Edited by Ane Palmo   
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                                    Journal of Viral Hepatitis 8 (5), 367-371
      © Blackwell Science Ltd

        Zinc supplementation enhances the response to interferon therapy in patients with chronic hepatitis C
       Takagi, Nagamine, Abe, Takayama, Sato, Otsuka, Kakizaki, Hashimoto, Matsumoto, Kojima, Takezawa, Suzuki, Sato and Mori

       We evaluated the synergistic effect of zinc supplementation on the response to interferon (IFN) therapy in patients with intractable chronic hepatitis C in a pilot study using natural IFN-a with or without zinc. No clinical differences were observed between patients treated with IFN alone (n=40) and IFN with polaprezinc (IFN + Zn, n=35). All patients were positive for HCV genotype Ib and had more than 105 copies of the virus/mL serum. Ten million units of natural IFN-a was administered daily for 4 weeks followed by the same dose every other day for 20 weeks. In the IFN + Zn group, patients received an additional dose of 150 mg/day polaprezinc orally throughout the 24-week IFN course. No additional side-effects of polaprezinc were noted but four out of 40 IFN alone treatment and three out of 35 IFN + Zn group withdrew because of side-effects. Complete response (CR) was defined as negative HCV RNA in the serum on PCR and normal aminotransferase level 6 months after therapy. Incomplete response (IR) was normal liver enzyme and positive serum HCV RNA. Both of them were evaluated at the 6 months after the completion of the treatment. Patients with higher levels of serum HCV (more than 5 × 105 copies/mL) had little response in both treatment groups. Patients with moderate amount of HCV (105 to 4.99 × 105/mL) showed high response rates in combination group (CR: 11/27, 40.7%;  CR + IR 15/27, 64.3%), better than IFN alone (CR: 2/15, 18.2%; CR + IR:  2/15, 18.2%). Serum zinc levels were higher in patients with IFN + Zn group than in the IFN group. Our results indicate that zinc supplementation enhances the response to interferon therapy in patients with intractable chronic hepatitis C.

Protein and calories

There must be enough of each of these, otherwise there is a sort of auto-cannibalism that takes place in the body, resulting in malnutrition (PCM=Protein-Calorie Malnutrition) 70-80% of transplant candidates have this condition, which is common in cirrhotic, and worsens with disease progression. The cause is poor nutritional intake due to: lack of appetite, nausea, early satiety, taste changes, dietary restrictions (salt, protein), fatigue, interferon, and/or financial issues.

Metabolic Changes
· There is a protein breakdown during fasting, even at night. Snack!
· Increased calorie burning in those with and without cirrhosis. This seems to be related to viral load.

Nutritional losses due to:
· Malabsorbtion
· Paracentisis (drainage of ascites or fluid buildup)

Why prevent PCM?
Good nutrition leads to improved healing and immunity and higher functionality.  With PCM (malnutrition), patients have a poor transplant outcome and low survival, better serum albumin and improved mortality and grade of cirrhosis.

Could treating malnutrition prevent cirrhosis? Does PCM influence HCV activity?

Recommendations:
Stage Protein g/k/day Calories cal/kg/day
Chronic Hep 1-1.5 30-40
Cirrhosis 1-1.5 30-40
Cirrhosis + PCM 1-1.8 40-50

Brain fog and diet

Brain fog occurs with cirrhosis. There is a theory that the liver doesn't detoxify the nitrogen, so protein is restricted. Brain fog can be aggravated by malnutrition. Reduced protein intake is not recommended when brain fog doesn't exist.

In a study, one group was tube fed 2600 calories (40 per kg. a day) and 103 g. of protein. These patients did better with brain fog than did a control group who took in orally 1600 calories and 50 grams of protein a day.

Maintain good bowel function with fiber and perhaps lactulose (prior to protein restriction)

Treatment of brain fog with Branched Chain Amino Acids (BCAA) is a controversial theory. Two studies show positive results in cirrhotics who can't tolerate protein. This is expensive, but available commercially (NutriHep)  [I don't sell this, and have never heard of it. The speaker mentioned it barely in passing.]

Iron and Hep C
There is a tendency for livers of those with Hep C to overload on iron. High iron causes liver damage. Iron probably catalyzes lipid peroxidation. Phlebotomy improves enzyme levels.

Recommendations:
Avoid iron supplements if you're not anemic. Take vitamins without iron Iron produces oxidative stress, and this in turn produces activation of stellate cells, which leads to collagen production.

Vitamin E: Enzyme levels improve with 400 U. daily, and this is safe for long term use. Vitamin E may prevent HCC, according to studies with animal models.

Vitamin A (Retinol) may prevent HCC. Retinol is low in HCV patients, and gets worse with progression. Less than 500 ng of retinal is equated with a higher risk of HCC.  Treatment of HCC with synthetic retinoide produces good results. Don't megadose!  Excess Vitamin A is toxic to the liver. Natural vitamin A may be even more toxic. (I think that's what I heard.) The exact amounts are unknown, but a maximum should be 10,000 IU/day. RDA is 3000 for males and 2300 for females. Avoid Vitamin A plus Beta Carotene. A normal multivitamin is OK.  Consume food with vitamin A.

Alcohol and HCV-is there a safe level?  Studies showed a graph of cell death measuring liver cells affected per square millimeter. Abstinence is the best. It is good to stop drinking.

Caffeine affects bone loss, common in HCV infection.

Avoid raw seafood, especially shellfish, because of the possible contamination and because of the iron content. Avoid aflatoxins, probably not a problem in North America. This is a fungus that grows on peanuts and other things. Don't eat bad-looking nuts.

Fatty Liver
Obesity may be a co-factor in fatty liver. Fatty infiltration is related to the fibrosis score.

Bone Loss
There is bone loss in 20-50% of HCV patients, and this increases with the stage of the disease.  Bone loss is greatly affected by post-transplant drugs. For those with cirrhosis, calcium intake should be 1500-1800 mg. A day, and vitamin D should be 800-1000 IU a day.

Drugs and Bone Loss:  Interferon doesn't seem to affect bone loss, but Ribavirin does, so patients taking Ribavirin may need more calcium and vitamin D.

Alternative Therapies:

Milk thistle: There have been conflicting studies done with milk thistle, probably due to badly designed studies. There is a current 2 yr. trial being done in Germany, combined it with the combo treatment.

NAC: This may slow the progression, according to studies with conflicting results. Most study results show no effect.

Alpha Lipoid Acid:  This is a good antioxidant and iron chelator. Study results are good in animals. There have been no positive results in humans, but perhaps the doses were too low.

SAMe (methionine): Animal studies look good. There is a small study in alcoholics where it delayed transplantation. A larger trial is necessary.

Newly developed enzyme immunoassay
for the detection of HCV core antigen 

The window period in hepatitis C virus (HCV) infection is still a major
problem in ensuring blood safety. HCV RNA detection by nucleic acid
amplification technology-based tests has contributed to reduce the
infectivity of blood products, but it is expensive, time-consuming and
affected by a high prevalence of false-positive results. The aim of this
study was to assess the performance of a newly developed enzyme immunoassay for the detection of HCV core antigen and its suitability for use in the screening of blood units in order to identify infecting samples that do not contain specific antibodies. For evaluation of laboratory performance,
different samples were selected: to evaluate specificity, we tested 2,586
sera from blood donors, 500 general population samples, and 58 "difficult
sera". All samples were tested by two screening assays, and results were
negative. To estimate clinical sensitivity, 103 HCV RNA-positive, anti-HCV-negative samples, 6 natural seroconversion panels, and 9 commercial seroconversion panels were tested. Intra- and interassay precision were determined on two HCV-RNA-positive, anti-HCV-negative sera. Seventeen (0.66%) blood donor samples, 2 (0.4%) general population samples, and 2 (3.44%) difficult sera were initially reactive; 3 sera were positive on
repetition. These 21 samples tested by reverse transcription-PCR were
negative. The clinical sensitivity calculated with seroconversion panels and
seroconverted patient samples was very similar to PCR sensitivity: 95% of
PCR-positive, antibody-negative samples contained detectable HCV antigen.
Data on intra- and interassay precision showed dispersion indices with
values of less than 10%. In conclusion, the HCV antigen assay showed high
sensitivity and specificity and could become a useful means of improving the
safety of blood and blood products.

Dentists Oppose Tongue Piercing

Hazards include infection, bleeding

By Nancy A. Melville
Health Scout Reporter

MONDAY, Aug. 7 (Health Scout) -- Getting your tongue pierced can leave you with a lot more than a bad taste in your mouth, dentists say. Whether the piercing is at the tip or the middle of your tongue, the potential health risks are so extensive that the American Dental Association (ADA) has formally declared its opposition to the practice.
Experts cite many potential complications from piercing, including obstruction of the airway caused by swelling of the pierced area, nerve injury, blood poisoning, chips, cracks or other damage to the teeth from biting the pierced object, foreign matters that can collect under, in or around the pierced object, sensitivity or allergic reaction to the metal and swallowing the "jewelry."
The experts consider ear piercing safer than tongue piercing, mostly because the earlobe has almost no blood supply. Because the tongue is so vascular, bleeding can be an especially serious problem, says ADA spokesman Dr. Michael Messina, a Cleveland, Ohio, dentist.
"Excessive bleeding can result under any conditions, but there are some very large arteries in the tongue, and it's certainly an anatomic possibility that you could sever an artery in the tongue and feasibly bleed to death," he says.
"As far as I know, no one has died because of the process, but if you look at the risk contained here, it becomes only a matter of time," he says.
Messina says, "I don't know the level of training in oral anatomy that your average piercing person has, but my hunch is that it's probably not very good."
Dentists also say the risk of infection is serious for any piercing, whether it's the lips, tongue or cheek, because so many bacteria live in the mouth.
The National Institutes of Health says piercing any body part invites hepatitis transmission, particularly when performed in a non-sterile, non-medical setting.
"We're especially concerned about the spread of things like hepatitis B or C, which can have an incubation period of years before people even know they've contracted it," says Dr. Anthony Antolini of Warren, Ohio, a member of the Ohio Dental Association.
Antolini says sterilization is essential to prevent the spread of bacteria.
"The use of autoclaves, which use steam under pressure, are standard in dental offices to kill things like the hepatitis virus and tuberculosis. If you're using anything less than that, you're not working in a sterile environment, and I don't think many of these piercing parlors have autoclaves," he says. Even less serious hazards of tongue piercing are enough to make someone's teeth chatter.
"For one thing, there's the chance you're left with a permanent hole in your tongue, since we don't really know the degree of the effectiveness of healing," Messina says. "There's then the risk in placing the needle through there -- if you've nicked a nerve or something you can have some paralysis of the tongue, loss of some taste sensation and inability to move part of the tongue, not to mention some speech impairment."  Antolini says, "We can't tell people not to do it because they're going to do it, so we're saying just look around and make sure the place is clean. Use the same criteria you might use for a restaurant, for instance -- see if the bathroom is clean. If it's not, use your common sense. Ask them if they have an autoclave, if they sterilize the device before they put it in your mouth. If they use that device on someone who has an infection before they use it on you, then there's potential for that infection being passed on and that includes HIV and hepatitis."

CAPSHAW - A prison within a prison, the Special Unit lives up to its name.

Inmates enrolled in the Substance Abuse Program at the Special Unit of the Limestone Correctional Facility hold hands during a meeting. The Special Unit is home to every man confined in the Alabama prison system known to have the AIDS virus. Every man in the Alabama prison system known to have AIDS is confined here, a converted warehouse at the Limestone Correctional Facility. More than 200 prisoners -- some frail and red-eyed, others fortified by bodybuilding -- inhabit long rows of bunk beds in the unit's main room, a cavernous, gray place as long as a football field.
To a degree unmatched in any other state, these men are systematically segregated round-the-clock and excluded from programs offered to other inmates. Eating, sleeping, worshipping, arguing, taking medication, perusing law books, playing dominoes -- every part of their daily routine occurs within a fenced-in compound that is like a quarantined island inside the larger prison complex. Inmates complain that living in such close quarters is stressful and unhealthy. The only privacy for each man is a drawer under his bed that he can padlock; pneumonia is more common in the unit than in other cell houses scattered across Limestone's grounds in North Alabama. But the segregation policy also has fueled a spirit of camaraderie and self-reliance. The men run their own substance abuse and AIDS-awareness courses. They organize memorial services when fellow inmates die. "We consider ourselves like family," said Arion Davis, who started a 17-year sentence for manslaughter in 1994. "At times, it causes tension. But we try to support each other." Davis and other inmates interviewed privately during a recent visit to the unit appreciate the efforts of their guards and medical staff to make life bearable, but they are bitter over their exclusion from educational and work-release programs that help shorten other prisoners' sentences.
The inmates -- ranging from first-time, nonviolent offenders to convicted murderers -- struggle with the reality that there are only two ways out: fight off the disease long enough to serve your time or die. 'No rehabilitation' "Keep us segregated if you want, but don't keep us from the programs," said Michael Merchant, jailed since 1999 on a drug conviction. "How are you going to keep a person from coming back here, if there's no rehabilitation?"
For nearly 16 years, Alabama's AIDS segregation policy was under legal attack by the American Civil Liberties Union and other groups. Last year, the U.S. Supreme Court refused to hear an appeal in which lawyers representing Davis and other HIV-infected inmates accused the state of unconstitutional discrimination. State officials welcomed the ruling and have made clear they plan to stick with the segregation policy despite criticism. The goal of preventing the spread of AIDS among prisoners "outweighs the rights they may have to equal programming," Department of Corrections attorney Andy Redd said. Mississippi and South Carolina also segregate their HIV-infected inmates, but South Carolina offers them some opportunities to share programs with other prisoners, and Mississippi officials recently promised to do likewise. "Alabama seems to be lagging behind in its understanding of how the virus is transmitted. Segregated religious services, segregated libraries -- they're not necessary," said Patrick Packer, a public health researcher at The University of Alabama-Birmingham. An estimated 30 incarcerated women with the AIDS virus also are isolated from other female inmates at the Tutwiller Prison for Women near Montgomery. Although offered parenting and substance-abuse courses, they have no access to educational and vocational programs provided the other women. But Packer doesn't expect any change unless state lawmakers suddenly see "what we're doing is completely wrong and inhumane."
Inmate resilience Packer visits the Special Unit at Limestone regularly, and he's impressed by the inmates' resilience. "They've transformed it from the place where they were going to die to a place of life and energy," he said. One example of their self-reliance is the inmate-run Substance Abuse Program, a six-month course open to 25 men at a time. The participants sleep in a bunk room separate from the main dormitory and engage in candid, sometimes confrontational group-therapy encounters. The men began a recent session by standing in a circle, holding hands, praying for inner strength. Then, seated, they took turns stating their names, their addiction problem and their mood. "I feel inspired," said one. "I feel locked up," said another. That's understandable. Though inmates have an outdoor exercise area in their compound, plus some tables in the shade for dominos or cards, they view the rest of the prison through a razor-wire fence that they rarely pass through -- except when seriously ill. In Alabama's midsummer heat, the unit is ventilated by a battery of industrial-size fans, and the temperature is tolerable. But many inmates still spend much of their spare time lying on thei bunks; there are few mandatory activities that require them to rouse. Special Unit inmate Ronald Hatcher, who received a life sentence for rape in 1989, says the lack of vocational programs and crowded living conditions breed tension in the unit. Three times daily, inmates line up outside the warehouse to get their medication through the window of a small nursing station. In the winter, inmates said, the wait of up to 90 minutes can be bone-chilling.
The unit's main room includes the bunk section, two TV-viewing areas with rows of wooden benches, a barber chair, a handcraft area where some inmates build model ships, and an elevated surveillance post in the middle of the room from which guards keep watch through windows and security cameras. Prison officials initially struggled to recruit guards for the unit because of fears of contracting AIDS. Incentives, including a salary bonus and four-day work week, solved the problem, and many on the current 21-member staff have worked in the unit for years. Good rapport
Capt. Wendy Williams, the unit supervisor, said the result is good rapport between guards and inmates. Many inmates "are going to die here, because of the length of their sentences, so it's almost like a death-row unit," Williams said. "You can't just treat them like other inmates. They have special problems, and we try to pick people to work here who can take that into consideration." Understanding that many inmates have nothing to lose gives the guards a strong incentive for minimizing confrontations, she said. "They have a deadly weapon in their system, and if they wanted to contaminate some of the staff, they could." Inmates who pose a serious threat, or are at risk of assault, are sometimes placed in solitary confinement in another building. "But we can't lock everybody up," Williams said. "It behooves us to work it out." Ronald Hatcher is among the Special Unit inmates who knows the depths of despair. He received a life sentence for rape in 1989, then learned he had the AIDS virus during the mandatory screening of all new inmates.
'Dying like flies' "When I first got here, I thought I'd die in six months," Hatcher said. "People were dying like flies. It was tough. One of my partners -- I tried to wake him up for breakfast one day, he was dead."
Gradually, improvements in AIDS medicines reduced the Special Unit death rate; officials said three of its inmates have died in the past year. But Hatcher, 34, says the lack of vocational programs and crowded living conditions still breed tension. "We're congested," he said. "It brings out a lot of hatred, a lot of envy." Initially sentenced to life without parole, Hatcher took a correspondence course in law and obtained a sentence revision so parole is possible. The Detroit native hopes his participation in group therapy and religious education programs will help him win release. "The toughest part is keeping yourself focused," he said. "There's a lot of stress." Williams said most of the fights in the unit stem from relationship conflicts and she estimated that more than 70 percent of the men engage in homosexual activity "We don't condone it, but it's a reality in this environment," she said. "I play marriage counselor. I divorce them sometimes. You're going to have lovers' quarrels, and as part of maintaining control and security, you have to deal with it."
The ACLU and other advocacy groups are trying to build grass-roots support in Alabama for reforms that would end the prison segregation policy or at least improve programs.
"They're just warehousing people," said Jackie Walker of the ACLU's National Prison Project. "It hurts the prisoners, and it hurts the community, because they're going out of prison in no better circumstances than when they went in." Williams agrees that vocational and academic courses -- perhaps through computer-based distance learning -- would be a welcome addition, but says there aren't enough resources for separate-but-equal programming. The state is grappling with a budget shortfall that has forced cutbacks in a wide array of programs and services. "Money's always an issue. We can't afford to buy the equipment," Williams said. Dr. Colette Simon, Limestone's infectious-disease expert, agrees with her Corrections Department superiors that the segregation policy is sound from a medical standpoint. It not only limits the spread of HIV, she said, but also enables the prison to assign dedicated, knowledgeable nurses to work exclusively with the Special Unit men. Nonetheless, many of the inmates and their families complain about the health risks of dormitory-style conditions.
"It's not an ideal situation," said Simon, who noted that pneumonia in the unit is more prevalent than among Limestone's 1,900 other inmates.
 Capt. Wendy Williams, left, supervisor at the Limestone Correctional Facility's Special Unit, with an inmate in the unit's dormitory area. The dorm houses some 230 HIV-positive inmates, segregated from the rest of Alabama's prison population. Even when a seriously ill inmate is moved from the Special Unit, segregation continues. There are both private rooms and a group ward at the main infirmary designated exclusively for inmates with the AIDS virus. In all, the atmosphere is daunting, even to an articulate, self-confident inmate like Keith Lewis. Lewis has been in the Special Unit for nine years, serving a 20-year sentence for first-degree robbery, and hopes to obtain parole soon. Now 34, he once studied business administration at Tennessee State University, but his leadership of the AIDS awareness program has convinced him he should become an AIDS counselor after his release. He strives to keep busy helping other inmates, but shares the anxiety that many of them feel. "Being caged up like this, there's a lot of fear," Lewis said. "You wonder, are you going to be able to be sociable any more, when you get out?"

From the Editor 

As this form of Hepatitis matures in the general,  institutionalized and military areas of our society so does the confusion over the exact numbers of affected persons due to this not being a reportable disease.  In some states it is now reportable in the chronic stages; in most it is and has been reportable in the acute phases.  The problem is the same existing problem as with other epidemics, the funding is not given to the State Department of Health to move forward and implement this program of "report ability".  The same thing happened with the "Look Back Program" which was theoretically designed to contact ALL persons who had received tainted blood from its inception through 1992.  The idealistic logistics of this program were to be lauded, but it fell through the cracks when it became evident of the cost needs involved and the fact it was thrown from the Red Cross to the hospitals and doctors to be the responsible parties for collecting data and sending out notices.  

The same economical drawback occurred with the letter to be sent out by the Surgeon General's Office in which the general population would be encouraged to be tested.  It was to be mailed out to each citizen in all states as a Federal project to give credence to this silent epidemic of huge and impacting proportions.  It was waylaid for financial reasons.  It seems that education and testing would ultimately pay off in the economy as less persons would end up in the late stages of liver failure and thus not have a need for a transplant later on in life or die.  A transplant costs around an average (give or take) $350,000.  With an average cost of $1300 per month for a 6 month treatment program that means that for this noted $350,000 for a liver transplant base amount around 785 persons could be treated and with the published 40% clearing the virus it would make education a valuable tool and testing a vital part of this scenario.  With reduced postal rates for this type of mailing done by the Federal Government it seems like the buck was once again passed and the patients and potential population who may be have been treated (thus generating monies) are falling through the cracks.

It all ultimately comes down to the impact this disease has on the economy and the burden of education of the patient and medical population.  The large pharmaceutical companies are, in their best interest, putting out statistics which often are a scale-down of the actual clearance rates for current products on the market to halt this virus.  The research often only includes a small percentage of the most difficult to clear persons with genotype 1b.  Thus the figures may 'seem' fairly encouraging to the general public when in actuality the most difficult genotype or strain encompasses 70% of the population.  1a genotype is difficult although the chances of clearing are much better than its other strain partner the 1b.

There seems to be a disturbing trend not to transplant those who need a second liver.  The shortage of livers no doubt bears witness to this situation.  The other component is that we realize that the virus does not go away with a liver transplant.  In fact the virus often manifests more aggressively than before the new liver was transplanted and often carries other pathogens imbedded in the new liver blood.  This is leading more and more to those who are in need of an original transplant being denied for just this reason.  This also occurred with Hepatitis B.  They now require a person to clear the HBV virus before a transplant will be performed in many transplant centers.  Is this what we have to look forward to in the future?  Are we being systematically railroaded into a difficult position just by being a person with this virus?  

Ane-Editor~Beacon

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