Hepatitis

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Hepatitis for December 5, 2011 SUMMARY AND COMMENT Histologic Features Can Differentiate Drug-Induced Liver Injury from Autoimmune Hepatitis December 2, 2011 | Atif Zaman, MD, MPH | Gastroenterology Investigators report progress in using histologic data to more accurately distinguish between the two conditions. Reviewing: Suzuki A et al. Hepatology 2011 Sep 54:931 SUMMARY AND COMMENT Long-Term Morbidity and Mortality with NAFLD and Advanced Fibrosis December 2, 2011 | Atif Zaman, MD, MPH | Gastroenterology At 7 years of follow-up, about 20% of patients with NAFLD developed liver complications and 13% died or received a transplant. Adjusted outcomes were favorable compared with similar patients with HCV infection. Reviewing: Bhala N et al. Hepatology 2011 Oct 54:1208 SUMMARY AND COMMENT Perioperative Death Rate from Bariatric Surgery Is Higher with Cirrhosis Free! November 18, 2011 | Atif Zaman, MD, MPH | Gastroenterology Clinicians should assess whether patients receiving bariatric surgery for obesity have cirrhosis and, if so, possibly refer them to a high-volume center for the procedure. Reviewing: Mosko JD and Nguyen GC. Clin Gastroenterol Hepatol 2011 Oct 9:897 FEATURE HCV Treatment Studies at AASLD: Wow . . . and I Mean WOW! Free! November 14, 2011 | HIV/AIDS Clinical Care Dr. Paul Sax reviews the "breathtaking" results just presented at The Liver Meeting, in his blog HIV and ID Observations. SUMMARY AND COMMENT Emerging Treatment Options for Severe Acute Alcoholic Hepatitis November 10, 2011 | Atif Zaman, MD, MPH | Gastroenterology Adding N-acetylcysteine to glucocorticoid therapy did not improve 6-month survival. Early liver transplant did, but in a selectively chosen subgroup. Reviewing: Nguyen-Khac E et al. N Engl J Med 2011 Nov 10; 365:1781 Mathurin P et al. N Engl J Med 2011 Nov 10; 365:1790 Brown RS Jr. N Engl J Med 2011 Nov 10; 365:1836 Free Full-Text Article Summary and Comment Histologic Features Can Differentiate Drug-Induced Liver Injury from Autoimmune Hepatitis Investigators report progress in using histologic data to more accurately distinguish between the two conditions. The clinical scenario of a patient who presents with acute hepatitis on potentially hepatotoxic medications, with negative viral serologies but low-level autoimmune markers, can be challenging. The difficulty lies in determining whether the patient has drug-induced liver injury (DILI), for which there is no specific treatment, or autoimmune hepatitis (AIH), for which immunosuppressants are indicated. To date, histologic findings have generally not been helpful. To explore possible differences in histologic profiles that could improve diagnostic accuracy, four experienced hepatopathologists conducted detailed, blinded reviews of 63 liver biopsies of clinically well-characterized cases of AIH and DILI. All were reviewed from clinical and histologic standpoints to verify diagnoses. Concordance of clinical diagnosis with histologic diagnosis was 65%. However, among the four hepatopathologists, complete agreement on histologic diagnosis was only 46%. Based on statistical modeling, several histologic characteristics predicted DILI versus AIH: portal inflammation, portal plasma cells, intra-acinar lymphocytes and eosinophils, rosette formation, and canalicular cholestasis (area under the curve, 0.9). Specifically, the presence of intra-acinar lymphocytes and canalicular cholestasis favored DILI, whereas the presence of rosette formation, portal plasma cells, and severe portal inflammation favored AIH. Of note, the presence of intra-acinar eosinophils, which has been regarded as one of the histologic findings suggesting DILI, was more frequently seen in AIH in this cohort. Comment: Results should be interpreted with caution because of the small sample size, and because even experts frequently disagreed on histologic diagnosis. Nonetheless, a larger study to assess interobserver variation and cross-validate these findings should be performed. Histologic criteria such as these that reliably differentiate DILI from AIH would be extremely useful in clinical practice. — Atif Zaman, MD, MPH Published in Journal Watch Gastroenterology December 2, 2011 Citation(s): Suzuki A et al. The use of liver biopsy evaluation in discrimination of idiopathic autoimmune hepatitis versus drug-induced liver injury. Hepatology 2011 Sep; 54:931. Medline abstract (Free)

Cuidado Clinico de VIH/sida

HIV/AIDS Clinical Care

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HIV/AIDS Clinical Care for December 5, 2011 NEWS IN CONTEXT Microbicide Use Discontinued in HIV Prevention Trial Free! December 5, 2011 | Raphael J. Landovitz, MD, MSc But the devil's in the details. SUMMARY AND COMMENT Suboptimal Control of HIV Is Associated with Poor Control of Comorbidities December 5, 2011 | Keith Henry, MD Poor adherence to treatments is likely the key factor behind the association. Reviewing: Monroe AK et al. J Acquir Immune Defic Syndr 2011 Dec 15; 58:458 FEATURE World AIDS Day Wanderings Free! December 5, 2011 Musings from Dr. Paul Sax, in his blog HIV and ID Observations CLINICAL PRACTICE GUIDELINE WATCH Updated AAP Policy Statement Promotes Routine HIV Testing in Adolescents Free! November 30, 2011 | Alain Joffe, MD, MPH, FAAP Routine testing should be offered to all adolescents in areas with high HIV prevalence at least once by age 16 to 18. Reviewing: Committee on Pediatric AIDS. Pediatrics 2011 Nov 128:1023 Editor's Picks from across Journal Watch SUMMARY AND COMMENT Low Vitamin D Levels Linked to Active Tuberculosis Free! November 30, 2011 | Richard T. Ellison III, MD | Infectious Diseases Seasonal declines in mean vitamin D levels were followed by seasonal increases in TB notifications. Reviewing: Martineau AR et al. Proc Natl Acad Sci U S A 2011 Nov 22; 108:19013 Realegeno S and Modlin RL. Proc Natl Acad Sci U S A 2011 Nov 22; 108:18861 Free Full-Text Article News in Context Microbicide Use Discontinued in HIV Prevention Trial But the devil's in the details. Just 2 months after the use of oral tenofovir was discontinued in the VOICE trial (JW AIDS Clin Care Oct 3 2011), study investigators have announced that the use of vaginal tenofovir gel is also being discontinued. The decision is based on an interim review at 2 years, showing similar rates of HIV acquisition in women assigned to a daily tenofovir-based vaginal microbicide and those assigned to placebo gel (6.0% and 6.1%, respectively). Notably, the review did not identify any safety concerns. The VOICE trial originally included five study arms — oral tenofovir (Viread), oral tenofovir/FTC (Truvada), oral placebo, vaginal tenofovir gel, and vaginal placebo gel — with each intervention prescribed for daily use. About 1000 HIV-uninfected women were assigned to each arm. At this point, only those receiving oral tenofovir/FTC or oral placebo will continue as planned. The trial is expected to be completed by mid-2012, with final results available by early 2013. Comment: In the past 18 months, HIV prevention research has yielded both tremendously exciting results and extremely disappointing ones, and this news from the VOICE trial is clearly in the latter category. Not only was the trial intended to clarify the comparative effectiveness of oral versus vaginal-gel strategies for HIV prevention in women, but it was also intended to be the second study required by regulatory bodies for approval of tenofovir gel — assuming the results of the CAPRISA 004 study could be replicated or improved upon. The negative results of the VOICE trial confirm the complexity of using medication-based HIV prevention strategies. Of note, the CAPRISA 004 study used a coitus-dependent dosing regimen (12 hours prior and 12 hours after intercourse), whereas VOICE used daily dosing. If an analogy can be made to the iPrEx trial (and it remains to be seen if such analogy is appropriate), it's that participants in HIV prevention studies seem to adhere poorly to daily dosing and thus potentially leave some episodes of intercourse "uncovered" by protective antiretrovirals. Details on adherence levels, drug levels in vaginal tissues, and risk behaviors are critical for understanding the vastly different results of VOICE and CAPRISA 004 — and also the conflicting results of various tenofovir/FTC trials in women (Partners PrEP, TDF2, and FEM-PrEP). Until the detailed results of all these trials are fully presented, it is virtually impossible to proceed with much-needed implementation research and demonstration projects in female populations. — Raphael J. Landovitz, MD, MSc Dr. Landovitz is Assistant Professor, Division of Infectious Diseases, Center for Clinical AIDS Research and Education, University of California, Los Angeles. He reports no conflicts of interest. Published in Journal Watch HIV/AIDS Clinical Care December 5, 2011 Citation(s): MTN statement on decision to discontinue use of tenofovir gel in VOICE, a major HIV prevention study in women [press release]. Pittsburgh, PA: Microbicide Trials Network; Nov 25 , 2011. (http://www.mtnstopshiv.org/node/3909)

VIH en jovenes

http://www.cdc.gov/hiv/youth/index.htm?source=govdelivery

HIV among Youth

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Fast Facts Young people aged 13–29 accounted for 39% of all new HIV infections in 2009. With regard to youth, HIV disproportionately affects young gay and bisexual men and young African Americans. All young people should know how to protect themselves from HIV infection.

Too many young people in the United States (US) are at risk for HIV infection. This risk is especially notable for young gay, bisexual, and other men who have sex with men (MSM) ¹ , especially young African American or Latino MSM, and all youth of minority races and ethnicities. Continual HIV prevention outreach and education efforts, including programs on abstinence, delaying the initiation of sex, and negotiating safer sex, are required as new generations replace the generations that benefited from earlier prevention strategies.

The Numbers

New HIV Infections (Ages 13–29 Years)

• In 2009, young persons accounted for 39% of all new HIV infections in the US. For comparison's sake, persons aged 15–29 comprised 21% of the US population in 2010.
• Young MSM, especially those of minority races and ethnicities, are at increased risk for HIV infection. In 2009, young MSM accounted for 27% of new HIV infections in the US and 69% of new HIV infections among persons aged 13–29. Among young black MSM, new HIV infections increased 48% from 2006 through 2009.

HIV and AIDS Diagnoses² (Ages 13–24 Years)

• An estimated 8,294 young persons were diagnosed with HIV infection in 2009 in the 40 states with long-term HIV reporting, representing about 20% of the persons diagnosed during that year.
  • Seventy-five percent (6,237) of these diagnoses occurred in young people aged 20–24 years. Indeed, those aged 20–24 had the highest number and rate of HIV diagnoses of any age group (36.9 new HIV diagnoses/100,000 people).
• In 2009, young blacks accounted for 65% (5,404) of diagnoses of HIV infection reported among persons aged 13–24 years.
• In 2008, an estimated 22% of persons aged 13–24 living with diagnosed HIV infection were infected through hemophilia, blood transfusion, birth, or unknown transmission mode, with the majority being infected perinatally.

Diagnoses of HIV Infection in the United States, 2009, by Age

Prevention Challenges

Sexual Risk Factors

Early age at sexual initiation; unprotected sex; older sex partners. According to CDC's 2009 National Youth Risk Behavior Survey (YRBS), many adolescents begin having sexual intercourse at early ages: 46.0% of high school students have had sexual intercourse, and 5.9% reported first sexual intercourse before the age of 13. Of the 34.2% of students reporting sexual intercourse during the 3 months before the survey, 38.9% did not use a condom. Young people with older sex partners may be at increased risk for HIV. HIV education needs to take place before young people engage in sexual behaviors that put them at risk. Parent communication and monitoring may play an important role in reaching youth early with prevention messages.
Male-to-male sex. CDC data have shown that young gay, bisexual, and other MSM, especially young African American and young Latino MSM, have high rates of new HIV infections. Another CDC study showed that young MSM and minority MSM were more likely to be unaware of their HIV infection, a situation that puts their health and the health of their partners at risk. Young MSM may be at risk because they have not always been reached by effective HIV interventions or prevention education—especially because some sex education programs exclude information about sexual orientation. A CDC study of MSM in 15 cities found that 80% had not been reached in the past year by HIV interventions known to be most effective. Young MSM may also have increased risk factors for HIV (such as risky sexual behaviors) due to isolation and lack of support.
Sexual abuse. Young adults, both male and female, who have experienced sexual abuse are more likely to engage in sexual or drug-related risk behaviors that could put them at risk for HIV infection.
Sexually transmitted infections (STIs). The presence of an STI greatly increases a person's likelihood of acquiring or transmitting HIV. Some of the highest STI rates in the country are among young people, especially young people of minority races and ethnicities.
Substance Use
Young people in the US use alcohol, tobacco, and other drugs at high rates. CDC's 2009 National YRBS found that 24.2% of high school students had had five or more drinks of alcohol in a row on at least 1 day during the 30 days before the survey, and 20.8% had used marijuana at least one time during the 30 days before the survey. Both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol. Runaways, homeless young people, and young persons who have become dependent on drugs are at high risk for HIV infection if they exchange sex for drugs, money, or shelter.
Lack of Awareness
Research has shown that a large proportion of young people are not concerned about becoming infected with HIV. This lack of awareness can translate into not taking measures that could protect their health. Abstaining from sex and drug use is the most effective way to avoid HIV infection, but adolescents need accurate, age-appropriate information about HIV and AIDS, how to reduce or eliminate risk factors, how to talk with a potential partner about risk factors and how to negotiate safer sex, where to get tested for HIV, and how to use a condom correctly. Parents also need to reinforce health messages, including how to protect oneself from HIV infection.

What CDC Is Doing

CDC employs a multifaceted approach to addressing the high number of HIV infections occurring in young people in the US.

Programs: CDC provides effective interventions that can be carried out locally for the highest impact. Examples include Project AIM to reduce HIV risk behaviors among at-risk youth; Mpowerment for young gay and bisexual men of diverse backgrounds to reduce sexual risk-taking, encourage regular HIV testing, and build positive social connections; Choosing Life: Empowerment! Action! Results! for those older than 16 living with HIV infection or AIDS or at high risk for HIV; and Focus on Youth for African American young people aged 12–15.

Research: CDC is engaged in research to better understand certain populations and to create or adapt interventions to reduce their risk for HIV infection. For example,

• The Division of Adolescent and School Health collects and reports data on youth health risk behaviors and school-based health policies and practices, and develops guidelines for schools to promote health among young people, among other activities.
• The Youth Risk Behavioral Surveillance System is a CDC surveillance system that monitors six types of health-risk behaviors that contribute to the leading causes of death and disability among youth and adults, including alcohol and other drug use, and sexual risk behaviors.
• The Division of HIV/AIDS Prevention evaluates HIV prevention interventions, such as those for adolescent African American girls in juvenile detention facilities, young African American MSM, and Hispanic parents; adapts current interventions for transgender young adults; and explores new forms of media, such as motion comics, that can deliver stories and content with HIV prevention messages over mobile phones, gaming systems, websites, and social media.

Overall, a multifaceted approach to HIV prevention, which includes individual, peer, familial, school, church, and community programs, is necessary to reduce the incidence of HIV infection and AIDS in young people.