Screening Emergency Admissions at Risk of Chronic Hepatitis C (SEARCH) to diagnose or 're-diagnose' infections is effective in Australia.

The World Health Organization has set ambitious viral hepatitis elimination targets; however, difficulties in identifying and engaging patients remain. The emergency visit is an opportunity for enhanced linkage to care (LTC). We assessed the effectiveness of an automated Emergency Department (ED) screening service in identifying patients with hepatitis C (HCV) and achieving LTC. A retrospective evaluation was undertaken, analysing the first 5000 patients screened through an automatic Australian service termed 'Screening Emergency Admissions at Risk of Chronic Hepatitis' (SEARCH). Screening was performed for those recommended in the Australian national testing policy, specifically overseas born (OB) and Aboriginal or Torres Strait Islanders (ATSI). Healthcare worker education, patient information materials and opt-out informed consent were used to test sera already collected for biochemistry assays. 5000 of 5801 (86.2%) consecutive eligible patients were screened (OB: 4778, ATSI: 222) from 14 093 ED presentations. HCV antibody was positive in 181 patients (3.6%); 51 (1.0%) were HCV RNA positive. Of 51 HCV RNA-positive patients, 12 were new diagnoses, 32 were 're-diagnoses' (aware but lost to follow-up [LTFU]), and 7 were previously known but treatment contraindicated. LTC was successful in 38 viraemic patients (7 deceased, 4 LTFU, 1 treatment ineligible and 1 declined). Of RNA-negative patients, 75 were previously treated and 49 had presumed spontaneous clearance. Opt-out consent was acceptable to all patients and staff involved. ED screening can lead to additional diagnosing and 're-diagnosing' of HCV, with high rates of LTC. Opt-out consent and automation removed major obstacles to testing.

Dairy product consumption and its association with metabolic disturbance in a prospective study of urban adults.

The role of dairy foods and related nutrients in cardiometabolic health aetiology is poorly understood. We investigated longitudinal associations between the metabolic syndrome (MetS) and its components with key dairy product exposures. We used prospective data from a bi-racial cohort of urban adults (30-64 years at baseline (n 1371)), the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS), in Baltimore City, MD (2004-2013). The average of two 24-h dietary recalls measured 4-10 d apart was computed at baseline (V1) and follow-up (V2) waves. Annual rates of change (Δ) in dairy foods and key nutrients were estimated. Incident obesity, central obesity and the MetS were determined. Among key findings, in the overall urban adult population, both cheese and yogurt (V1 and Δ) were associated with an increased risk of central obesity (hazard ratio (HR) 1·13; 95 % CI 1·05, 1·23 per oz equivalent of cheese (V1); HR 1·21; 95 % CI 1·01, 1·44 per fl oz equivalent of yogurt (V1)]. Baseline fluid milk intake (V1 in cup equivalents) was inversely related to the MetS (HR 0·86; 95 % CI 0·78, 0·94), specifically to dyslipidaemia-TAG (HR 0·89; 95 % CI 0·81, 0·99), although it was directly associated with dyslipidaemia-HDL-cholesterol (HR 1·10; 95 % CI 1·01, 1·21). Furthermore, ΔCa and ΔP were inversely related to dyslipidaemia-HDL and MetS incidence, respectively, whereas Δdairy product fat was positively associated with incident TAG-dyslipidaemia and HDL-cholesterol-dyslipidaemia and the MetS. A few of those associations were sex and race specific. In sum, various dairy product exposures had differential associations with metabolic disturbances. Future intervention studies should uncover how changes in dairy product components over time may affect metabolic disorders.

Vitamin D Receptor and Megalin Gene Polymorphisms Are Associated with Longitudinal Cognitive Change among African-American Urban Adults.

Background: The link between longitudinal cognitive change and polymorphisms in the vitamin D receptor (VDR) and MEGALIN [or LDL receptor-related protein 2 (LRP2)] genes remains unclear, particularly among African-American (AA) adults.Objectives: We aimed to evaluate associations of single nucleotide polymorphisms (SNPs) for VDR [rs11568820 (Cdx-2:T/C), rs1544410 (BsmI:G/A), rs7975232 (ApaI:A/C), rs731236 (TaqI:G/A)] and LRP2 [rs3755166:G/A,rs2075252:C/T, rs2228171:C/T] genes with longitudinal cognitive performance change in various domains of cognition.Methods: Data from 1024 AA urban adult participants in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (Baltimore, Maryland) with complete genetic data were used, of whom 660-797 had complete data on 9 cognitive test scores at baseline and/or the first follow-up examination and complete covariate data (∼52% female; mean age: ∼52 y; mean years of education: 12.6 y). Time between examination visits 1 (2004-2009) and 2 (2009-2013) ranged from <1 y to ∼8 y, with a mean ± SD of 4.64 ± 0.93 y. Latent class and haplotype analyses were conducted by creating gene polymorphism groups that were related to longitudinal annual rate of cognitive change predicted from mixed-effects regression models.Results: Among key findings, the rs3755166:G/A MEGALIN SNP was associated with faster decline on the Mini-Mental State Examination overall (ß = -0.002, P = 0.018) and among women. VDR2 (BsmI/ApaI/TaqI: G-/A-/A-) SNP latent class [SNPLC; compared with VDR1 (ApaI: "AA")] was linked to faster decline on the Verbal Fluency Test, Categorical, in women, among whom the MEGALIN2 (rs2228171: "TT") SNPLC (compared with MEGALIN1:rs2228171: "CC") was also associated with a faster decline on the Trailmaking Test, Part B (Trails B), but with a slower decline on the Digit Span Backward (DS-B). Moreover, among men, the VDR1 SNP haplotype (SNPHAP; GCA:baT) was associated with a slower decline on the Trails B, whereas the MEGALIN1 SNPHAP (GCC) was associated with a faster decline on the DS-B, reflected as a faster decline on cognitive domain 2 ("visual/working memory").Conclusion:VDR and MEGALIN gene variations can alter age-related cognitive trajectories differentially between men and women among AA urban adults, specifically in global mental status and domains of verbal fluency, visual/working memory, and executive function.

Sex, Race, and Socioeconomic Disparities in Patients With Aortic Stenosis (from a Nationwide Inpatient Sample).

Aortic stenosis (AS) is the third most prevalent cardiovascular disease following hypertension and coronary artery disease. The primary objective of this cross-sectional study is to examine gender, racial, and socioeconomic disparities in AS-related health care utilization in patients aged ≥50 years using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AS was identified among inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1. Using stratum-specific weighted totals, means, proportions, and regression models, we examined time trends and disparities for inhospital AS prevalence according to gender, race, and income over the 2002 to 2012 period, predictors of AS (gender, race, income, age, health insurance, co-morbidities, and hospital-level characteristics), and AS's role as a predictor of inhospital death, length of stay, and total charges. Inhospital AS prevalence increased from 2.10% in 2002 to 2.37% in 2012, with similar trends observed within gender, race, and income strata. Women were less likely to have AS compared with men (adjusted odds ratio [ORadj] 0.84; 95% confidence interval [CI] 0.83 to 0.86). Blacks (ORadj 0.68; 95% CI 0.66 to 0.71), Hispanics (ORadj 0.79; 95% CI 0.76 to 0.84), and Asians/Pacific Islanders (ORadj 0.68; 95% CI 0.64 to 0.74) were less likely than whites to have AS diagnosis that was directly associated with income. AS was inversely related to inhospital death but positively linked to total charges overall and longer hospital stays among men, whites, and middle-income patients. However, shorter stays with AS were observed among blacks. In conclusion, among older inpatients, AS prevalence was ∼2% and was higher among males, whites, and higher income groups. Although inhospital death was lower and total charges were higher in AS, length of stay's association with AS varied by gender, race, and income.

Alternative Pathway Analyses Indicate Bidirectional Relations between Depressive Symptoms, Diet Quality, and Central Adiposity in a Sample of Urban US Adults.

BACKGROUND: Temporality between socioeconomic status (SES), depressive symptoms (DS), dietary quality (DQ), and central adiposity (CA) is underexplored. OBJECTIVES: Alternative pathways linking SES to DQ, DS, and CA were tested and models compared, stratified by race and sex. METHODS: With the use of data from the Healthy Aging in Neighborhoods of Diversity across the Life Span (baseline age: 30-64 y; 2 visits; mean follow-up: 4.9 y), 12 structural equation models (SM) were conducted and compared. Time-dependent factors included the Center for Epidemiologic Studies-Depression [CES-D total score, baseline or visit 1 (v1), follow-up or visit 2 (v2), mean across visits (m), and annual rate of change (Δ)], 2010 Healthy Eating Index (HEI) (same notation), and central adiposity principal components' analysis score of waist circumference and trunk fat (kg) (Adipcent) (same notation). Sample sizes were white women (WW, n = 236), white men (WM, n = 159), African American women (AAW, n = 395), and African American men (AAM, n = 274), and a multigroup analysis within the SM framework was also conducted. RESULTS: In the best-fitting model, overall, ∼31% of the total effect of SES→Adipcent(v2) (α ± SE: -0.10 ± 0.03, P < 0.05) was mediated through a combination of CES-D(v1) and ΔHEI. Two dominant pathways contributed to the indirect effect: SES→(-)CES-D(v1)→(+)Adipcent(v2) (-0.015) and SES→(+) ΔHEI→(-)Adipcent(v2) (-0.017), with a total indirect effect of -0.031 (P < 0.05). In a second best-fitting model, SES independently predicted Adipcent(v1, -0.069), ΔHEI(+0.037) and CES-D(v2, -2.70) (P < 0.05), with Adipcent(v1) marginally predicting ΔHEI(-0.014) and CES-D(v2, +0.67) (P < 0.10). These findings were indicative of DS's and CA's marginally significant bidirectional association (P < 0.10). Although best-fit-selected models were consistent across race × sex categories, path coefficients differed significantly between groups. Specifically, SES→Adipcent[v1(+0.11), v2(+0.14)] was positive among AAM (P < 0.05), and the overall positive association of Adipcent(v1)→CES-D(v2) was specific to AAW (+0.97, P < 0.10). CONCLUSIONS: Despite consistent model fit, pathways linking SES to DQ, DS, and CA differed markedly among the race × sex groups. Our findings can inform the potential effectiveness of various mental health and dietary interventions.

Thyroid hormones are associated with longitudinal cognitive change in an urban adult population.

Recent evidence indicates that thyroid hormones may be closely linked to cognition among adults. We investigated associations between thyroid hormones and longitudinal cognitive change, within and outside of reference ranges, stratifying by sex and race. This longitudinal study used data from the Healthy Aging in Neighborhoods of Diversity Across the Lifespan study, set in Baltimore City, MD, 2004-2013, on adults aged 30-64 years at baseline visit, with a length of follow-up between visits 1 and 2 ranging from <1 to 8 years; mean ± standard deviation: 4.64 ± 0.93. The final analytic sample sizes ranged from 1486 to 1602 participants with 1.6-1.7 visits per participant (total visits: 2496-2757), depending on the cognitive test. Eleven cognitive test scores spanning domains of learning or memory, language or verbal, attention, visuospatial and/or visuoconstruction, psychomotor speed, executive function, and mental status were used. Mixed-effects regression models were conducted, interacting time of follow-up with several thyroid exposures. Whites performed better than African Americans, with only 4 cognitive test scores of 11 declining significantly over time. Importantly, above reference range thyroid stimulating hormone (vs. reference range, thyroid stimulating hormone, above reference range [TSHarr]) was linked to faster rates of decline on the digits span backwards test, reflecting working memory (TSHarr × time γ ± standard error: -0.14 ± 0.05, p = 0.006) and clock-command, at test of visuospatial and/or visuoconstruction abilities (TSHarr × Time γ ± standard error: -0.10 ± 0.04, p = 0.004). The latter finding was replicated when comparing normal thyroid function to "subclinical hypothyroidism". Within-reference ranges, a higher thyroid stimulating hormone was related to faster decline on the clock-command test scores in women. In sum, higher baseline thyroid stimulating hormone was associated with faster cognitive decline over-time among urban US adults, specifically in domains of working memory and visuospatial and/or visuoconstruction abilities.

Nationwide Inpatient Prevalence, Predictors, and Outcomes of Alzheimer's Disease among Older Adults in the United States, 2002-2012.

In the inpatient setting, prevalence, predictors, and outcomes [mortality risk (MR), length of stay (LOS), and total charges (TC)] of Alzheimer's disease (AD) are largely unknown. We used data on older adults (60+ y) from the Nationwide Inpatient Sample (NIS) 2002-2012. AD prevalence was ∼3.12% in 2012 (total weighted discharges with AD ± standard error: 474, 410 ± 6,276). Co-morbidities prevailing more in AD inpatient admissions included depression (OR = 1.67, 95% CI: 1.63-1.71, p <  0.001), fluid/electrolyte disorders (OR = 1.25, 95% CI: 1.22-1.27, p <  0.001), weight loss (OR = 1.26, 95% CI: 1.22-1.30, p <  0.001), and psychosis (OR = 2.59, 95% CI: 2.47-2.71, p <  0.001), with mean total co-morbidities increasing over time. AD was linked to higher MR and longer LOS, but lower TC. TC rose in AD, while MR and LOS dropped markedly over time. In AD, co-morbidities predicting simultaneously higher MR, TC, and LOS (2012) included congestive heart failure, chronic pulmonary disease, coagulopathy, fluid/electrolyte disorders, metastatic cancer, paralysis, pulmonary circulatory disorders, and weight loss. In sum, co-morbidities and TC increased over time in AD, while MR and LOS dropped. Few co-morbidities predicted occurrence of AD or adverse outcomes in AD.

Helicobacter pylori seropositivity's association with markers of iron, 1-carbon metabolism, and antioxidant status among US adults: a structural equations modeling approach.

OBJECTIVES: We tested a model in which Helicobacter pylori seropositivity (Hps) predicted iron status, which in turn acted as a predictor for markers of 1-C metabolism that were then allowed to predict antioxidant status. METHODS: National Health and Nutrition Examination Surveys (NHANES 1999-2000) cross-sectional data among adults aged 20-85 y were analyzed (n = 3,055). Markers of Hps, iron status (serum ferritin and transferrin saturation (TS)); 1-C metabolism (serum folate (FOLserum), B-12, total homocysteine (tHcy), methylmalonic acid (MMA)) and antioxidant status (vitamins A and E) were entered into a structural equations model (SEM). RESULTS: Predictors of Hps included older age, lower education and income, racial/ethnic groups (lowest among Non-Hispanic Whites), and lifetime cigarette smoking. SEM modeling indicated that Hps had a direct inverse relationship with iron status (combining serum ferritin and TS) which in turn was positively related to 1-C metabolites (higher serum folate, B-12 or lower tHcy/MMA) that were positively associated with antioxidant status (combining serum vitamins A and E). Another pathway that was found bypassed 1-C metabolites (Hps → Iron_st → Antiox). The sum of all indirect effects from Hps combining both pathways and the other indirect pathways in the model (Hps → Iron_st → OneCarbon; Hps →OneCarbon →Antiox) was estimated at ß = -0.006±0.003, p<0.05. CONCLUSIONS: In sum, of the total effect of H. pylori seropositivity on antioxidant status, two significant indirect pathways through Iron status and 1-Carbon metabolites were found. Randomized controlled trials should be conducted to uncover the concomitant causal effect of H. pylori eradication on improving iron status, folate, B-12 and antioxidant status among H. pylori seropositive individuals.

Per-event probability of hepatitis C infection during sharing of injecting equipment.

BACKGROUND: Shared injecting apparatus during drug use is the premier risk factor for hepatitis C virus (HCV) transmission. AIMS: To estimate the per-event probability of HCV infection during a sharing event, and the transmission probability of HCV from contaminated injecting apparatus. METHODS: Estimates were obtained using a maximum likelihood method with estimated IDU and sharing events obtained from behavioural data. SETTINGS: Cohort study in multiple correction centres in New South Wales, Australia. PARTICIPANTS: Subjects (N = 500) with a lifetime history of injecting drug use (IDU) who were followed up between 2005 and 2012. During follow-up, interviews for risk behaviours were taken and blood sampling (HCV-antibody and RNA testing) was performed. MEASUREMENTS: Self-reported frequencies of injecting drugs and sharing events, as well as other risk behaviours and details on the nature of injecting events. FINDINGS: The best estimate of the per-event probability of infection was 0.57% (CI: 0.32-1.05%). A sensitivity analysis on the likely effect of under-reporting of sharing of the injecting apparatus indicated that the per event infection probability may be as low as 0.17% (95% CI: 0.11%-0.25%). The transmission probability was similarly shown to range up to 6%, dependent on the presumed prevalence of the virus in injecting equipment. CONCLUSIONS: The transmission probability of HCV during a sharing event is small. Hence, strategies to reduce the frequency and sharing of injecting equipment are required, as well as interventions focused on decreasing the per event risk.

Assessment of HBV flare in a randomized clinical trial in HIV/HBV coinfected subjects initiating HBV-active antiretroviral therapy in Thailand.

BACKGROUND: Hepatic Flare (HF) after initiation of highly active antiretroviral therapy (HAART) in HIV-HBV coinfected individuals is well recognized but prospective data on predictors and subsequent outcome are limited. METHODS: The Tenofovir in HIV-HBV coinfection study was a randomized clinical trial of HBV-active HAART including lamivudine and/or tenofovir in antiretroviral naïve HIV-HBV individuals in Thailand. RESULTS: Early HF (EHF) was defined as ALT > 5 × ULN during the first 12 weeks. EHF was observed in 8 (22%) of individuals at a median of 56 days. 6/8 EHF cases were asymptomatic and resolved with HAART continuation, however one subject with underlying cirrhosis died following rapid hepatic decompensation. EHF was significantly associated with higher baseline ALT (79 IU/L vs 36 IU/L non-EHF, p = 0.008) and HBV DNA (9.9 log10 c/ml vs 8.4 log10 c/ml non EHF, p = 0.009), and subsequent serological change. HBeAg loss occurred in 75% of EHF cases versus 22% in non-EHF (p = 0.04), and HBsAg loss in 25% of EHF cases versus 4% of non-EHF (p = 0.053). CONCLUSION: EHF after HBV active HAART initiation was frequently observed in this population. Timing of EHF, association with elevated ALT and HBV DNA and high rate of seroconversion are all consistent with immune restoration as the likely underlying process. CLINICAL TRIAL NUMBER: NCT00192595.

Evidence of a large, international network of HCV transmission in HIV-positive men who have sex with men.

BACKGROUND & AIMS: Since 2000, there has been a marked rise in acute hepatitis C virus (HCV) in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM). We conducted an international phylogenetic study to investigate the existence of an HCV transmission network among MSM. METHODS: HIV-positive MSM diagnosed with recent HCV (n = 226) in England (107), The Netherlands (58), France (12), Germany (25), and Australia (24) between 2000 and 2006 were enrolled into a molecular phylogenetic study. Using real-time polymerase chain reaction (PCR), the NS5B region of the HCV genome (436 base pair) was amplified, sequenced, and compared with unrelated NS5B sequences. RESULTS: NS5B sequences were obtained from 200 (89%) cases. Circulating HCV genotypes were 1a (59%), 4d (23%), 3a (11%), 1b (5%), and 2b/c (3%). Phylogenetic analysis revealed 156 (78%) sequences that formed 11 clusters (bootstrap value > 70%) containing between 4 and 37 individual sequences. Country mixing was associated with larger cluster size (17 vs 4.5 sequences; P = .03). "Molecular clock" analysis indicated that the majority (85%) of transmissions occurred since 1996. CONCLUSIONS: Phylogenetic analysis revealed a large international network of HCV transmission among HIV-positive MSM. The rapid spread of HCV among neighboring countries is supported by the large proportion (74%) of European MSM infected with an HCV strain co-circulating in multiple European countries, the low evolutionary distances among HCV isolates from different countries, and the trend toward increased country mixing with increasing cluster size. Temporally, this epidemic coincides with the introduction of highly active antiretroviral therapy and associated increases in sexual risk behaviors. International collaborative public health efforts are needed to mitigate HCV transmission among this population.

Modelling the hepatitis C virus epidemic in Australia.

BACKGROUND: Hepatitis C virus (HCV) infection in Australia is predominantly transmitted through injecting drug use. A reduction in the heroin supply in Australia in late 2000 and early 2001 may have impacted the number of injecting drug users (IDUs) and consequently the number of new hepatitis C infections in Australia. This paper updates estimates of HCV incidence and prevalence between 1960 and 2005. METHODS: Simple mathematical models were used to estimate HCV incidence among IDUs, migrants to Australia from high HCV-prevalence countries, and other HCV exposure groups. Recent trends in numbers of IDUs were based on indicators of injecting drug use. A natural history of HCV model was applied to estimate the prevalence of HCV in the population. RESULTS: The modelled best estimate of past HCV incidence showed a consistent increasing rate of HCV infections to a peak of 14,000 new seroconversions in 1999, followed by a decline in 2001-2002 coincident with the decline in heroin availability. HCV incidence was estimated to be 9700 (lower and upper limits of 6600 and 13,200) in 2005. Of these, 88.7% were estimated to be through injecting drug use, 7.2% among migrants and 4.1% through other transmission routes. An estimated 264,000 (lower and upper limits of 206,000 and 318,000) people were HCV antibody positive in 2005. CONCLUSIONS: Mathematical models suggest that HCV incidence in Australia decreased from a peak of 14,000 new infections in 1999 to 9700 new infections in 2005, largely attributable to a reduction in injecting drug use. The numbers of people living with HCV in Australia is, however, estimated to continue to increase.

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey.

OBJECTIVES: To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States. DESIGN: Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected. RESULTS: National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk. CONCLUSIONS: The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Prevalence and risk factors of hepatitis C in HIV-negative homosexual men in Sydney, Australia.

OBJECTIVE: To determine the prevalence and risk factors for hepatitis C (HCV) in HIV-negative homosexual men in Sydney. METHODS: A cohort study was conducted in a sample of community-based, HIV-negative, homosexual men in Sydney. Participants underwent a face-to-face interview regarding sexual behaviour, sexually transmissible infections, and injecting drug use (IDU). RESULTS: Eight hundred and twenty-four men consented to HCV testing, and the prevalence was 0.85% (95% CI 0.34-1.74). HCV seropositivity was strongly associated with a history of IDU (OR = 60.43, 95% CI 6.70-544.79). All HCV seropositive individuals reported a history of either IDU or other means by which they may have had parenteral exposure to HCV. There was no evidence of an independent association between sexual behaviour and HCV infection. CONCLUSION: The prevalence of HCV in this cohort was about the same as in the general population in Australia, and there was no evidence for sexual transmission in this population.

Severe diverticulitis after heart, lung, and heart-lung transplantation.

BACKGROUND: In this study, we reviewed our experience with severe diverticulitis in patients who have undergone heart and/or lung transplantation to assess whether transplant recipients are at increased risk of having severe diverticulitis compared with the general population. METHODS: We reviewed the records of patients who underwent heart and/or lung transplantation from 1984 to 2000, inclusive, and identified patients with severe diverticulitis that required surgery or that resulted in death. We compared this incidence with the incidence of such complications in the general population, served by the same institution during a 2-year period, 1999 to 2000. RESULTS: A total of 953 patients underwent transplantation in the study period. The mean follow-up was 57 months, a total follow-up of 4528 patient-years. Nine patients (mean age, 54 years) had severe diverticulitis that required surgical intervention (8 patients) or that resulted in death (1 patient died without surgical intervention). During 1999 to 2000, 16 patients (mean age, 66 years) from the general population were treated for severe diverticulitis that required surgical intervention, 3 of whom died. From census and area health data, we found that the study institution serves approximately 90000 people older than 40 years, with a total follow-up of 180000 patient-years. The incidence rate ratio for severe diverticulitis when comparing the transplant with the non-transplant groups was 22.2 (95% confidence interval; 9.9-50.0; p < 0.001). CONCLUSIONS: Patients with severe diverticulitis who have undergone heart and/or lung transplantation can be treated surgically with a small mortality rate. Transplant recipients probably are at substantially increased risk of experiencing severe diverticulitis.

Hepatitis C prevalence--a nationwide serosurvey.

Hepatitis C is the most commonly notified disease in Australia. In 1998 the Hepatitis C Virus Projections Working Group (HCPWG) estimated that there were approximately 210,000 people who had been infected by hepatitis C virus (HCV) in Australia by 2001. Population-based serosurveys are required to validate this estimate. Here we estimate HCV prevalence on the basis of HCV antibody seroprevalence in the Australian national serosurvey. Between 1996 and 1998, 2,800 sera opportunistically collected from pathology laboratories throughout Australia were tested for HCV antibody. National HCV notifications reported from 1991 through 1998 were also assessed. Eighty-one sera were HCV antibody positive, giving an age standardised prevalence of 2.3 per cent (95% CI 1.8%-2.9%). The 20-24 year age group had the highest HCV prevalence, 5.3 per cent (95% CI 3.3%-8.1%) and the male to female ratio was 1.8:1.0. Approximately 111,000 HCV notifications were received from 1991 through 1998. HCV prevalence estimated by the serosurvey is approximately three times higher than cumulative HCV notifications. Age and sex distributions of seroprevalence are broadly consistent with cumulative notification data. These distributions are consistent with the majority of HCV infections in Australia being transmitted by injecting drug use. Very low age specific seroprevalence estimates in the over 50 years age group indicate that there is not a large pool of undiagnosed infection in this age group. The serosurvey provides an estimate of Australian HCV prevalence and baseline data to determine incidence trends, both of which are required for health-care planning.

Antiretroviral therapy-related hepatotoxicity: predictors and clinical management.

Severe hepatotoxicity develops in 5-10% of people with HIV infection in the first 12 months following initiation of highly-active antiretroviral therapy (HAART), with continuing risk in subsequent years. The major risk factors for severe hepatotoxicity are underlying chronic viral hepatitis, abnormal baseline levels of serum hepatic transaminases, and nevirapine or high-dose ritonavir-containing antiretroviral therapy regimens. The vast majority of severe hepatotoxicity cases are not associated with development of symptoms of acute hepatitis or other adverse hepatic outcomes and resolve within a few months. Antiretroviral therapy should be discontinued in association with grade 4 elevations in serum hepatic transaminase measurements, hyperlactataemia, symptoms of acute hepatitis, or features of drug hypersensitivity.