Prevalence and determinants of hepatitis delta virus infection among HIV/hepatitis B-coinfected adults in care in the United States.

Hepatitis delta virus (HDV) infection increases the risk of liver complications compared to hepatitis B virus (HBV) alone, particularly among persons with human immunodeficiency virus (HIV). However, no studies have evaluated the prevalence or determinants of HDV infection among people with HIV/HBV in the US. We performed a cross-sectional study among adults with HIV/HBV coinfection receiving care at eight sites within the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) between 1996 and 2019. Among patients with available serum/plasma specimens, we selected the first specimen on or after their initial HBV qualifying test. All samples were tested for HDV IgG antibody and HDV RNA. Multivariable log-binomial generalized linear models were used to estimate prevalence ratios (PRs) with 95% CIs of HDV IgG antibody-positivity associated with determinants of interest (age, injection drug use [IDU], high-risk sexual behaviour). Among 597 adults with HIV/HBV coinfection in CNICS and available serum/plasma samples (median age, 43 years; 89.9% male; 52.8% Black; 42.4% White), 24/597 (4.0%; 95% CI, 2.4%-5.6%) were HDV IgG antibody-positive, and 10/596 (1.7%; 95% CI, 0.6%-2.7%) had detectable HDV RNA. In multivariable analysis, IDU was associated with exposure to HDV infection (adjusted PR = 2.50; 95% CI, 1.09-5.74). In conclusion, among a sample of adults with HIV/HBV coinfection in care in the US, 4.0% were HDV IgG antibody-positive, among whom 41.7% had detectable HDV RNA. History of IDU was associated with exposure to HDV infection. These findings emphasize the importance of HDV testing among persons with HIV/HBV coinfection, especially those with a history of IDU.

The Hepatitis C Care Cascade During the Direct-Acting Antiviral Era in a United States Commercially Insured Population.

Background: Periodic surveillance of the hepatitis C virus (HCV) care cascade is important for tracking progress toward HCV elimination goals, identifying gaps in care, and prioritizing resource allocation. In the pre-direct-acting antiviral (DAA) era, it was estimated that 50% of HCV-infected individuals were diagnosed and that 16% had been prescribed interferon-based therapy. Since then, few studies utilizing nationally representative data from the DAA era have been conducted in the United States. Methods: We performed a cross-sectional study to describe the HCV care cascade in the United States using the Optum de-identified Clinformatics® Data Mart Database to identify a nationally representative sample of commercially insured beneficiaries between January 1, 2014 and December 31, 2019. We estimated the number of HCV-viremic individuals in Optum based on national HCV prevalence estimates and determined the proportion who had: (1) recorded diagnosis of HCV infection, (2) recorded HCV diagnosis and underwent HCV RNA testing, (3) DAA treatment dispensed, and (4) assessment for cure. Results: Among 120,311 individuals estimated to have HCV viremia in Optum during the study period, 109,233 (90.8%; 95% CI, 90.6%-91.0%) had a recorded diagnosis of HCV infection, 75,549 (62.8%; 95% CI, 62.5%-63.1%) had a recorded diagnosis of HCV infection and underwent HCV RNA testing, 41,102 (34.2%; 95% CI, 33.9%-34.4%) were dispensed DAA treatment, and 25,760 (21.4%; 95% CI, 21.2%-21.6%) were assessed for cure. Conclusions: Gaps remain between the delivery of HCV-related care and national treatment goals among commercially insured adults. Efforts are needed to increase HCV treatment among people diagnosed with chronic HCV infection to achieve national elimination goals.

Epidemiology, Natural History, and Treatment of Hepatitis Delta Virus Infection in HIV/Hepatitis B Virus Coinfection.

PURPOSE OF REVIEW: Limited data exist on the prevalence, determinants, and outcomes of hepatitis delta virus (HDV) infection among HIV/hepatitis B virus (HBV)-coinfected persons. This review provides current evidence on the epidemiology, natural history, and treatment of HDV infection in patients with HIV/HBV coinfection and highlights future research needs. RECENT FINDINGS: Cross-sectional studies in Europe, Africa, South America, and Asia show that the prevalence of HDV among HIV/HBV-coinfected patients ranges from 1.2 to 25%. No studies have evaluated the prevalence of HDV infection among HIV/HBV-coinfected patients in the USA. HDV infection increases the risk of hepatic decompensation and hepatocellular carcinoma among HIV/HBV-coinfected patients. HDV treatment remains limited to pegylated interferon-alpha, which results in sustained virologic response in fewer than 25%. Data on the epidemiology, natural history, and treatment of HDV among HIV/HBV-coinfected persons remain limited. More research is needed to address these knowledge gaps in order to better manage HDV coinfection in HIV/HBV-coinfected patients.

Update on the Diagnosis and Treatment of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fourth-leading cause of cancer-related mortality worldwide and the fastest-rising cause of cancer-related death in the United States. Given the strong association between tumor stage and prognosis, HCC surveillance is recommended in high-risk patients, including patients with cirrhosis from any etiology. The diagnosis can be made based on characteristic imaging findings, with histologic confirmation primarily reserved for patients with atypical imaging findings. Over the last 2 decades, the treatment landscape for HCC has experienced significant advances. Curative therapies, including liver transplantation and surgical resection, are available to patients with early-stage HCC; however, recent data have expanded the potentially eligible patient population. Locoregional therapies, including transarterial chemoembolization and transarterial radio-embolization, continue to be standard therapies for patients with intermediate-stage disease. The greatest advances have been observed for patients with advanced HCC, where there are now multiple first- and second-line options that can prolong survival by up to 2 years when used sequentially. The increasing complexity of HCC treatment options underlies the necessity for multidisciplinary care, which has been associated with increased survival. This article reviews data on best practices for early detection and diagnosis of HCC and the current status of treatment options.

Transplantation in foreign nationals: Lower rates of waitlist mortality and higher rates of lost to follow-up posttransplant.

A controversial issue in the transplant community is whether or not to provide deceased donor liver transplantation (DDLT) to noncitizen/nonresidents (NCNRs) who travel for liver transplantation (LT). The expectation is that transplantation of NCNRs will not compromise access for US citizens/residents (USCRs), and that NCNRs would have similar post-LT follow-up. This has never been formally assessed. The United Network for Organ Sharing (UNOS) data from February 27, 2002 to December 31, 2016 were used to identify NCNRs and compare to USCRs, excluding Status 1 adults. Multivariable logistic regression was used to analyze waitlist outcomes, and competing risk analysis was used to assess rates of lost to follow-up post-LT. From February 27, 2002 to December 31, 2016, 1260 NCNRs were listed for LT (0.86% of listings). Adjusted probability of DDLT was not significantly different for NCNRs and USCRs (P > .5), but NCNRs were significantly less likely to be removed from the waitlist for death or clinical deterioration (aOR: 0.80, 95% CI: 0.69-0.93, P = .003). In multivariable competing risk models, NCNRs had an 11-fold higher risk of being lost to follow-up after accounting for the competing risk of death (SHR: 11.44, 95% CI: 8.72-15.01, P < .001), as well as lower rates of posttransplant mortality (SHR: 0.67, 95% CI: 0.49-0.91, P = .012). Our findings speak to the need to standardize practices for NCNRs and set expectations for post-LT care.

The thoracic outlet syndromes: Part 1. Overview of the thoracic outlet syndromes and review of true neurogenic thoracic outlet syndrome.

The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOS as a cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and the electrodiagnostic manifestations of their pathophysiologies is required. This review of the TOSs is provided in 2 parts. In this first part we address information pertinent to all 5 TOSs and reviews true neurogenic TOS. In part 2 we review the other 4 TOSs. Muscle Nerve 55: 782-793, 2017.

The thoracic outlet syndromes: Part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes.

The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOSs as cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and electrodiagnostic manifestations of these pathophysiologies is required. This review of the TOSs is provided in 2 parts. In part 1 we covered general information pertinent to all 5 TOSs and reviewed true neurogenic TOS in detail. In part 2, we review the arterial, venous, traumatic neurovascular, and disputed forms of TOS. Muscle Nerve 56: 663-673, 2017.