Trends in healthcare utilisation during COVID-19: a longitudinal study from the UK

OBJECTIVE

The first wave of the COVID-19 pandemic had a major impact on healthcare utilisation. The aim of this retrospective review was to quantify how utilisation of non-COVID care changed during this time so as to gain insight and inform planning of future services during potential second and subsequent waves.

METHODS AND ANALYSIS

A longitudinal design was used to analyse anonymous private UK health insurer datasets covering the period of January 2018 to August 2020. Taken as a measure of healthcare utilisation in the UK, incidence rates of claims broken down by service area and condition were calculated alongside overall monthly totals and costs. Pre-COVID-19 years were compared with the current year.

RESULTS

Healthcare utilisation during the first wave of COVID-19 decreased by as much as 70% immediately after lockdown measures were implemented. After 2 months, the trend reversed and claims steadily began to increase, but did not reach rates seen from previous years by the end of August 2020. Assessment by service and diagnostic category showed that most areas, especially those highly reliant on in-person treatment, reflected the same pattern (ie, rapid drop followed by a steady recovery). The provision of mental health services differed from this observed trend, where utilisation increased by 20% during the first wave of COVID-19, in comparison to pre-COVID-19 years. The utilisation of maternity services and the treatment of existing cancers also stayed stable, or increased slightly, during this time.

CONCLUSIONS

Healthcare utilisation in a UK-based privately insured population decreased dramatically during the first wave of the COVID-19 pandemic, being over 70% lower at its height. However, mental health services remained resilient during this time, possibly due to greater virtualisation of diagnostics and care.

Identification of microbial signatures linked to oilseed rape yield decline at the landscape scale

BACKGROUND

The plant microbiome plays a vital role in determining host health and productivity. However, we lack real-world comparative understanding of the factors which shape assembly of its diverse biota, and crucially relationships between microbiota composition and plant health. Here we investigated landscape scale rhizosphere microbial assembly processes in oilseed rape (OSR), the UK's third most cultivated crop by area and the world's third largest source of vegetable oil, which suffers from yield decline associated with the frequency it is grown in rotations. By including 37 conventional farmers' fields with varying OSR rotation frequencies, we present an innovative approach to identify microbial signatures characteristic of microbiomes which are beneficial and harmful to the host.

RESULTS

We show that OSR yield decline is linked to rotation frequency in real-world agricultural systems. We demonstrate fundamental differences in the environmental and agronomic drivers of protist, bacterial and fungal communities between root, rhizosphere soil and bulk soil compartments. We further discovered that the assembly of fungi, but neither bacteria nor protists, was influenced by OSR rotation frequency. However, there were individual abundant bacterial OTUs that correlated with either yield or rotation frequency. A variety of fungal and protist pathogens were detected in roots and rhizosphere soil of OSR, and several increased relative abundance in root or rhizosphere compartments as OSR rotation frequency increased. Importantly, the relative abundance of the fungal pathogen Olpidium brassicae both increased with short rotations and was significantly associated with low yield. In contrast, the root endophyte Tetracladium spp. showed the reverse associations with both rotation frequency and yield to O. brassicae, suggesting that they are signatures of a microbiome which benefits the host. We also identified a variety of novel protist and fungal clades which are highly connected within the microbiome and could play a role in determining microbiome composition.

CONCLUSIONS

We show that at the landscape scale, OSR crop yield is governed by interplay between complex communities of both pathogens and beneficial biota which is modulated by rotation frequency. Our comprehensive study has identified signatures of dysbiosis within the OSR microbiome, grown in real-world agricultural systems, which could be used in strategies to promote crop yield. Video abstract.

Global burden of atherosclerotic cardiovascular disease in people with hepatitis C virus infection: a systematic review, meta-analysis, and modelling study

Background

More than 70 million people worldwide are estimated to have hepatitis C virus (HCV) infection. Emerging evidence indicates an association between HCV and atherosclerotic cardiovascular disease. We aimed to determine the association between HCV and cardiovascular disease, and estimate the national, regional, and global burden of cardiovascular disease attributable to HCV.

Methods

For this systematic review and meta-analysis, we searched MEDLINE, Embase, Ovid Global Health, and Web of Science databases from inception to May 9, 2018, without language restrictions, for longitudinal studies that evaluated the risk ratio (RR) of cardiovascular disease in people with HCV compared with those without HCV. Two investigators independently reviewed and extracted data from published reports. The main outcome was cardiovascular disease, defined as hospital admission with, or mortality from, acute myocardial infarction or stroke. We calculated the pooled RR of cardiovascular disease associated with HCV using a random-effects model. Additionally, we calculated the population attributable fraction and disability-adjusted life-years (DALYs) from HCV-associated cardiovascular disease at the national, regional, and global level. We also used age-stratified and sex-stratified HCV prevalence estimates and cardiovascular DALYs for 100 countries to estimate country-level burden associated with HCV. This study is registered with PROSPERO, number CRD42018091857.

Findings

Our search identified 16 639 records, of which 36 studies were included for analysis, including 341 739 people with HCV. The pooled RR for cardiovascular disease was 1·28 (95% CI 1·18–1·39). Globally, 1·5 million (95% CI 0·9–2·1) DALYs per year were lost due to HCV-associated cardiovascular disease. Low-income and middle-income countries had the highest disease burden with south Asian, eastern European, north African, and Middle Eastern regions accounting for two-thirds of all HCV-associated cardiovascular DALYs.

Interpretation

HCV infection is associated with an increased risk of cardiovascular disease. The global burden of cardiovascular disease associated with HCV infection was responsible for 1·5 million DALYs, with the highest burden in low-income and middle-income countries.

Funding

British Heart Foundation and Wellcome Trust.

The development of 'Make One Small Change': an e-health intervention for the workplace developed using the Person-Based Approach

Background

The application of digital health interventions is widespread and many employers are implementing employee e-health programs. Intended to enhance productivity by increasing wellbeing, workplace interventions often lack evidence of effectiveness and have low rates of retention. Use of the person-based approach (PBA) is one solution, which offers a systematic framework for developing effective digital health interventions. This paper describes the application of the PBA to the development of ‘Make one small change’ (Cigna MSC™), an online behaviour change system for lifestyle habits focused on resilience, movement, eating and sleep.

Method and results

The development of Cigna MSC™ took place over four stages with colleagues (n = 79) across Cigna globally. Application of the PBA entailed using high amounts of qualitative data to inform development and a cyclical process of ‘listening, applying and delivering’ was adhered to throughout. Early stages involved review of current literature and the collection of feedback in relation to existing interventions. Combined, results revealed key intervention development issues that were then used to form guiding principles. Guiding principles ensured intervention objectives translated into relevant design features. The final stages of evaluation included testing images, text and content approaches. Feedback dictated that the intervention should be fun, easy to use and include milestones for self-monitoring. The resulting version was finalised and made ready to pilot so future analysis can be made in relation to real-world engagement and the embedded evaluative content can be used to provide evidence of intervention effectiveness.

Conclusions

Using the PBA, which was evolved specifically to improve development of digital interventions, resulted in a workplace intervention embedded with in-depth user input combined with evidenced-based theory. This paper illustrates how using a rigorous methodology can drive the creation of an effective digital health intervention that uniquely allows for refinement at each stage.

Impact of previous hepatitis B infection on the clinical outcomes from chronic hepatitis C? A population-level analysis

Chronic coinfection with hepatitis C virus (HCV) and hepatitis B virus (HBV) is associated with adverse liver outcomes. The clinical impact of previous HBV infection on liver disease in HCV infection is unknown. We aimed at determining any association of previous HBV infection with liver outcomes using antibodies to the hepatitis B core antigen (HBcAb) positivity as a marker of exposure. The Scottish Hepatitis C Clinical Database containing data for all patients attending HCV clinics in participating health boards was linked to the HBV diagnostic registry and mortality data from Information Services Division, Scotland. Survival analyses with competing risks were constructed for time from the first appointment to decompensated cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality. Records of 8513 chronic HCV patients were included in the analyses (87 HBcAb positive and HBV surface antigen [HBsAg] positive, 1577 HBcAb positive and HBsAg negative, and 6849 HBcAb negative). Multivariate cause-specific proportional hazards models showed previous HBV infection (HBcAb positive and HBsAg negative) significantly increased the risks of decompensated cirrhosis (hazard ratio [HR]: 1.29, 95% CI: 1.01-1.65) and HCC (HR: 1.64, 95% CI: 1.09-2.49), but not liver-related death (HR: 1.02, 95% CI: 0.80-1.30). This is the largest study to date showing an association between previous HBV infection and certain adverse liver outcomes in HCV infection. Our analyses add significantly to evidence which suggests that HBV infection adversely affects liver health despite apparent clearance. This has important implications for HBV vaccination policy and indications for prioritization of HCV therapy.

The impact of digital health interventions on health-related outcomes in the workplace: A systematic review

BACKGROUND

The impact of employee health on productivity in the workplace is generally evidenced through absenteeism and presenteeism. Multicomponent worksite health programmes, with significant online elements, have gained in popularity over the last two decades, due in part to their scalability and low cost of implementation. However, little is known about the impact of digital-only interventions on health-related outcomes in employee groups. The aim of this systematic review was to assess the impact of pure digital health interventions in the workplace on health-related outcomes.

METHODS

Multiple databases, including MEDLINE, EMBASE, PubMed and PsycINFO, were used to review the literature using PRISMA guidelines.

RESULTS

Of 1345 records screened, 22 randomized controlled trial studies were found to be eligible. Although there was a high level of heterogeneity across these studies, significant improvements were found for a broad range of outcomes such as sleep, mental health, sedentary behaviours and physical activity levels. Standardized measures were not always used to quantify intervention impact. All but one study resulted in at least one significantly improved health-related outcome, but attrition rates ranged widely, suggesting sustaining engagement was an issue. Risk of bias assessment was low for one-third of the studies and unclear for the remaining ones.

CONCLUSIONS

This review found modest evidence that digital-only interventions have a positive impact on health-related outcomes in the workplace. High heterogeneity impacted the ability to confirm what interventions might work best for which health outcomes, although less complex health outcomes appeared to be more likely to be impacted. A focus on engagement along with the use of standardized measures and reporting of active intervention components would be helpful in future evaluations.

Mortality in hepatitis C patients who achieve a sustained viral response compared to the general population

BACKGROUND & AIMS

The number of people living with previous hepatitis C infection that have attained a sustained viral response (SVR) is expected to grow rapidly. So far, the prognosis of this group relative to the general population is unclear.

METHODS

Individuals attaining SVR in Scotland in 1996-2011 were identified using a national database. Through record-linkage, we obtained cause-specific mortality data complete to Dec 2013. We calculated standardised mortality ratios (SMRs) to compare the frequency of mortality in SVR patients to the general population. In a parallel analysis, we used Cox regression to identify modifiable patient characteristics associated with post-SVR mortality.

RESULTS

We identified 1824 patients, followed on average for 5.2years after SVR. In total, 78 deaths were observed. Overall, all-cause mortality was 1.9 times more frequent for SVR patients than the general population (SMR: 1.86; 95% confidence interval (CI): 1.49-2.32). Significant cause-specific elevations were seen for death due to primary liver cancer (SMR: 23.50; 95% CI: 12.23-45.16), and death due to drug-related causes (SMR: 6.58, 95% CI: 4.15-10.45). Together these two causes accounted for 66% of the total excess death observed. All of the modifiable characteristics associated with increased mortality were markers either of heavy alcohol use or injecting drug use. Individuals without these behavioural markers (32.8% of cohort) experienced equivalent survival to the general population (SMR: 0.70; 95% CI: 0.41-1.18) CONCLUSIONS: Mortality in Scottish SVR patients is higher overall than the general population. The excess was driven by death from drug-related causes and liver cancer. Health risk behaviours emerged as important modifiable determinants of mortality in this population.

LAY SUMMARY

Patients cured of hepatitis C through treatment had a higher mortality rate overall than the general population. Most of the surplus mortality was due to drug-related causes and death from liver cancer. A history of heavy alcohol and injecting drug use were associated with a higher mortality risk.

A matched comparison study of hepatitis C treatment outcomes in the prison and community setting, and an analysis of the impact of prison release or transfer during therapy

Prisoners are a priority group for hepatitis C (HCV) treatment. Although treatment durations will become shorter using directly acting antivirals (DAAs), nearly half of prison sentences in Scotland are too short to allow completion of DAA therapy prior to release. The purpose of this study was to compare treatment outcomes between prison- and community-based patients and to examine the impact of prison release or transfer during therapy. A national database was used to compare treatment outcomes between prison treatment initiates and a matched community sample. Additional data were collected to investigate the impact of release or transfer on treatment outcomes. Treatment-naïve patients infected with genotype 1/2/3/4 and treated between 2009 and 2012 were eligible for inclusion. 291 prison initiates were matched with 1137 community initiates: SVRs were 61% (95% CI 55%-66%) and 63% (95% CI 60%-66%), respectively. Odds of achieving a SVR were not significantly associated with prisoner status (P=.33). SVRs were 74% (95% CI 65%-81%), 59% (95% CI 42%-75%) and 45% (95% CI 29%-62%) among those not released or transferred, transferred during treatment, or released during treatment, respectively. Odds of achieving a SVR were significantly associated with release (P<.01), but not transfer (P=.18). Prison-based HCV treatment achieves similar outcomes to community-based treatment, with those not released or transferred during treatment doing particularly well. Transfer or release during therapy should be avoided whenever possible, using anticipatory planning and medical holds where appropriate.

Impact of a Health Promotion Program on Employee Health Risks and Work Productivity

Purpose.

Evaluate the impact of a multicomponent workplace health promotion program on employee health risks and work productivity.

Design.

Quasi-experimental 12-month before-after intervention-control study.

Setting.

A multinational corporation headquartered in the United Kingdom.

Subjects.

Of 618 employees offered the program, 266 (43%) completed questionnaires before and after the program. A total of 1242 of 2500 (49.7%) of a control population also completed questionnaires 12 months apart.

Intervention.

A multicomponent health promotion program incorporating a health risk appraisal questionnaire, access to a tailored health improvement web portal, wellness literature, and seminars and workshops focused upon identified wellness issues.

Measures.

Outcomes were (1) cumulative count of health risk factors and the World Health Organization health and work performance questionnaire measures of (2) workplace absenteeism and (3) work performance.

Results.

After adjusting for baseline differences, improvements in all three outcomes were significantly greater in the intervention group compared with the control group. Mean excess reductions of 0.45 health risk factors and 0.36 monthly absenteeism days and a mean increase of 0.79 on the work performance scale were observed in the intervention group compared with the control group. The intervention yielded a positive return on investment, even using conservative assumptions about effect size estimation.

Conclusion.

The results suggest that a well-implemented multicomponent workplace health promotion program can produce sizeable changes in health risks and productivity.

Hepatitis C reinfection following treatment induced viral clearance among people who have injected drugs

BACKGROUND

Although people who inject drugs (PWID) are an important group to receive Hepatitis C Virus (HCV) antiviral therapy, initiation onto treatment remains low. Concerns over reinfection may make clinicians reluctant to treat this group. We examined the risk of HCV reinfection among a cohort of PWID (encompassing all those reporting a history of injecting drug use) from Scotland who achieved a sustained virological response (SVR).

METHODS

Clinical and laboratory data were used to monitor RNA testing among PWID who attained SVR following therapy between 2000 and 2009. Data were linked to morbidity and mortality records. Follow-up began one year after completion of therapy, ending on 31st December, 2012. Frequency of RNA testing during follow-up was calculated and the incidence of HCV reinfection estimated. Cox proportional hazards regression was used to examine factors associated with HCV reinfection.

RESULTS

Among 448 PWID with a SVR, 277 (61.8%) were tested during follow-up, median 4.5 years; 191 (69%) received one RNA test and 86 (31%) received at least two RNA tests. There were seven reinfections over 410 person years generating a reinfection rate of 1.7/100py (95% CI 0.7-3.5). For PWID who have been hospitalised for an opiate or injection related cause post SVR (11%), the risk of HCV reinfection was greater [AHR=12.9, 95% CI 2.2-76.0, p=0.002] and the reinfection rate was 5.7/100py (95% CI 1.8-13.3).

CONCLUSION

PWID who have been tested, following SVR, for HCV in Scotland appear to be at a low risk of reinfection. Follow-up and monitoring of this population are warranted as treatment is offered more widely.

Factors associated with spontaneous clearance of chronic hepatitis C virus infection

BACKGROUND & AIMS

Spontaneous clearance of chronic hepatitis C virus (HCV) infection (CHC) is rare. We conducted a retrospective case-control study to identify rates and factors associated with spontaneous clearance of CHC.

METHODS

We defined cases as individuals who spontaneously resolved CHC, and controls as individuals who remained chronically infected. We used data obtained on HCV testing between 1994 and 2013 in the West of Scotland to infer case/control status. Specifically, untreated patients with ⩾2 sequential samples positive for HCV RNA ⩾6months apart followed by ⩾1 negative test, and those with ⩾2 positive samples ⩾6months apart with no subsequent negative samples were identified. Control patients were randomly selected from the second group (4/patient of interest). Case notes were reviewed and patient characteristics obtained.

RESULTS

25,113 samples were positive for HCV RNA, relating to 10,318 patients. 50 cases of late spontaneous clearance were identified, contributing 241 person-years follow-up. 2,518 untreated, chronically infected controls were identified, contributing 13,766 person-years follow-up, from whom 200 controls were randomly selected. The incidence rate of spontaneous clearance was 0.36/100 person-years follow-up, occurring after a median 50months' infection. Spontaneous clearance was positively associated with female gender, younger age at infection, lower HCV RNA load and co-infection with hepatitis B virus. It was negatively associated with current intravenous drug use.

CONCLUSIONS

Spontaneous clearance of CHC occurs infrequently but is associated with identifiable host and viral factors. More frequent HCV RNA monitoring may be appropriate in selected patient groups.

LAY SUMMARY

Clearance of hepatitis C virus infection without treatment occurs rarely once chronic infection has been established. We interrogated a large Scottish patient cohort and found that it was more common in females, patients infected at a younger age or with lower levels of HCV in the blood, and patients co-infected with hepatitis B virus. Patients who injected drugs were less likely to spontaneously clear chronic infection.

Tracking TCRβ Sequence Clonotype Expansions during Antiviral Therapy Using High-Throughput Sequencing of the Hypervariable Region

To maintain a persistent infection viruses such as hepatitis C virus (HCV) employ a range of mechanisms that subvert protective T cell responses. The suppression of antigen-specific T cell responses by HCV hinders efforts to profile T cell responses during chronic infection and antiviral therapy. Conventional methods of detecting antigen-specific T cells utilize either antigen stimulation (e.g., ELISpot, proliferation assays, cytokine production) or antigen-loaded tetramer staining. This limits the ability to profile T cell responses during chronic infection due to suppressed effector function and the requirement for prior knowledge of antigenic viral peptide sequences. Recently, high-throughput sequencing (HTS) technologies have been developed for the analysis of T cell repertoires. In the present study, we have assessed the feasibility of HTS of the TCRβ complementarity determining region (CDR)3 to track T cell expansions in an antigen-independent manner. Using sequential blood samples from HCV-infected individuals undergoing antiviral therapy, we were able to measure the population frequencies of >35,000 TCRβ sequence clonotypes in each individual over the course of 12 weeks. TRBV/TRBJ gene segment usage varied markedly between individuals but remained relatively constant within individuals across the course of therapy. Despite this stable TRBV/TRBJ gene segment usage, a number of TCRβ sequence clonotypes showed dramatic changes in read frequency. These changes could not be linked to therapy outcomes in the present study; however, the TCRβ CDR3 sequences with the largest fold changes did include sequences with identical TRBV/TRBJ gene segment usage and high junction region homology to previously published CDR3 sequences from HCV-specific T cells targeting the HLA-B*0801-restricted ¹³⁹⁵HSKKKCDEL¹⁴⁰³ and HLA-A*0101-restricted ¹⁴³⁵ATDALMTGY¹⁴⁴³ epitopes. The pipeline developed in this proof of concept study provides a platform for the design of future experiments to accurately address the question of whether T cell responses contribute to SVR upon antiviral therapy. This pipeline represents a novel technique to analyze T cell dynamics in situations where conventional antigen-dependent methods are limited due to suppression of T cell functions and highly diverse antigenic sequences.

High Dose Atorvastatin Associated with Increased Risk of Significant Hepatotoxicity in Comparison to Simvastatin in UK GPRD Cohort

Background & Aims

Occasional risk of serious liver dysfunction and autoimmune hepatitis during atorvastatin therapy has been reported. We compared the risk of hepatotoxicity in atorvastatin relative to simvastatin treatment.

Methods

The UK GPRD identified patients with a first prescription for simvastatin [164,407] or atorvastatin [76,411] between 1997 and 2006, but with no prior record of liver disease, alcohol-related diagnosis, or liver dysfunction. Incident liver dysfunction in the following six months was identified by biochemical value and compared between statin groups by Cox regression model adjusting for age, sex, year treatment started, dose, alcohol consumption, smoking, body mass index and comorbid conditions.

Results

Moderate to severe hepatotoxicity [bilirubin >60μmol/L, AST or ALT >200U/L or alkaline phosphatase >1200U/L] developed in 71 patients on atorvastatin versus 101 on simvastatin. Adjusted hazard ratio [AHR] for all atorvastatin relative to simvastatin was 1.9 [95% confidence interval 1.4–2.6]. High dose was classified as 40–80mg daily and low dose 10–20mg daily. Hepatotoxicity occurred in 0.44% of 4075 patients on high dose atorvastatin [HDA], 0.07% of 72,336 on low dose atorvastatin [LDA], 0.09% of 44,675 on high dose simvastatin [HDS] and 0.05% of 119,732 on low dose simvastatin [LDS]. AHRs compared to LDS were 7.3 [4.2–12.7] for HDA, 1.4 [0.9–2.0] for LDA and 1.5 [1.0–2.2] for HDS.

Conclusions

The risk of hepatotoxicity was increased in the first six months of atorvastatin compared to simvastatin treatment, with the greatest difference between high dose atorvastatin and low dose simvastatin. The numbers of events in the analyses were small.

Viral genotype correlates with distinct liver gene transcription signatures in chronic hepatitis C virus infection

BACKGROUND

Chronic hepatitis C virus (HCV) infection of the liver with either genotype 1 or genotype 3 gives rise to distinct pathologies, and the two viral genotypes respond differently to antiviral therapy.

METHODS

To understand these clinical differences, we compared gene transcription profiles in liver biopsies from patients infected with either gt1 or gt3, and uninfected controls.

RESULTS

Gt1-infected biopsies displayed elevated levels of transcripts regulated by type I and type III interferons (IFN), including genes that predict response to IFN-α therapy. In contrast, genes controlled by IFN-γ were induced in gt3-infected biopsies. Moreover, IFN-γ levels were higher in gt3-infected biopsies. Analysis of hepatocyte-derived cell lines confirmed that the genes upregulated in gt3 infection were preferentially induced by IFN-γ. The transcriptional profile of gt3 infection was unaffected by IFNL4 polymorphisms, providing a rationale for the reduced predictive power of IFNL genotyping in gt3-infected patients.

CONCLUSIONS

The interactions between HCV genotypes 1 and 3 and hepatocytes are distinct. These unique interactions provide avenues to explore the biological mechanisms that drive viral genotype-specific differences in disease progression and treatment response. A greater understanding of the distinct host-pathogen interactions of the different HCV genotypes is required to facilitate optimal management of HCV infection.

Evidence of continued injecting drug use after attaining sustained treatment-induced clearance of the hepatitis C virus: Implications for reinfection

BACKGROUND

People who inject drugs (PWID) are at the greatest risk of hepatitis C virus (HCV) infection, yet are often denied immediate treatment due to fears of on-going risk behaviour. Our principal objective was to examine evidence of continued injecting drug use among PWID following successful treatment for HCV and attainment of a sustained viral response (SVR).

METHODS

PWID who attained SVR between 1992 and June 2012 were selected from the National Scottish Hepatitis C Clinical Database. Hospitalisation and mortality records were sourced for these patients using record linkage techniques. Our primary outcome variable was any hospitalisation or death, which was indicative of injecting drugs post-SVR.

RESULTS

The cohort comprised 1170 PWID (mean age at SVR 39.6y; 76% male). The Kaplan Meier estimate of incurring the primary outcome after three years of SVR was 10.59% (95% CI, 8.75-12.79) After adjusting for confounding, the risk of an injection related hospital episode or death post-SVR was significantly increased with advancing year of SVR: AHR:1.07 per year (95% CI, 1.01-1.14), having a pre-SVR acute alcohol intoxication-related hospital episode: AHR:1.83 (95% CI, 1.29-2.60), and having a pre-SVR opiate or injection-related hospital episode: AHR:2.59 (95% CI, 1.84-3.64).

CONCLUSION

Despite attaining the optimal treatment outcome, these data indicate that an increasing significant minority of PWID continue to inject post-SVR at an intensity which leads to either hospitalisation or death and increased risk of reinfection.

Liver Fibrosis, but No Other Histologic Features, Is Associated With Long-term Outcomes of Patients With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Histologic analysis of liver biopsy specimens allows for grading and staging of nonalcoholic fatty liver disease (NAFLD). We performed a longitudinal study to investigate the long-term prognostic relevance of histologic features for patients with NAFLD.

METHODS

We performed a retrospective analysis of 619 patients diagnosed with NAFLD from 1975 through 2005 at medical centers in the United States, Europe, and Thailand. Patients underwent laboratory and biopsy analyses, and were examined every 3-12 months after their diagnosis. Outcomes analyzed were overall mortality, liver transplantation, and liver-related events. Cumulative outcomes were compared by log-rank analysis. Cox proportional-hazards regression was used to estimate adjusted hazard ratios (HRs). Time at risk was determined from the date of liver biopsy to the date of outcome or last follow-up examination.

RESULTS

Over a median follow-up period of 12.6 years (range, 0.3-35.1 y), 193 of the patients (33.2%) died or underwent liver transplantation. Features of liver biopsies significantly associated with death or liver transplantation included fibrosis stage 1 (HR, 1.88; 95% confidence interval [CI], 1.28-2.77), stage 2 (HR, 2.89; 95% CI, 1.93-4.33), stage 3 (HR, 3.76; 95% CI, 2.40-5.89), and stage 4 (HR, 10.9; 95% CI, 6.06-19.62) compared with stage 0, as well as age (HR, 1.07; 95% CI, 1.05-1.08), diabetes (HR, 1.61; 95% CI, 1.13-2.30), current smoking (HR, 2.62; 95% CI, 1.67-4.10), and statin use (HR, 0.32; 95% CI, 0.14-0.70). Twenty-six patients (4.2%) developed liver-related events; fibrosis stage 3 (HR, 14.2; 95% CI, 3.38-59.68) and stage 4 (HR, 51.5; 95% CI, 9.87-269.2) compared with stage 0, were associated significantly with the events. Patients with fibrosis, regardless of steatohepatitis or NAFLD activity score, had shorter survival times than patients without fibrosis.

CONCLUSIONS

In a longitudinal study of patients with NAFLD, fibrosis stage, but no other histologic features of steatohepatitis, were associated independently with long-term overall mortality, liver transplantation, and liver-related events.

Toward a more complete understanding of the association between a hepatitis C sustained viral response and cause-specific outcomes

Sustained viral response (SVR) is the optimal outcome of hepatitis C virus (HCV) therapy, yet more detailed data are required to confirm its clinical value. Individuals receiving treatment in 1996-2011 were identified using the Scottish HCV clinical database. We sourced data on 10 clinical events: liver, nonliver, and all-cause mortality; first hospitalisation for severe liver morbidity (SLM); cardiovascular disease (CVD); respiratory disorders; neoplasms; alcohol-intoxication; drug intoxication; and violence-related injury (note: the latter three events were selected a priori to gauge ongoing chaotic lifestyle behaviours). We determined the association between SVR attainment and each outcome event, in terms of the relative hazard reduction and absolute risk reduction (ARR). We tested for an interaction between SVR and liver disease severity (mild vs. nonmild), defining mild disease as an aspartate aminotransferase-to-platelet ratio index (APRI) <0.7. Our cohort comprised 3,385 patients (mean age: 41.6 years), followed-up for a median 5.3 years (interquartile range: 3.3-8.2). SVR was associated with a reduced risk of liver mortality (adjusted hazard ratio [AHR]: 0.24; P < 0.001), nonliver mortality (AHR, 0.68; P = 0.026), all-cause mortality (AHR, 0.49; P < 0.001), SLM (AHR, 0.21; P < 0.001), CVD (AHR, 0.70; P = 0.001), alcohol intoxication (AHR, 0.52; P = 0.003), and violence-related injury (AHR, 0.51; P = 0.002). After 7.5 years, SVR was associated with significant ARRs for liver mortality, all-cause mortality, SLM, and CVD (each 3.0%-4.7%). However, we detected a strong interaction, in that ARRs were considerably higher for individuals with nonmild disease than for individuals with mild disease.

CONCLUSIONS

The conclusions are 3-fold: (1) Overall, SVR is associated with reduced hazard for a range of hepatic and nonhepatic events; (2) an association between SVR and behavioral events is consistent with SVR patients leading healthier lives; and (3) the short-term value of SVR is greatest for those with nonmild disease.

Elevated interferon-stimulated gene transcription in peripheral blood mononuclear cells occurs in patients infected with genotype 1 but not genotype 3 hepatitis C virus

Hepatitis C virus (HCV) can be classified into seven distinct genotypes that are associated with differing pathologies and respond differently to antiviral therapy. In the UK, genotype 1 and 3 are present in approximately equal proportions. Chronic infection with HCV genotype 3 is associated with increased liver steatosis and reduced peripheral total cholesterol levels, which potentially influences peripheral immune responses. To understand these differences, we investigated host gene transcription in peripheral blood mononuclear cells by microarray and quantitative PCR in patients with genotype 1 (n = 22) or genotype 3 infection (n = 22) and matched healthy controls (n = 15). Enrichment of genes involved in immune response and inflammatory pathways were present in patients infected with HCV genotype 1; however, no differences in genes involved in lipid or cholesterol metabolism were detected. This genotype-specific induction of genes is unrelated to IL28B genotype or previous treatment failure. Our data support the hypothesis that genotype 1 infection drives a skewed Type I interferon response and provides a foundation for future investigations into the host-pathogen interactions that underlie the genotype-specific clinical outcomes of chronic HCV infection.

Multicentre randomised controlled study comparing carvedilol with variceal band ligation in the prevention of variceal rebleeding

BACKGROUND & AIMS

Rebleeding after an initial oesophageal variceal haemorrhage remains a significant problem despite therapy with band ligation, non-selective β-blockers or a combination of these. Carvedilol is a vasodilating non-selective β-blocker with alpha-1 receptor and calcium channel antagonism. A recent study has suggested it is effective in the prevention of a first variceal bleed. Our aim was to compare oral carvedilol with variceal band ligation (VBL) in the prevention of rebleeding following a first variceal bleed.

METHODS

Patients who were stable 5 days after presentation with a first oesophageal variceal haemorrhage and had not been taking β-blockers were randomised to oral carvedilol or VBL. Patients were followed-up after one week, monthly, then every 3 months. The primary end point was variceal rebleeding on intention-to-treat analysis.

RESULTS

64 patients were randomised, 33 to carvedilol and 31 to VBL. 58 (90.6%) patients had alcohol related liver disease. Age and Child-Pugh score were similar in both groups at baseline. Median follow-up was 26.3 (interquartile range [IQR] 10.2-46.6)months. Compliance was 68% and 65% for carvedilol and VBL respectively (p=0.993) and serious adverse events between the two groups were similar (p=0.968). Variceal rebleeding occurred during follow-up in 12 (36.4%) and 11 (35.5%) patients in the carvedilol and VBL groups, respectively (p=0.857), with 9 (27.3%) and 16 (51.6%) deaths in each group, respectively (p=0.110).

CONCLUSIONS

Carvedilol is not superior to VBL in the prevention of variceal rebleeding. The trend to a survival benefit for patients taking this drug compared with those undergoing banding requires further exploration.

The efficacy and safety of treating hepatitis C in patients with a diagnosis of schizophrenia

Treating chronic hepatitis C with pegylated interferon alpha may induce or exacerbate psychiatric illness including depression, mania and aggressive behaviour. There is limited data regarding treatment in the context of chronic schizophrenia. We sought to establish the safety and efficacy of treating patients with schizophrenia. Patient and treatment data, prospectively collected on the Scottish hepatitis C database, were analysed according to the presence or absence of a diagnosis of schizophrenia. Time from referral to treatment, and the proportion of patients commencing treatment in each group, was calculated. Outcomes including sustained viral response rates, reasons for treatment termination and adverse events were compared. Of 5497 patients, 64 (1.2%) had a diagnosis of schizophrenia. Patients with schizophrenia (PWS) were as likely to receive treatment as those without [28/61(46%) vs 1639/4415 (37%) P = 0.19]. Sustained viral response (SVR) rates were higher in PWS [21/25 (84%) vs 788/1453 (54%) P < 0.01]. SVR rates by genotype were similar [4/8 (50%) vs 239/684 (35%) Genotype 1 (P = 0.56), 17/17 (100%) vs 599/742 (81%) non-Genotype 1 (P = 0.09)]. Adverse events leading to cessation of treatment were comparable [2/25(8%) vs 189/1453 (13%) P: 0.66]. Patients with schizophrenia are good candidates for hepatitis C treatment, with equivalent SVR and treatment discontinuation rates to patients without schizophrenia.

Patient-important benefits of clearing the hepatitis C virus through treatment: a simulation model

BACKGROUND & AIMS

Given an appreciable risk of adverse-effects, current therapies for chronic hepatitis C virus (HCV) infection pose a dilemma to patients. We explored, via simulation modelling, patient-important benefits of attaining a sustained viral response (SVR).

METHODS

We created the HCV Individualised Treatment-decision model (the HIT-model) to simulate, on a per patient basis, the lifetime course of HCV-related liver disease according to two distinct scenarios: (i) SVR attained, and (ii) SVR not attained. Then, for each model subject, the course of liver disease under these alternative scenarios was compared. The benefit of SVR was considered in terms of two patient-important outcomes: (1) the percent-probability that SVR confers additional life-years, and (2) the percent-probability that SVR confers additional healthy life-years, where "healthy" refers to years spent in compensated disease states (i.e., the avoidance of liver failure).

RESULTS

The benefit of SVR varied strikingly. It was lowest for patients aged 60 years with initially mild fibrosis; 1.6% (95% CI: 0.8-2.7) and 2.9% (95% CI: 1.5-4.7) probability of gaining life-years and healthy life-years, respectively. Whereas it was highest for patients with initially compensated cirrhosis aged 30 years; 57.9% (95% CI: 46.0-69.0) and 67.1% (95% CI: 54.1-78.2) probability of gaining life-years and healthy life-years, respectively.

CONCLUSIONS

For older patients with less advanced liver fibrosis, SVR is less likely to confer benefit when measured in terms of averting liver failure and premature death. These data have important implications. Foremost, it may inform the contemporary patient dilemma of immediate treatment with existing therapies (that have poor adverse effect profiles) vs. awaiting future regimens that promise better tolerability.

Attendance at specialist hepatitis clinics and initiation of antiviral treatment among persons chronically infected with hepatitis C: examining the early impact of Scotland's Hepatitis C Action Plan

Primary goals of the Hepatitis C Action Plan for Scotland Phase II (May 2008-March 2011) were to increase, among persons chronically infected with the hepatitis C (HCV) virus, attendance at specialist outpatient clinics and initiation on antiviral therapy. We evaluated progress towards these goals by comparing the odds, across time, of (a) first clinic attendance within 12 months of HCV diagnosis (n = 9747) and (b) initiation on antiviral treatment within 12 months of first attendance (n = 5736). Record linkage between the national HCV diagnosis (1996-2009) and HCV clinical (1996-2010) databases and logistic regression analyses were conducted for both outcomes. For outcome (a), 32% and 45% in the respective pre-Phase II (before 1 May 2008) and Phase II periods attended a specialist clinic within 12 months of diagnosis; the odds of attendance within 12 months increased over time (OR = 1.05 per year, 95% CI: 1.04-1.07), but was not significantly greater for persons diagnosed with HCV in the Phase II era, compared with the pre-Phase II era (OR = 1.1, 95% CI: 0.9-1.3), after adjustment for temporal trend. For outcome (b), 13% and 28% were initiated on treatment within 12 months of their first clinic attendance in the pre-Phase II and Phase II periods, respectively. Higher odds of treatment initiation were associated with first clinic attendance in the Phase II (OR = 1.9, 95% CI: 1.5-2.4), compared with the pre-Phase II era. Results were consistent with a positive impact of the Hepatitis C Action Plan on the treatment of chronically infected individuals, but further monitoring is required to confirm a sustained effect.

Non cell autonomous upregulation of CDKN2 transcription linked to progression of chronic hepatitis C disease

Chronic hepatitis C virus infection (C-HC) is associated with higher mortality arising from hepatic and extrahepatic disease. This may be due to accelerated biological aging; however, studies in C-HC have thus far been based solely on telomere length as a biomarker of aging (BoA). In this study, we have evaluated CDKN2 locus transcripts as alternative BoAs in C-HC. Our results suggest that C-HC induces non-cell-autonomous senescence and accelerates biological aging. The CDKN2 locus may provide a link between C-HC and increased susceptibility to age-associated diseases and provides novel biomarkers for assessing its impact on aging processes in man.

Transcriptomic analysis of the interactions between Agaricus bisporus and Lecanicillium fungicola

Agaricus bisporus is susceptible to a number of diseases, particularly those caused by fungi, with Lecanicillium fungicola being the most serious. Control of this disease is important for the security of crop production, however given the lack of knowledge about fungal-fungal interactions, such disease control is rather limited. Exploiting the recently released genome sequence of A. bisporus, here we report studies simultaneously investigating both the host and the pathogen, focussing on transcriptional changes associated with the cap spotting lesions typically seen in this interaction. Forward-suppressive subtractive hybridisation (SSH) analysis identified 68 A. bisporus unigenes induced during infection. Chitin deacetylase showed the strongest response, with almost 1000-fold up-regulation during infection, so was targeted for down-regulation by silencing to see if it was involved in defence against L. fungicola. Transgenic lines were made expressing hairpin RNAi constructs, however no changes in susceptibility to L. fungicola were observed. Amongst the other up-regulated genes there were none with readily apparent roles in resisting infection in this susceptible interaction. Reverse-SSH identified 72 unigenes from A. bisporus showing reduced expression, including two tyrosinases, several genes involved in nitrogen metabolism and a hydrophobin. The forward-SSH analysis of infected mushrooms also yielded 64 unigenes which were not of A. bisporus origin and thus derived from L. fungicola. An EST analysis of infection-mimicking conditions generated an additional 623 unigenes from L. fungicola including several oxidoreductases, cell wall degrading enzymes, ABC and MFS transporter proteins and various other genes believed to play roles in other pathosystems. Together, this analysis shows how both the pathogen and the host modify their gene expression during an infection-interaction, shedding some light on the disease process, although we note that some 40% of unigenes from both organisms encode hypothetical proteins with no ascribed function which highlights how much there is still to discover about this interaction.

Quantifying the fraction of cirrhosis attributable to alcohol among chronic hepatitis C virus patients: implications for treatment cost-effectiveness

A substantial baseline risk of liver cirrhosis exists for patients with chronic hepatitis C virus (HCV) infection. However, the extent to which this could be driven by heavy alcohol use is unclear. Therefore, our principal aim was to determine the fraction of cirrhosis attributable to heavy alcohol use among chronic HCV patients attending a liver clinic. The study population comprised chronic HCV patients who had attended one of five liver clinics in Scotland during 1996-2010 and had (1) remained in follow-up for at least 6 months, (2) acquired HCV through either injecting drugs or blood transfusion, and (3) an estimated date of acquiring infection. Predictors of cirrhosis were determined from multivariate logistic regression. Regression parameters were used to determine the fraction of cirrhosis attributable to heavy alcohol use. Among 1,620 patients, 9% were diagnosed with cirrhosis, and 34% had ever engaged in heavy alcohol use (>50 units/week for a sustained period). Significant predictors of cirrhosis were age, duration of infection, and ever heavy alcohol use. The fraction of cirrhosis attributable to ever heavy alcohol use was 36.1% (95% confidence interval [CI]: 24.4-47.4). Moreover, among patients who had ever engaged in heavy alcohol use specifically, this attributable fraction exceeded 50% (61.6%; 95% CI: 47.0-72.2).

CONCLUSIONS

A substantial proportion of patients with chronic HCV develop liver cirrhosis as a consequence of heavy alcohol use. This has not been adequately acknowledged by cost utility analyses (CUAs). As such, estimates of cost-effectiveness may be exaggerated. Thus, these data are important to guide forthcoming CUAs in terms of taking better account of the factors leading to cirrhosis among patients with chronic HCV.

The diversity and management of chronic hepatitis B virus infections in the United Kingdom: a wake-up call

BACKGROUND

Through migration, diversity of chronic hepatitis B virus (HBV) infection has changed, affecting disease burden and control. We describe clinical and viral characteristics of chronic HBV in the United Kingdom.

METHODS

A total of 698 individuals with chronic HBV infection were recruited from referral liver centers. Demographic, clinical, and laboratory data were collected.

RESULTS

Sixty-one percent of patients were male, 80% were not born in the United Kingdom, and the largest ethnicity was East/Southeast Asian (36%). Twenty-two percent were hepatitis B e antigen (HBeAg) seropositive; 20.4% (59/289) had cirrhosis and 10 (1.7%) had hepatocellular carcinoma. Genotype D was most common (31%) followed by A, C, B, and E (20%, 20%, 19%, and 9%, respectively). Genotype was significantly associated with country of birth, length of time in the United Kingdom, HBeAg status, and precore and basal core promoter mutations. One-third were on treatment, with men independently more likely to be treated. Only 18% of those on treatment were on recommended first-line therapies, and 30% were on lamivudine monotherapy. Among treated individuals, 27% had antiviral drug resistance. Testing rates for human immunodeficiency virus, hepatitis C virus, and delta coinfections were low.

CONCLUSIONS

We demonstrated diversity of chronic HBV infections in UK patients, suggesting that optimal management requires awareness of the variable patterns of chronic HBV in countries of origin. We also found less-than-optimal clinical management practices, possible gender-based treatment bias, and the need to improve testing for coinfections.

UK consensus guidelines for the use of the protease inhibitors boceprevir and telaprevir in genotype 1 chronic hepatitis C infected patients

BACKGROUND

The nonstructural 3 serine protease inhibitors (PIs), boceprevir and telaprevir, represent the first in a new generation of directly acting antivirals against genotype 1 hepatitis C (HCV) infection. When used in combination with pegylated interferon and ribavirin, these drugs greatly improve sustained virological response rates in both treatment-naïve patients and patients who have had previous virological failure on treatment. However, the addition of these new agents will increase the complexity of therapeutic regimens, the rates of side-effects and costs.

AIMS

To review concisely the current evidence and to suggest current best practice, for the use of telaprevir and boceprevir in the management of chronic genotype 1 HCV infection.

METHODS

These guidelines for the use of boceprevir and telaprevir have been formulated following extensive review of the current literature, are based on the consensus opinion of a panel of national experts, and have been openly discussed and debated at a national meeting of HCV care providers.

RESULTS

We have made recommendations on a number of the key practical issues facing HCV care providers: (i) Which patients to treat?; (ii) Standards for the provision of care; (iii) Pre-treatment considerations; (iv) Which treatment regimens to use?; (v) Stopping rules; and (vi) Management of adverse effects. Finally, we have produced suggested algorithms for the assessment and treatment of these patients.

CONCLUSIONS

These UK Consensus guidelines indicate the current best practice for the use of boceprevir and telaprevir in the management of genotype 1 chronic HCV infection.

UK consensus guidelines for the use of the protease inhibitors boceprevir and telaprevir in genotype 1 chronic hepatitis C infected patients

BACKGROUND

The nonstructural 3 serine protease inhibitors (PIs), boceprevir and telaprevir, represent the first in a new generation of directly acting antivirals against genotype 1 hepatitis C (HCV) infection. When used in combination with pegylated interferon and ribavirin, these drugs greatly improve sustained virological response rates in both treatment-naïve patients and patients who have had previous virological failure on treatment. However, the addition of these new agents will increase the complexity of therapeutic regimens, the rates of side-effects and costs.

AIMS

To review concisely the current evidence and to suggest current best practice, for the use of telaprevir and boceprevir in the management of chronic genotype 1 HCV infection.

METHODS

These guidelines for the use of boceprevir and telaprevir have been formulated following extensive review of the current literature, are based on the consensus opinion of a panel of national experts, and have been openly discussed and debated at a national meeting of HCV care providers.

RESULTS

We have made recommendations on a number of the key practical issues facing HCV care providers: (i) Which patients to treat?; (ii) Standards for the provision of care; (iii) Pre-treatment considerations; (iv) Which treatment regimens to use?; (v) Stopping rules; and (vi) Management of adverse effects. Finally, we have produced suggested algorithms for the assessment and treatment of these patients.

CONCLUSIONS

These UK Consensus guidelines indicate the current best practice for the use of boceprevir and telaprevir in the management of genotype 1 chronic HCV infection.

Identifying former injecting drug users infected with hepatitis C: an evaluation of a general practice-based case-finding intervention

BACKGROUND

In Scotland, a general practice-based case-finding initiative, to diagnose and refer hepatitis C virus (HCV) chronically infected former injecting drug users (IDUs), was evaluated.

METHODS

Testing was offered in eight Glasgow general practices in areas of high deprivation and high HCV and IDU prevalence to attendees aged 30-54 years with a history of IDU. Test uptake and diagnosis rates were compared with those in eight demographically similar control practices.

RESULTS

Of 422 eligible intervention practice attendees, 218 (52%) were offered an HCV test and, of these, 121 (56%) accepted. Poor venous access in 13 individuals prevented testing. Of 105 tested, 70% (74/105) were antibody positive of which 58% (43/74) were RNA positive by PCR. Of 43 chronically infected individuals identified in intervention practices, 22 (51%) had attended specialist care within 30 months of the study, while 9 (21%) had defaulted. In control practices, 8 (22%) of 36 individuals tested were antibody positive. Test uptake and case yield were approximately 3 and 10 times higher in intervention compared with control practices, respectively.

CONCLUSIONS

Targeted case-finding in primary care demonstrated higher test uptake and diagnosis rates; however, to optimize diagnosis and referral of chronically infected individuals, alternative means of testing (e.g. dried blood spots) and retention in specialist care (e.g. outreach services) must be explored.

Excess liver-related morbidity of chronic hepatitis C patients, who achieve a sustained viral response, and are discharged from care

Our objective was to address two shortfalls in the hepatitis C virus (HCV) literature: (1) Few data exist comparing post-treatment liver-related mortality/morbidity in HCV-sustained virologic response (SVR) patients to non-SVR patients and (2) no data exist examining liver-related morbidity among treatment response subgroups,particularly among noncirrhotic SVR patients, a group who in the main are discharged from care without further follow-up. A retrospective cohort of 1,215 previously naïve HCV interferon patients (treated 1996-2007)was derived using HCV clinical databases from nine Scottish clinics. Patients were followed up post-treatment for a mean of 5.3 years. (1) By Cox-regression, liver-related hospital episodes (adjusted hazard ratio [AHR]:0.22; 95% confidence interval [CI]: 0.15-0.34) and liver-related mortality [corrected] (AHR: 0.22; 95% CI: 0.09-0.58)were significantly lower in SVR patients, compared to non-SVR patients. (2) Rates of liver-related hospitalization were elevated among all treatment subgroups compared to the general population: Among noncirrhotic SVR patients, adjusted standardized morbidity ratio (SMBR) up to 5.9 (95% CI: 4.5-8.0); among all SVR patients,SMBR up to 10.5 (95% CI: 8.7-12.9); and among non-SVR patients, SMBR up to 53.2 (95% CI: 49.4-57.2).Considerable elevation was also noted among patients who have spontaneously resolved their HCV infection(a control group used to gauge the extent to which lifestyle factors, and not chronic HCV, can contribute toliver-related morbidity), SMBR up to 26.8 (95% CI: 25.3-28.3).

CONCLUSIONS

(1) Patients achieving an SVR were more than four times less likely to be hospitalized, or die for a liver-related reason, than non-SVR patients and (2) although discharged, noncirrhotic SVR patients harbor a disproportionate burden of liver-related morbidity; up to six times that of the general population. Further, alarming levels of liver-related morbidity in spontaneous resolvers is an important finding warranting further study..

Design, development and validation of the RedBrick Health Assessment: a questionnaire-based study

OBJECTIVES

Health risk assessment (HRA) questionnaires have become a popular tool to help quantify health issues within populations. Over the last decade HRAs have increasingly been delivered in the online environment. The objective of this study was to create and validate an HRA that is optimized for delivery via the Internet.

DESIGN

After an iterative process of user testing and interface design the RedBrick Health Assessment (RBHA) was validated against known domain specific questionnaires with 464 working Americans, and with medical claims data from over 25,000 employees.

SETTING

All consumer testing, data capture and analysis occurred at the offices of RedBrick Health Corporation, Minneapolis, USA and via a secure online portal.

PARTICIPANTS

Individuals in full-time employment in the USA, who were between 18 and 65 years of age at the time inquiry.

MAIN OUTCOME MEASURES

Correlation of the included RBHA domains with the output from known gold standard health question sets for each assessed health domain.

RESULTS

The iterative development process employed in creating the RBHA produced a tool that had a high degree of user acceptability. The domains demonstrated good correlations with relevant gold standard questionnaire measures, good internal consistency, and acceptable sensitivity and specificity when compared to gold standard risk stratification and high-risk classification (specificity of domains ranged from 76-94%). A test-retest correlation co-efficient of 0.7, or greater, was achieved 8 weeks after initial completion.

CONCLUSIONS

The RBHA is a new breed of HRA that has been specifically developed for capturing health status information in an online environment. At its heart is user centricity and this focus has enabled the creation of a tool that is not only highly engaging but also captures accurate and robust health status information.

Uptake of hepatitis C antibody testing in patients with end-stage liver disease in Glasgow, 1993-2007

Individuals infected with hepatitis C virus (HCV) need to be diagnosed well before developing end-stage liver disease to benefit from treatment. We aimed to ascertain what proportion of cases had been tested for HCV to inform on the effectiveness of current guidelines. Record linkage between national databases of HCV tests, hospital discharges and deaths identified 10,645 persons who were hospitalized or had died with mention of end-stage liver disease in Glasgow, Scotland, between 1993 and 2007. We estimated HCV test uptake and prevalence of HCV infection within the study population. The associations between both HCV test uptake and HCV-antibody status and sex, age group and deprivation quintile were estimated using logistic regression. We found that 43% of those hospitalized (n = 9153) and 23% of those who otherwise died (n = 1492) with first-time mention of end-stage liver disease had been tested for HCV during this period. Test uptake in those hospitalized increased from 13 (95% CI: 12-14%) in 1993-1997 to 58% (56-59%) in 2003-2007. The adjusted odds of being tested for HCV were significantly higher for men (OR=1.3, 95% CI: 1.2-1.5), for ages 25-54 (25-34 years: 2.7, 95% CI: 2.1-3.4; 35-44 years: 2.3, 95% CI: 2.0-2.6; 45-54 years: 1.5, 95% CI: 1.4-1.7) compared with 55+ years, and for those residing in the two most deprived quintiles (1.1, 95% CI: 1.0-1.2). Twenty-eight per cent of the HCV testees aged 25-44 years were HCV infected. These results highlight the continuing need for raising awareness among medical professionals for comprehensive HCV testing in patients with liver disease.

The influence of hepatitis C and alcohol on liver-related morbidity and mortality in Glasgow's injecting drug user population

Infection with the hepatitis C virus (HCV) is associated with the development of severe liver disease, but cofactors--namely alcohol abuse--in Scotland's HCV-positive population complicate estimation of the unique contribution of HCV. We compared the risk of hospital admission/death for a liver-related cause in a large cohort of Glasgow's injecting drug users (IDUs) testing HCV-positive with IDUs testing HCV negative. Data for 6566 current/former IDUs who had been tested for anti-HCV and/or HCV RNA by polymerase chain reaction in Greater Glasgow health board between 1993 and 2007 were linked to the national hospitalization database and deaths registry to identify all admissions and deaths from a liver-related condition. Relative risks were estimated using Cox proportional hazards regression for recurrent events. Time at risk was censored at 2 years following an HCV test to address bias owing to unobserved seroconversion. The risk of hospitalization/death from a liver-related or an alcoholic liver-related condition following HCV testing was greater for those IDUs with no prior alcohol-related hospitalization who tested positive [adjusted hazard ratio (HR) = 3.2, 95% CI: 1.5-6.7; 4.9, 95% CI: 1.8-13.1, respectively], compared with those who tested anti-HCV negative, but not for those IDUs with a prior alcohol admission (HR = 0.8, 95% CI: 0.4-1.5; 0.8, 95% CI: 0.4-1.6). There was little evidence for an increased risk of hospitalization/death for an exclusively nonalcoholic liver condition for those testing positive (HR = 1.5, 95% CI: 0.8-2.7), after adjustment for previous alcohol-related admission. Within Glasgow's IDU population, HCV positivity is associated with an increased risk of a liver-related outcome, but this is not observed for those IDUs whose problem alcohol use already increases their risk.

The Changing Face of Hepatitis B in Greater Glasgow: epidemiological trends 1993–2007

Background and Aims

Whilst hepatitis B (HBV) is historically uncommon in Scotland, anecdotal experience suggests an increasing prevalence of chronic infection. We sought to establish whether the incidence of chronic HBV is increasing in Greater Glasgow, and whether patients are assessed in secondary care.

Methods

The regional virus centre database identified HBV surface antigen (HBsAg) positive samples. For adult patients tested in Glasgow between 1993–2007 the first positive test was identified and classified as acute or chronic infection serologically. Clinic referral and attendance data was then obtained.

Results

1,672 patients tested HBsAg positive; 1051 with chronic infection, 421 acute and 200 indeterminate. New diagnoses of HBV remained stable over time, however falling numbers of acute cases were mirrored by a rise in chronic cases from 40 to 119 per annum between 2000 and 2007. Of 193 patients diagnosed in 2006 and 2007, 51% were not seen in secondary care due to non referral (43%) or non attendance (8%).

Conclusion

Chronic HBV trebled in Glasgow between 2000 and 2007. Most patients were not assessed in secondary care. Improved levels of clinic referral and attendance are required to ensure best care for HBV patients in Glasgow.

The growing contribution of hepatitis C virus infection to liver-related mortality in Scotland

The large number of individuals in Scotland who became infected with the hepatitis C virus (HCV) in the 1970s and 1980s leads us to expect liver-related morbidity and mortality to increase in the coming years. We investigated the contribution of HCV to liver-related mortality in the period January 1991 to June 2006. The study population consisted of 26,861 individuals whose death record mentioned a liver-related cause (underlying or contributing). Record-linkage to the national HCV Diagnosis database supplied HCV-diagnosed status for the study population. The proportion diagnosed with HCV among people dying from a liver-related cause rose from 2.8% (1995-1997) to 4.4% (2004-June 2006); the largest increase occurred in those aged 35-44 years at death (7% to 17%). Among all deaths from a liver-related cause, an HCV-positive diagnosis was more likely in those who died in 2001 or later than those who died in 1995-1997 (2001-2003: odds ratio=1.4, 95% confidence interval: 1.1-1.7; 2004-June 2006: 1.6, 1.3-2.0), and in those who died at under 55 compared with at least 55 years of age. HCV infection represents a significant, growing, public health burden in Scotland in terms of early deaths from liver disease.

The growing contribution of hepatitis C virus infection to liver-related mortality in Scotland

The large number of individuals in Scotland who became infected with the hepatitis C virus (HCV) in the 1970s and 1980s leads us to expect liver-related morbidity and mortality to increase in the coming years. We investigated the contribution of HCV to liver-related mortality in the period January 1991 to June 2006. The study population consisted of 26,861 individuals whose death record mentioned a liver-related cause (underlying or contributing). Record-linkage to the national HCV Diagnosis database supplied HCV-diagnosed status for the study population. The proportion diagnosed with HCV among people dying from a liver-related cause rose from 2.8% (1995-1997) to 4.4% (2004-June 2006); the largest increase occurred in those aged 35-44 years at death (7% to 17%). Among all deaths from a liver-related cause, an HCV-positive diagnosis was more likely in those who died in 2001 or later than those who died in 1995-1997 (2001-2003: odds ratio (OR)=1.4, 95% confidence interval (CI): 1.1-1.7; 2004-June 2006: 1.6, 1.3-2.0), and in those who died at under 55 compared with at least 55 years of age. HCV infection represents a significant, growing, public health burden in Scotland in terms of early deaths from liver disease.

The pmk1-like mitogen-activated protein kinase from Lecanicillium (Verticillium) fungicola is not required for virulence on Agaricus bisporus

In plant-pathogenic fungi, the pmk1 mitogen-activated protein kinase (MAPK) signalling pathway plays an essential role in regulating the development of penetration structures and the sensing of host-derived cues, but its role in other pathosystems such as fungal-fungal interactions is less clear. We report the use of a gene disruption strategy to investigate the pmk1-like MAPK, Lf pmk1 in the development of Lecanicillium fungicola (formerly Verticillium fungicola) infection on the cultivated mushroom Agaricus bisporus. Lf pmk1 was isolated using a degenerate PCR-based approach and was shown to be present in a single copy by Southern blot analysis. Quantitative RT-PCR showed the transcript to be fivefold upregulated in cap lesions compared with pure culture. Agrobacterium-mediated targeted disruption was used to delete a central portion of the Lf pmk1 gene. The resulting mutants showed normal symptom development as assessed by A. bisporus mushroom cap assays, sporulation patterns were normal and there were no apparent changes in overall growth rates. Our results indicate that, unlike the situation in fungal-plant pathogens, the pmk1-like MAPK pathway is not required for virulence in the fungal-fungal interaction between the L. fungicola pathogen and A. bisporus host. This observation may be of wider significance in other fungal-fungal and/or fungal-invertebrate interactions.

Evaluation of a general practice based hepatitis C virus screening intervention

BACKGROUND

In 2003 an estimated 37,500 of Scotland's population was chronically infected with HCV; 44% were undiagnosed former injecting drug users (IDU)--a priority group for antiviral therapy.

AIM

To evaluate a hepatitis C virus (HCV) screening intervention.

DESIGN

Outcome measures among two similar General Practice populations in an area of high HCV and drug use prevalence, one of which was exposed to an HCV screening intervention, were compared.

METHODS

Thirty to fifty four year old attendees of the intervention practice were opportunistically offered testing and counselling, where clinically appropriate, (November 2003-April 2004).

OUTCOMES

HCV test uptake, case detection, referral and treatment administration rates.

RESULTS

Of 584 eligible attendees, 421 (72%) were offered and 117 (28%) accepted testing in the intervention practice; no testing was undertaken in the comparison practice. Prevalences of HCV antibody were 13% (15/117), 75% (3/4) and 91% (10/11) among all tested persons, current IDUs and former IDUs respectively. For 4/15 (27%) evidence of binge drinking following the receipt of their positive result, was available. Of the 11 referred to specialist care because they were HCV RNA positive, nine attended at least one appointment. Two received treatment: one had achieved a sustained viral response as of February 2008.

CONCLUSION

While non targeted HCV screening in the general practice setting can detect infected former IDU, the low diagnostic yield among non IDUs limited the effectiveness of the intervention. A more targeted approach for identifying former IDUs is recommended. Additionally, the low uptake of treatment among chronically infected persons four years after diagnosis demonstrates the difficulties in clinically managing such individuals. Strategies, including support for those with a history of problem alcohol use, to improve treatment uptake are required.

Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed

Current therapy for preventing the first variceal bleed includes beta-blocker and variceal band ligation (VBL). VBL has lower bleeding rates, with no differences in survival, whereas beta-blocker therapy can be limited by side effects. Carvedilol, a non-cardioselective vasodilating beta-blocker, is more effective in reducing portal pressure than propranolol; however, there have been no clinical studies assessing the efficacy of carvedilol in primary prophylaxis. The goal of this study was to compare carvedilol and VBL for the prevention of the first variceal bleed in a randomized controlled multicenter trial. One hundred fifty-two cirrhotic patients from five different centers with grade II or larger esophageal varices were randomized to either carvedilol 12.5 mg once daily or VBL performed every 2 weeks until eradication using a multibander device. Seventy-seven patients were randomized to carvedilol and 75 to VBL. Baseline characteristics did not differ between the groups (alcoholic liver disease, 73%; median Child-Pugh score, 8; median age, 54 years; median follow-up, 20 months). On intention-to-treat analysis, carvedilol had lower rates of the first variceal bleed (10% versus 23%; relative hazard 0.41; 95% confidence interval 0.19-0.96 [P = 0.04]), with no significant differences in overall mortality (35% versus 37%, P = 0.71), and bleeding-related mortality (3% versus 1%, P = 0.26). Six patients in the VBL group bled as a result of banding ulcers. Per-protocol analysis revealed no significant differences in the outcomes.

CONCLUSION

Carvedilol is effective in preventing the first variceal bleed. Carvedilol is an option for primary prophylaxis in patients with high-risk esophageal varices.

Association of self-reported alcohol use and hospitalization for an alcohol-related cause in Scotland: a record-linkage study of 23,183 individuals

AIMS

To investigate the extent to which self-reported alcohol consumption level in the Scottish population is associated with first-time hospital admission for an alcohol-related cause.

DESIGN

Observational record-linkage study.

SETTING

Scotland, 1995-2005.

PARTICIPANTS

A total of 23,183 respondents aged 16 and over who participated in the 1995, 1998 and 2003 Scottish Health Surveys, followed-up via record-linkage from interview date until 30 September 2005.

MEASUREMENTS

Rate of first-time hospital admission with at least one alcohol-related diagnosis. Cox proportional hazards regression analysis was applied to estimate the relative risk of first-time hospitalization with an alcohol-related condition associated with usual alcohol consumption level (1-7, 8-14, 15-21, 22-35, 36-49, 50+ units/week and ex-drinker, compared with <1 unit per week).

FINDINGS

Of the SHS participants, 527 were hospitalized for an alcohol-related cause during 135,313 person-years of follow-up [39 first admissions per 10,000 person-years, 95% confidence interval (CI) 36-42]. Alcohol-related hospitalization rates were considerably higher for males (61/10,000 person-years, 95% CI 54-67) than for females (22/10,000 person-years, 95% CI 18-26). Compared with the lowest alcohol consumption category (<1 unit per week), the relative risk of first-time alcohol-related admission increased with reported consumption: age-adjusted hazard ratios ranged from 3 (1-5) for 1-7 units/week to 19 (10-37) for 50+ units/week (males); and from 2 (1-3) for 1-7 units/week to 28 (14-56) for 50+ units/week (females). After adjusting for age and usual alcohol consumption, the relative risk of first-time alcohol-related admission remained significantly higher for males reporting binge drinking and for both males and females residing in the most deprived localities.

CONCLUSIONS

Moderate and higher levels of usual alcohol consumption and binge drinking are serious risk factors for alcohol-related hospitalization in the Scottish population. These findings contribute to our understanding of the relationship between alcohol intake and alcohol-related morbidity.

Quantifiable downregulation of endogenous genes in Agaricus bisporus mediated by expression of RNA hairpins

Functional gene studies in the cultivated white button mushroom Agaricus bisporus have been constrained by the absence of effective gene-silencing tools. Using two endogenous genes from A. bisporus, we have tested the utility of dsRNA hairpin constructs to mediate downregulation of specific genes. Hairpin constructs for genes encoding orotidine 5'- monophosphate decarboxylase (URA3) and carboxin resistance (CBX) were introduced into A. bisporus using Agrobacteriummediated transfection. Although predicted changes in phenotype were not observed in vitro, quantitative-PCR analyses indicated unambiguously that transcripts in several transformants were substantially reduced compared with the non-transformed controls. Interestingly, some hairpin transformants exhibited increased transcription of target genes. Our observations show that hairpin transgenic sequences can mediate downregulation of A. bisporus endogenous genes and that the technology has the potential to expedite functional genomics of the mushroom.

A population-based record linkage study of mortality in hepatitis C-diagnosed persons with or without HIV coinfection in Scotland

Infection with the hepatitis C virus (HCV) is known to increase the risk of death from severe liver disease and, because HCV status is strongly associated with a history of injecting drug use, the effect of a key disease progression cofactor, infection with human immunodeficiency virus (HIV), is of interest . We examined all-cause, liver-related and drug-related mortality and excess risk of death from these causes in a large cohort of HCV-monoinfected and HIV-coinfected persons in Scotland. The study population consisted of 20,163 persons confirmed to be infected with hepatitis C through laboratory testing in Scotland between 1991 and 2005. Records with sufficient identifiers were linked to the General Register Office for Scotland death register to retrieve associated mortality data, and were further linked to a national database of HIV-positive individuals to determine coinfection status. A total of 1715 HCV monoinfected and 305 HIV coinfected persons died of any cause during the follow-up period (mean of 5.4 and 6.4 years, respectively). Significant excess mortality was observed in both HCV monoinfected and HIV coinfected populations from liver-related underlying causes (standardised mortality ratios of 25, 95% CI = 23—27; and 37, 95% CI = 26—52 for the two groups, respectively) and drug-related causes (25, 95% CI = 23—27; 39, 95% CI = 28—53. The risk of death from hepatocellular carcinoma, alcoholic or non-alcoholic liver disease, or from a drug-related cause, was greatly increased compared with the general Scottish population, with the highest standardised mortality ratio observed for hepatocellular carcinoma in the monoinfected group (70, 95% CI = 57—85). This study has revealed considerable excess mortality from liver- and drug-related causes in the Scottish HCV-diagnosed population; these data are crucial to inform on the clinical management, and projected future public health burden, of HCV infection.

Mutations in the HFE Gene and Cardiovascular Disease Risk

Background— Whether mutations in the hemochromatosis (HFE) gene increase cardiovascular disease risk is still undetermined. The main reason is the low frequency of the mutations, in particular of the compound C282Y/H63D genotype. We combined the data of 11 observational studies for an individual patient data meta-analysis.

Methods and Results— Individual patient data were obtained from published as well as unpublished studies that had information available on the C282Y mutation as well as the H63D mutation in relation to coronary heart disease risk. Individual records were provided on each of the 53 880 participants in 11 studies. In total, 10 541 patients with coronary events were documented, of whom 5724 had an acute myocardial infarction. The crude and adjusted association between HFE genotypes and coronary events was examined by logistic regression analysis. We explored potential effect modification of the association between traditional cardiovascular risk factors and coronary events by HFE genotypes. After full adjustment, the odds ratio for coronary heart disease was 1.12 (95% CI, 0.92 to 1.37) for subjects with the compound heterozygous (C282Y/H63D) genotype relative to those with the wild-type/wild-type genotype. The odds ratios for C282Y/C282Y, C282Y/wild-type, H63D/H63D, and H63D/wild-type were 0.78 (95% CI, 0.49 to 1.26), 0.98 (95% CI, 0.90 to 1.07), 1.16 (95% CI, 0.97 to 1.38), and 1.07 (95% CI, 1.00 to 1.14), respectively. There was no evidence for effect modification.

Conclusions— The results of this large individual patient data meta-analysis do not support the view that HFE gene mutations are associated with an increased risk of coronary heart disease or acute myocardial infarction.

A record-linkage study of the development of hepatocellular carcinoma in persons with hepatitis C infection in Scotland

We investigated trends in first-time hospital admissions and deaths attributable to hepatocellular carcinoma (HCC) in a large population-based cohort of 22 073 individuals diagnosed with hepatitis C viral (HCV) infection through laboratory testing in Scotland in 1991–2006. We identified new cases of HCC through record-linkage to the national inpatient hospital discharge database and deaths registry. A total of 172 persons diagnosed with HCV were admitted to hospital or died with first-time mention of HCC. Hepatocellular carcinoma incidence increased between 1996 and 2006 (average annual change of 6.1, 95% confidence interval (CI): 0.9–11.6%, P=0.021). The adjusted relative risk of HCC was greater for males (hazard ratio=2.7, 95% CI: 1.7–4.2), for those aged 60 years or older (hazard ratio=2.7, 95% CI: 1.9–4.1) compared with 50–59 years, and for those with a previous alcohol-related hospital admission (hazard ratio=2.5, 95% CI: 1.7–3.7). The risk of individuals diagnosed with HCV developing HCC was greatly increased compared with the general Scottish population (standardised incidence ratio=127, 95% CI: 102–156). Owing to the advancing age of the Scottish HCV-diagnosed population, the annual number of HCC cases is projected to increase, with a consequent increasing burden on the public healthcare system.

Oligonucleotide sequences forming short self-complimentary hairpins can expedite the down-regulation of Coprinopsis cinerea genes

Gene silencing in fungi is often induced by dsRNA hairpin forming constructs the preparation of which can require multiple cloning steps. To simplify gene silencing in the filamentous fungi we have evaluated a high throughput cloning method for target sequences using the homobasidiomycete Coprinopsis cinerea, the GFP reporter and a commercially available vector system. The pSUPER RNAi System, which was developed for mammalian experiments, exploits the human H1 Polymerase III (Pol III) RNA gene promoter and expedites cloning/expression of specific user-defined oligonucleotide sequences to form short self-complimentary hairpins. Transformation of C. cinerea with pSUPER constructs harboring specific oligonucleotides (19 nt stem length) enabled recovery of transformants with reduced transcripts of the GFP transgene, that were less fluorescent in protein assays and microscopic phenotypes. This technological advance should expedite functional genomic studies in C. cinerea and has wider potential for utility in other homobasidiomycete and filamentous fungi.