Prevalence and correlates of stocking up on drugs during the COVID-19 pandemic: Data from the C3PNO Consortium

BACKGROUND

Data from the COVID-19 pandemic describes increases in drug use and related harms, especially fatal overdose. However, evidence is needed to better understand the pathways from pandemic-related factors to substance use behaviours. Thus, we investigated stockpiling drugs among people who use drugs (PWUD) in five cities in the United States and Canada.

METHODS

We used data from two waves of interviews among participants in nine prospective cohorts to estimate the prevalence and correlates of stockpiling drugs in the previous month. Longitudinal correlates were identified using bivariate and multivariate generalized linear mixed-effects modeling analyses.

RESULTS

From May 2020 to February 2021, we recruited 1873 individuals who completed 2242 interviews, of whom 217 (11.6%) reported stockpiling drugs in the last month at baseline. In the multivariate model, stockpiling drugs was significantly and positively associated with reporting being greatly impacted by COVID-19 (Adjusted Odds Ratio [AOR]= 1.21, 95% CI: 1.09-1.45), and at least daily use of methamphetamine (AOR = 4.67, 95% CI: 2.75-7.94) in the past month.

CONCLUSIONS

We observed that approximately one-in-ten participants reported stocking up on drugs during the COVID-19 pandemic. This behaviour was associated with important drug-related risk factors including high-intensity methamphetamine use. While these correlations need further inquiry, it is possible that addressing the impact of COVID-19 on vulnerable PWUD could help limit drug stockpiling, which may lower rates of high-intensity stimulant use.

Internet-delivered cognitive behaviour therapy for chronic health conditions: self-guided versus team-guided

There is growing interest in offering Internet-delivered cognitive behaviour therapy (ICBT) to individuals with chronic health conditions, with this process often being guided by a single clinician. Due to lack of full time personnel, it is sometimes necessary to have multiple clinicians offer guidance or for no guidance to be offered. In this randomized trial, we compared team-guided ICBT (n = 90) to self-guided ICBT (n = 88). Participants completed measures at pre-, post-, and 3-months post-ICBT. Both groups showed similar rates of treatment completion and large improvements on depression and anxiety at post-treatment and follow-up. Unexpectedly, more participants in the self-guided versus team-guided condition showed clinically significant improvement on depression at post-treatment (76.5% vs 49.2%) and follow-up (70% vs 45.6%). Thus, team-guided ICBT may not provide significant benefits compared to self-guided ICBT. However, it may be an alternative approach to consider among a population of high risk individuals that wants or requires closer monitoring of symptoms.

Trail registration TRN: NCT03500237; Date: April 18, 2018.

Diversity of hepatitis C virus infection among HIV-infected people who inject drugs in India

The availability of generic direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has prompted many low-and-middle-income countries to launch HCV elimination programs. Because the efficacy of some of these generic DAAs varies by HCV viral subtype, information on subtype distribution can contribute important information to these elimination programs. We conducted a cross-sectional serosurvey to characterize HCV subtype diversity among HIV positive people who inject drugs (PWID) across 14 cities in India. Of 801 HIV positive PWID sampled, 639 tested HCV antibody positive (78.9%). Among 105 samples sequenced, genotype 3 (58.1%) was the most commonly observed followed by genotype 1 (36.2%) and genotype 6 (5.7%). Of the genotype 3 infections, 65% were subtype 3a and 35% were subtype 3b. Of the genotype 1 infections, 94% were subtype 1a and 6% were subtype 1b. All genotype 6 samples were subtype 6n. There was some variability in genotype diversity depending on geographic region and PWID epidemic stage with greater diversity observed in older PWID epidemics. One sequence, HY018, did not cluster with any known reference sequences in phylogenetic analysis. Nearly 80% of HIV infected PWID across India are co-infected with HCV, and subtype prevalence and genetic diversity varied by region and PWID epidemic stage. HCV elimination programs in India will need to consider HCV subtype.

Directly observed therapy of sofosbuvir/ribavirin +/- peginterferon with minimal monitoring for the treatment of chronic hepatitis C in people with a history of drug use in Chennai, India (C-DOT)

We assessed the feasibility of field-based directly observed therapy (DOT) with minimal monitoring to deliver HCV treatment to people with a history of drug use in Chennai, India. Fifty participants were randomized 1:1 to sofosbuvir+peginterferon alfa 2a+ribavirin (SOF+PR) for 12 weeks (Arm 1) vs sofosbuvir+ribavirin (SOF+R) for 24 weeks (Arm 2). SOF+R was delivered daily at participant chosen venues and weekly peginterferon injections at the study clinic. HCV RNA testing was performed to confirm active HCV infection and sustained virologic response 12 weeks after treatment completion (SVR12). No baseline genotyping or on-treatment viral loads were performed. Median age was 46 years. All were male and 20% had significant fibrosis/cirrhosis. All self-reported history of injection drug use, 18% recent noninjection drug use and 38% alcohol dependence. Six discontinued treatment (88% completed treatment in each arm). Of 22 who completed SOF+PR, all achieved SVR12 (22/25=88%); 15 of 22 who completed SOF+R achieved SVR12 (15/25=60%; P=.05). Among those completing SOF+R, SVR12 was significantly less common in participants reporting ongoing substance use (36% vs 100%) and missed doses. Active substance use and missed doses did not impact SVR with SOF+PR. Field-based DOT of HCV therapy without real-time HCV RNA monitoring was feasible; however, achieving 100% adherence was challenging. SOF+PR appeared superior to SOF+R in achieving SVR12, even when doses were missed with no discontinuations due to side effects. Further exploration of short duration treatment with peginterferon plus direct-acting antivirals is warranted.

Genetic basis for variation in plasma IL-18 levels in persons with chronic hepatitis C virus and human immunodeficiency virus-1 infections

Inflammasomes are multi-protein complexes integrating pathogen-triggered signaling leading to the generation of pro-inflammatory cytokines, including interleukin-18 (IL-18). Hepatitis C virus (HCV) and human immunodeficiency virus-1 (HIV) infections are associated with elevated IL-18, suggesting inflammasome activation. However, there is marked person-to-person variation in the inflammasome response to HCV and HIV. We hypothesized that host genetics may explain this variation. To test this, we analyzed the associations of plasma IL-18 levels and polymorphisms in 10 genes in the inflammasome cascade. 1538 participants with active HIV and/or HCV infection in 3 ancestry groups are included. Samples were genotyped using the Illumina Omni 1-quad and Omni 2.5 arrays. Linear regression analyses were performed to test the association of variants with logIL-18 including HCV and HIV infection status and HIV-RNA, in each ancestry group and then meta-analyzed. Eleven highly correlated SNPs (r2=0.98-1) in the IL18-BCO2 region were significantly associated with logIL-18; Each T allele of rs80011693 confers a decrease of 0.06 log pg/mL of IL-18 after adjusting for covariates (rs80011693; rs111311302 β=-0.06, P-value=2.7×10^-4). In conclusion, genetic variation in IL18 is associated with IL-18 production in response to HIV and HCV infection and may explain variability in the inflammatory outcomes of chronic viral infections.

Primary Care Providers Knowledge, Attitude and Practices Related to Hepatitis C Screening and Treatment in the Oral Direct Acting Antiviral Agents Era

Background

There are over 3 million Americans infected with hepatitis C virus (HCV). Despite recent advances in HCV treatment, a major barrier to care remains a limited number of treaters. HCV therapy provision by primary care providers (PCPs) could expand access by increasing the pool of HCV treating clinicians.

Objective

To characterize current HCV care practices, willingness and self-efficacy of PCPs to become HCV treaters.

Design, participants and main measures

Two hundred and seventy one PCPs were identified from community clinics affiliated with a large academic center and 4 large federally qualified health centers in Baltimore, MD. An internet-based survey was administered to assess provider demographics, clinical practice site and willingness to provide HCV care. Factors associated with willingness to provide HCV care were examined using odds ratios (OR).

Key results

Among 129 (48%) PCPs who responded, the majority (70%) had an MD/DO degree and were white (60%). Only a few PCPs, 12 (10%), had treated at least 1 patient for HCV in the prior year. Although only 22% agreed that HCV treatment should be provided by PCPs, 84% were interested in more HCV training. Willingness to provide treatment was strongly linked to having a high proportion of HCV-infected patients (>20% versus <20%; OR 3.9; 95% confidence interval [CI] 1.5–10) and availability of other services at the primary care site including HIV treatment (OR 6.5; 95% CI 2.5–16.5), substance abuse treatment (OR 3.3; 95% CI 1.3–8.4) and mental health services (OR 4.9; 95% CI 2.0–12.1).

Conclusion

These data suggest that efforts to expand HCV medical provider capacity will be most impactful if they initially focus HCV training on PCPs with a high prevalence of HCV among their patients and existing systems to support HCV care.

Building a Community - Academic Partnership to Enhance Hepatitis C Virus Screening

BACKGROUND

An estimated 3.5 million Americans are chronically infected with hepatitis C virus (HCV). However, the majority are unaware of their HCV diagnosis and few are treated. New models are required to diagnose and link HCV infected patients to HCV care. This paper describes an innovative partnership between Sisters Together and Reaching (STAR), Inc., a community organization, and Johns Hopkins University (JHU), an academic institution, for the identification of HCV cases.

METHODS

STAR and JHU identified a mutual interest in increasing hepatitis C screening efforts and launched an HCV screening program which was designed to enhance STAR's existing HIV efforts. STAR and JHU used the Bergen Model of Collaborative Functioning as theoretical framework for the partnership. We used descriptive statistics to characterize the study population and correlates of HCV antibody positivity were reported in univariable/multivariable logistic regression.

RESULTS

From July 2014 to June 2015, 325 rapid HCV antibody tests were performed in community settings with 49 (15%) positive HCV antibody tests. 33 of the 49 HCV antibody positive individuals answered questions about their HCV testing history and 42% reported a prior positive result but were not engaged in care and 58% reported that they were unaware of their HCV status. In multivariable analysis, factors that were significantly associated with screening HCV antibody positive were increasing age (AOR: 1.06, 95% CI 1.02-1.10), male sex (AOR: 5.56, 95% CI 1.92-14.29), and history of injection drug use (AOR: 39.3, 95% CI 15.20-101.49).

CONCLUSIONS

The community-academic partnership was successful in identifying individuals with hepatitis C infection through a synergistic collaboration. The program data suggests that community screening may improve the hepatitis C care continuum by identifying individuals unaware of their HCV status or aware of their HCV status but not engaged in care and linking them to care.

The HIV care continuum among men who have sex with men in Moscow, Russia: a cross-sectional study of infection awareness and engagement in care

OBJECTIVES

Early diagnosis and treatment of HIV infection is critical to improving clinical outcomes for HIV-infected individuals. We sought to characterise the HIV care continuum and identify correlates of being unaware of one's HIV infection among men who have sex with men (MSM) in Moscow, Russia.

METHODS

Participants (N=1376) were recruited via respondent-driven sampling and completed a sociobehavioural survey and HIV testing from 2010 to 2013. Sample and population estimates were calculated for key steps along the HIV care continuum for HIV-infected MSM and logistic regression methods were used to examine correlates of being unaware of one's HIV infection.

RESULTS

15.6% (184/1177; population estimate: 11.6%; 95% CI 8.5% to 14.7%) of participants were HIV infected. Of these, only 23.4% (43/184; population estimate: 13.2; 95% CI 11.0 to 15.4) were previously aware of their infection, 8.7% (16/184 population estimate: 4.7; 95% CI 1.0 to 8.5) were on antiretroviral therapy (ART), and 4.4% (8/164; population estimate: 3.0; 95% CI 0.3 to 5.6) reported an undetectable viral load. Bisexual identity (reference: homosexual; adjusted odds ratio (AOR): 3.69; 95% CI 1.19 to 11.43), having ≥5 sexual partners in the last 6 months (reference: ≤1; AOR: 4.23; 95% CI 1.17 to 15.28), and employer HIV testing requirements (reference: no; AOR: 15.43; 95% CI 1.62 to 147.01) were associated with being unaware of one's HIV infection. HIV testing in a specialised facility (reference: private; AOR: 0.06; 95% CI 0.01 to 0.53) and testing ≥2 times in the last 12 months (reference: none; AOR: 0.17; 95% CI 0.04 to 0.73) were inversely associated with being unaware of HIV infection.

CONCLUSIONS

There is a steep gradient along the HIV care continuum for Moscow-based MSM beginning with low awareness of HIV infection. Efforts that improve access to acceptable HIV testing strategies, such as alternative testing facilities, and linkage to care are needed for key populations.

The new paradigm of hepatitis C therapy: integration of oral therapies into best practices

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.

Diagnostic value of the rapid assessment of postural instability in Parkinson's disease (RAPID) questionnaire

BACKGROUND

People with idiopathic Parkinson's disease (PD) develop postural instability in the later stages of the ailment. Postural instability has traditionally been quantified with the Pull test even though its face validity is limited. We previously established cut-off scores for a three-part rapid assessment of postural instability (RAPID) questionnaire as a non-physical complement to the physical test. In the current study, the questionnaire was administered to a new group of PD subjects to evaluate the diagnostic value of the instrument.

METHODS

Sensitivity and specificity values were calculated for single and combined sections of the questionnaire by using the Pull test as the gold standard for assessing the presence of postural instability.

RESULTS

The questionnaire when used in its entirety gave the highest sensitivity (.71), whereas specificity was highest in the activities of daily living (.74) and fear of falling sections (.74). Net specificity decreased to .44 when the scores from the three sections of the questionnaire were combined.

CONCLUSIONS

The high sensitivity of the RAPID questionnaire suggests that it may be used as an adjunct to the Pull test or solely if it is not convenient or contraindicated. The questionnaire may also be adapted for use via the telephone or internet. The limitation of the Pull test in revealing postural instability may explain the low specificity of the questionnaire, i.e. the questionnaire correctly identifies patients as unstable when the Pull test indicates normal postural control. It is hoped that the rapid identification of postural instability in PD may lead to increased awareness of the disease progression and fewer falls.

Transient elastography for predicting clinical outcomes in patients with chronic liver disease

There is increasing interest in developing noninvasive means to evaluate liver fibrosis in patients with chronic liver disease to determine disease severity, prognosis and optimal treatment. Transient elastography (TE) has previously been demonstrated to predict the presence or absence of advanced fibrosis. The current study was conducted to determine whether TE can identify patients with chronic liver disease at risk of clinical decompensation. A total of 667 patients underwent TE and were followed for a median of 861 days and 57 patients achieved the primary outcome, a composite of clinical endpoints including death, ascites, encephalopathy, increased Child Score ≥ 2, variceal bleed, hepatocellular carcinoma or listing for transplant. Overall, TE had an area under the receiver operating characteristic curve of 0.87 for predicting clinical outcome. Using a cut-off of 10.5 kPa, TE has a sensitivity, specificity, positive predictive value and negative predictive value (NPV) of 94.7%, 63.0%, 19.3% and 99.2%, respectively. A predictive model for clinical events was developed using generalized cross-validation for clinical endpoints considering TE, liver biopsy results and multiple other predictors. Individually, TE performed better than biopsy, or any other variable, for predicting clinical outcome [Harrell's C Statistic 0.86 for TE, 0.78 for stage]. Patients with a TE score of >12.5 kPa were found to have a relative hazard for clinical event of 18.99 compared with patients with TE score <10.5. A combined variable model including TE, aspartate aminotransferase/alanine aminotransferase ratio and model for end-stage liver disease (MELD) yielded the highest predictive accuracy with Harrell's C value of 0.93. In the subset of patients with cirrhosis, TE was not found to be independently associated with clinical outcomes in univariate or multivariate analysis although it retained a high sensitivity and NPV of 97.5% and 92.3%, respectively, at a kPa cut-off of 10.5. TE can successfully identify patients with chronic liver disease who are at low risk of clinical decompensation over a time period of 2 years.

Rapid assessment of postural instability in Parkinson's disease (RAPID): a pilot study

BACKGROUND

The Fahn's pull (or retropulsion) test is an item in the motor section of the Unified Parkinson's Disease Rating Scale, which is used almost exclusively to classify postural instability in Parkinson's disease (PD). However, the test is hard to standardize and is often performed incorrectly, making it hard to interpret. Moreover, it may not be safe to administer in patients who experience pain in the shoulders, neck, trunk and/or lower extremities. Identifying and grading postural instability in PD without requiring a physical challenge would not only be useful for the clinician but would assist patients and caregivers in its recognition. We propose the use of the rapid assessment of postural instability in Parkinson's disease (RAPID) questionnaire as a non-physical assessment tool.

METHODS

We determined the associations between the pull test and items on a risk-assessment questionnaire that consisted of three parts: activities of daily living, fear of falling, and frequency of falling.

RESULTS

Significant correlations were found between the pull test and the predictor variables, which ranged between 0.51 and 0.56 whilst the correlations amongst the predictor variables ranged between 0.58 and 0.70. The three parts of the questionnaire, when used in combination, produced a 96% sensitivity in the classification of postural instability.

CONCLUSIONS

The RAPID questionnaire can be used as an adjunct to the pull test or solely if the pull test is contraindicated. It may also be possible to administer the questionnaire via the telephone or Internet. It is hoped that the rapid identification of postural instability would lead to fewer falls.

Early immunologic and virologic responses to highly active antiretroviral therapy and subsequent disease progression among HIV-infected injection drug users

We examined the prevalence and prognostic value of early responses to highly active antiretroviral therapy (HAART) among community-based injection drug users (IDUs) in Baltimore. Virologic (HIV RNA <1000 copies/ml) and immunologic (CD4 >500 cells/ul or increase of 50 cells/ul from the pre-HAART level) responses were examined in the 1st year of HAART initiation. Cox regression was used to examine the effect of early response on progression to new AIDS diagnosis or AIDS-related death. Among 258 HAART initiators, 75(29%) had no response, 53(21%) had a virologic response only, 38(15%) had an immunologic response only and 92(36%) had a combined immunologic and virologic response in the first year of therapy. Poorer responses were observed in those who were older, had been recently incarcerated, reported injecting drugs, had not had a recent outpatient visit and had some treatment interruption within the 1st year of HAART. In multiple Cox regression analysis, the risk of progression was lower in those with combined virologic and immunologic response than in non-responders, (relative hazard [RH], 0.32; 95% confidence interval [CI], 0.17-0.60). Those with discordant responses had reduced risk of progression compared to non-responders but experienced faster progression than those with a combined response, although none of these differences was statistically significant. Early discordant and non response to HAART was common, often occurred in the setting of injection drug use and treatment interruption and was associated with poorer survival. Interventions to reduce treatment interruptions and to provide continuity of HIV care during incarceration among IDUs are needed to improve responses and subsequent survival.

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users

BACKGROUND

Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined.

OBJECTIVE

To estimate the frequency and risk factors for use of street methadone.

METHODS

Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression.

RESULTS

Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment.

CONCLUSION

The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.

A study to determine if acute maternal and fetal hyperglycemia/insulinemia induces leptin production during pregnancy

BACKGROUND

In pregnant primates, the effect of post-prandial hyperglycemic or insulinemic states on leptin production is not known. Our goal was to conduct a controlled study using an established pregnant baboon model ( PAPIO ANUBIS) to determine whether acute glucose changes would have an effect on maternal or fetal plasma leptin levels.

METHODS

Two animals were operated on at 138 and 140 days of gestation (term approximately 184 days) by placing 4 cannulae in the maternal aorta, inferior vena cava, fetal carotid artery, and the amniotic cavity. At 145 and 150 days, glucose infusions were started via the maternal femoral vein. Animal 1 received 7.5 gm of glucose over a 2-hour period at 145 th day. Animal 2 received 20 gm of glucose over a 1-hour period at 150th day. Both animals remained ad libitum throughout the experiments. Maternal and fetal blood samples were obtained from the arterial lines before the glucose infusion and at half hour intervals to include 30 minutes post-infusion.

RESULTS

Significant changes from baseline concentrations were observed for maternal and fetal glucose and insulin concentrations in response to both glucose challenges. Maternal and fetal plasma leptin concentrations did not correlate with glucose or insulin changes.

CONCLUSION

This preliminary study demonstrated that in primates, acute changes in circulating maternal or fetal glucose or insulin concentration do not affect maternal or fetal plasma leptin concentrations. These results suggest that alterations in leptin secretion by the maternal-placental-fetal unit may only occur in pathological states.

What factors are associated with neonatal injury following shoulder dystocia?

OBJECTIVE

To identify factors associated with the development of neonatal injury in the setting of shoulder dystocia.

STUDY DESIGN

Medical record ICD-9 codes and a computerized perinatal database were reviewed to identify cases of shoulder dystocia from January 1996 to January 2001 in a tertiary care center. For confirmation of the diagnosis and collection of data, both maternal and neonatal charts were then reviewed and neonatal injuries categorized as either neurological (brachial plexus injury) or skeletal (clavicular fracture, humeral fracture). Shoulder dystocia cases were divided into groups based on the presence of neonatal injury at delivery or at discharge (with or without Erb's palsy). The group with neonatal injury was compared for demographic and obstetrical factors to the group without injury (control). chi (2) test, Mann-Whitney test and logistic regression were used as appropriate.

RESULTS

During this 5-year period, there were 25,995 deliveries and 206 (0.8%) confirmed cases of shoulder dystocia. Of these cases, 36 (17.5%) had neonatal injury diagnosed at delivery and 25 (12%) remained with significant residual injury at discharge. Of these there were 19 cases of Erb's palsy and six cases of clavicular fracture. No association was found between neonatal injury and maternal age, ethnicity, diabetes, operative vaginal delivery or number of obstetrical maneuvers. However, maternal body mass index >30 kg/m2, a second stage of labor >20 min and a birth weight >4500 g were all associated with an increased risk of neonatal injury at delivery and at discharge, including Erb's palsy. After logistic regression analysis, only a second stage of delivery >20 min remained significantly associated with neonatal injury at discharge.

CONCLUSION

In our population, maternal obesity was associated with an increased risk of neonatal injury after shoulder dystocia. In addition, a short second stage of labor (<20 min) was associated with a lower rate of neonatal injury.

Liver enzyme values in injection drug users with chronic hepatitis C

BACKGROUND

Liver enzymes fluctuate in chronic hepatitis C virus infection. However, the range that can be attributed to the course of hepatitis C virus (versus an intercurrent cause of hepatitis) is unknown.

AIMS

To characterise the range of liver enzyme values as a function of the upper limit of normal (ULN) of the assay among persons chronically infected with hepatitis C virus.

PATIENTS

One thousand and fifty-nine hepatitis C virus chronically infected individuals with > or =5 semi-annual evaluations.

METHODS

Alanine aminotransferase and aspartate aminotransferase levels were prospectively obtained. Potential causes of elevations were examined using serologic testing.

RESULTS

Among 1059 individuals, 11,463 enzyme measurements were obtained over 6.5 years, of which 63.5% were <1.25x ULN, 26.5% were 1.25-2.5x ULN, 8.3% were 2.5-5x ULN, and 1.6% were 5-10x ULN; only 0.2% were >10x ULN. Elevations >10x ULN were transient, the alanine aminotransferase/aspartate aminotransferase ratio tended to be different at the time of the elevation compared to before and after and 24% were associated with acute viral hepatitis. On the other hand, subjects with elevations 5-10x ULN tended to have elevated levels throughout follow-up and only 8% were associated with acute viral hepatitis.

CONCLUSIONS

Liver enzymes fluctuate up to 5x ULN in most hepatitis C virus-infected persons; clinicians should seek alternate explanations for those with higher alanine aminotransferase or aspartate aminotransferase levels, especially among hepatitis C virus-infected persons with greater than 10-fold elevations.

Prevalence of type 2 diabetes mellitus among persons with hepatitis C virus infection in the United States

BACKGROUND

Hepatitis C virus (HCV) infection may contribute to the development of diabetes mellitus. This relationship has not been investigated at the population level, and its biological mechanism remains unknown.

OBJECTIVE

To examine the prevalence of type 2 diabetes among persons with HCV infection in a representative sample of the general adult population of the United States.

DESIGN

Cross-sectional national survey.

SETTING

The Third National Health and Nutrition Examination Survey, 1988-1994.

PARTICIPANTS

9841 persons older than 20 years of age for whom data on HCV infection and diabetes were complete.

MEASUREMENTS

The presence of diabetes was ascertained by using American Diabetes Association guidelines based on fasting plasma glucose measurement and medication history. Presence of HCV infection was assessed by testing for serum HCV-specific antibodies (anti-HCV).

RESULTS

Of the 9841 persons evaluated, 8.4% had type 2 diabetes and 2.1% were anti-HCV positive. Type 2 diabetes occurred more often in persons who were older, were nonwhite, had a high body mass index, and had low socioeconomic status. Type 2 diabetes was less common in persons who acknowledged previous illicit drug use. After adjustment for these factors, persons 40 years of age or older with HCV infection were more than three times more likely than those without HCV infection to have type 2 diabetes (adjusted odds ratio, 3.77 [95% CI, 1.80 to 7.87]). None of the 19 persons with type 1 diabetes were anti-HCV positive.

CONCLUSION

In the United States, type 2 diabetes occurs more often in persons with HCV infection who are older than 40 years of age.