected. Methods: In 2016, 38 non-governmental organisations, universities and public health institutions that work with PWID in 34 European countries were invited to complete a 16-item online survey about current national HCV treatment policies and guidelines. Data from 2016 were compared to those from 2013 for 33 European countries, and time trends are presented. Differences in the data were analysed. Data from 2016 on general access to DAAs in PWID are presented separately. Results: The response rate was 100%. Fourteen countries (42%) reported having a national HCV strategy covering HCV treatment; 12 of these addressed HCV treatment for PWID. Respondents from ten countries (29%) reported having a national HCV action plan. PWID were specifically included in seven of them. Twenty-nine countries (85%) reported having national HCV treatment guidelines. PWID were specifically included in 23 (79%) of them. Compared to 2013, respondents reported that an additional seven countries (25%) had national strategies, an additional eight countries (29%) had action plans and an additional six countries (19%) had HCV treatment guidelines. However, PWID were not included in two, four and six of those countries, respectively. DAAs were reported to be available in 91% of the study countries, with restrictions reported in 71% of them. Conclusion: Respondents reported that fewer than half of the European countries in this study had a national HCV strategy and/or action plan, with even fewer including PWID. However, when compared to 2013, the number of such countries had slightly increased. Although PWID are often addressed in clinical guidelines, strategic action is needed to increase access to HCV treatment for this group and the situation should be regularly monitored

Hepatitis C virus prevalence and level of intervention required to achieve the WHO targets for elimination in the European Union by 2030: a modelling study

Abstract BACKGROUND: Hepatitis C virus (HCV) is a leading cause of liver-related morbidity and mortality worldwide. In the European Union (EU), treatment and cure of HCV with direct-acting antiviral therapies began in 2014. WHO targets are to achieve a 65% reduction in liver-related deaths, a 90% reduction of new viral hepatitis infections, and 90% of patients with viral hepatitis infections being diagnosed by 2030. This study assessed the prevalence of HCV in the EU and the level of intervention required to achieve WHO targets for HCV elimination. METHODS: We populated country Markov models for the 28 EU countries through a literature search of PubMed and Embase between Jan 1, 2000, and March 31, 2016, and a Delphi process to gain expert consensus and validate inputs. We aggregated country models to create a regional EU model. We used the EU model to forecast HCV disease progression (considering the effect of immigration) and developed a strategy to acehive WHO targets. We used weighted average sustained viral response rates and fibrosis restrictions to model the effect of current therapeutic guidelines. We used the EU model to forecast HCV disease progression (considering the effect of immigration) under current screening and therapeutic guidelines. Additionally, we back-calculated the total number of patients needing to be screened and treated to achieve WHO targets. FINDINGS: We estimated the number of viraemic HCV infections in 2015 to be 3 238 000 (95% uncertainty interval [UI] 2 106 000-3 795 000) of a total population of 509 868 000 in the EU, equating to a prevalence of viraemic HCV of 0·64% (95% UI 0·41-0·74). We estimated that 1 180 000 (95% UI 1 003 000-1 357 000) people were diagnosed with viraemia (36·4%), 150 000 (12 000-180 000) were treated (4·6% of the total infected population or 12·7% of the diagnosed population), 133 000 (106 000-160 000) were cured (4·1%), and 57 900 (43 900-67 300) were newly infected (1·8%) in 2015. Additionally, 30 400 (26 600-42 500) HCV-positive immigrants entered the EU. To achieve WHO targets, unrestricted treatment needs to increase from 150 000 patients in 2015 to 187 000 patients in 2025 and diagnosis needs to increase from 88 800 new cases annually in 2015 to 180 000 in 2025. INTERPRETATION: Given its advanced health-care infrastructure, the EU is uniquely poised to eliminate HCV; however, expansion of screening programmes is essential to increase treatment to achieve the WHO targets. A united effort, grounded in sound epidemiological evidence, will also be necessary

Hepatitis C virus prevalence and level of intervention required to achieve the WHO targets for elimination in the European Union by 2030: a modelling study

Abstract BACKGROUND: Hepatitis C virus (HCV) is a leading cause of liver-related morbidity and mortality worldwide. In the European Union (EU), treatment and cure of HCV with direct-acting antiviral therapies began in 2014. WHO targets are to achieve a 65% reduction in liver-related deaths, a 90% reduction of new viral hepatitis infections, and 90% of patients with viral hepatitis infections being diagnosed by 2030. This study assessed the prevalence of HCV in the EU and the level of intervention required to achieve WHO targets for HCV elimination. METHODS: We populated country Markov models for the 28 EU countries through a literature search of PubMed and Embase between Jan 1, 2000, and March 31, 2016, and a Delphi process to gain expert consensus and validate inputs. We aggregated country models to create a regional EU model. We used the EU model to forecast HCV disease progression (considering the effect of immigration) and developed a strategy to acehive WHO targets. We used weighted average sustained viral response rates and fibrosis restrictions to model the effect of current therapeutic guidelines. We used the EU model to forecast HCV disease progression (considering the effect of immigration) under current screening and therapeutic guidelines. Additionally, we back-calculated the total number of patients needing to be screened and treated to achieve WHO targets. FINDINGS: We estimated the number of viraemic HCV infections in 2015 to be 3 238 000 (95% uncertainty interval [UI] 2 106 000-3 795 000) of a total population of 509 868 000 in the EU, equating to a prevalence of viraemic HCV of 0·64% (95% UI 0·41-0·74). We estimated that 1 180 000 (95% UI 1 003 000-1 357 000) people were diagnosed with viraemia (36·4%), 150 000 (12 000-180 000) were treated (4·6% of the total infected population or 12·7% of the diagnosed population), 133 000 (106 000-160 000) were cured (4·1%), and 57 900 (43 900-67 300) were newly infected (1·8%) in 2015. Additionally, 30 400 (26 600-42 500) HCV-positive immigrants entered the EU. To achieve WHO targets, unrestricted treatment needs to increase from 150 000 patients in 2015 to 187 000 patients in 2025 and diagnosis needs to increase from 88 800 new cases annually in 2015 to 180 000 in 2025. INTERPRETATION: Given its advanced health-care infrastructure, the EU is uniquely poised to eliminate HCV; however, expansion of screening programmes is essential to increase treatment to achieve the WHO targets. A united effort, grounded in sound epidemiological evidence, will also be necessary