Natural History of Acute Symptomatic Hepatitis Type C

Abstract.Background: Spontaneous clearance of hepatitis C virus (HCV) after acute hepatitis C, and the course of chronic HCV infection in patients who did not clear the virus, were studied.Patients and Methods: Patients with acute C or non-A, non-B hepatitis who were hospitalized between 1988 and 1998 were called for evaluation in 2001. They were tested for anti-HCV, serum HCV-RNA, HCV-RNA in peripheral blood mononuclear cells (PBMC) and liver enzymes. A liver biopsy was performed on chronically infected patients. The course of acute hepatitis C was compared between HCV-RNA-positive and negative subjects to look for factors that might influence spontaneous viral clearance. Factors influencing more progressive liver disease were analyzed in chronic hepatitis C.Results: Out of 159 acute hepatitis C patients, 77 (48.4%) participated in the study, and the median observation time was 8 years. Spontaneous clearance of serum HCV was found in 23 subjects (29.9%), but in two cases HCV-RNA was detected in peripherical blood mononuclear cells (PBMC). Only three patients negative for HCV-RNA in serum and PBMC lost anti-HCV. Severity of acute HCV infection and previous alcohol abuse seemed to influence resolution. In non-alcoholic patients, older age at time of primary infection was a significant predictor of virus clearance. In chronic hepatitis C, more than 75% of patients had minimal or mild activity in biopsy, but 40% had advanced fibrosis. Older age at infection, male gender, alcohol abuse, and higher iron content were connected with advanced fibrosis.Conclusion: Studies on HCV infection resolution should include at least PBMC testing for HCV-RNA. A healthy carrier state of HCV can be discussed. A longer observation time increased the likelihood of seroreversion. Fibrosis in chronic hepatitis C probably is not a direct result of inflammatory activity.     

Ethnic and Racial Differences in Autoimmune Liver Diseases

Purpose of the review

To discuss the ethnic and racial disparities observed in patients with autoimmune liver diseases, with special focus on epidemiology, patterns of inheritance, clinical presentation, and outcomes.

Recent findings

Black, Hispanics, and Asians with autoimmune hepatitis appear to have more aggressive clinical features, poorer initial response to standard therapy, and higher rates of complications including hepatocellular carcinoma, with worse survival than their White counterparts. African American and Hispanic patients with primary biliary cholangitis have more advanced disease at presentation and Hispanics appear to have lower rates of biochemical response to UDCA compared to non-Hispanics. African American patients with PSC are significantly younger at presentation and appear to have more aggressive liver disease when compared to European Americans.

Summary

The clinical presentation and outcomes of autoimmune liver diseases vary by ethnicity and race, with significant disparities reported in recent years. The goal of this review is to make clinicians aware of these differences to facilitate diagnosis and management of autoimmune liver diseases and eventually improve outcomes across various races and ethnicities.

     

Natural History and Treatment of Hepatitis C in Liver Transplant Recipients

Hepatitis C is not cured with liver transplantation. Patients with hepatitis C virus (HCV) infection have reduced graft and patient survivals compared with non-HCV patients following liver transplantation. Both HCV recurrence and fibrosis are accelerated under the influence of transplantation and immunosuppression. Antiviral therapy has been shown to reduce fibrosis progression and graft loss. The goal of therapy is sustained virologic response and reduction of damage. However, the optimal timing and treatment regimen for patients with HCV following transplant is unclear. Following transplant, sustained virologic response rates are reduced and patient tolerance is limited. Improved treatment strategies are needed to reduce patient side effects and increase efficacy in this population of patients.     

Racial and Ethnic Differences in Preferences for End-of-Life Treatment

BACKGROUND  Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables. OBJECTIVE  To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables. DESIGN  Dual-language (English/Spanish), mixed-mode (telephone/mail) survey. PARTICIPANTS  A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response). MEASUREMENTS  Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. RESULTS  Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% “other” race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment [adjusted OR = 2.0 (1.5–2.7)], preference for dying in a hospital [AOR = 2.3 (1.6–3.2)], receiving life-prolonging drugs [1.9 (1.4–2.6)], MV for 1 week [2.3 (1.6–3.3)] or 1 month’s [2.1 (1.6–2.9)] life extension, and a preference not to take potentially life-shortening palliative drugs [0.4 (0.3–0.5)]. Hispanic ethnicity remained an independent predictor of preference for dying in the hospital [2.2 (1.3–4.0)] and against potentially life-shortening palliative drugs [0.5 (0.3–0.7)]. CONCLUSIONS  Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Source of support: Funding was provided by the National Institute on Aging (NIA) grant P01 AG19783 and the Robert Wood Johnson Foundation 050488. Dr. Barnato was supported by NIA career-development grant K08 AG021921.     

Racial/Ethnic Differences in Emergency Department Utilization and Experience

BackgroundPrevious work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.ObjectiveTo examine differences in self-reported healthcare utilization and experiences with ED care by patients’ race/ethnicity.DesignAdult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.Participants3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January–March 2016.Main MeasuresSix measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient’s ability to receive follow-up care, and willingness to recommend the ED.Key ResultsBlack and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).ConclusionsHispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06738-0.KEY WORDS: emergency department, patient experience, utilization, race, communication     

Racial and Ethnic Differences in the Management of Childhood Asthma in the United States

Objectives. We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices. Methods. Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities). Results. African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child’s asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments. Conclusions. This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.     

Racial/Ethnic Differences in Cardiovascular Risk Factors Among Women Veterans

BACKGROUND

Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors.

OBJECTIVE

To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs.

DESIGN AND PARTICIPANTS

Cross-sectional, national population-based telephone survey of 3,611 women Veterans.

MEASUREMENTS

Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over).

KEY RESULTS

Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81).

CONCLUSIONS

Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.

     

Racial and Ethnic Differences in Heart Failure Etiology,Prognosis, and Management

Heart failure (HF) remains a major health care burden for the USA. Racial/ethnic groups in the USA are at increased risk for developing HF and incur higher rates of morbidity. Understanding the variations in the clinical syndrome of HF among different racial/ethnic groups is fundamental to addressing how to effectively treat these sub-groups. Despite evidence-based guideline-recommended medical and device therapy for HF, eligible patients from various racial/ethnic groups suffer disparities in receiving guideline-based HF therapy. The initiation of performance improvement programs has improved adherence to guideline-based therapy. The racial/ethnic differences that exist regarding the etiology and responses to medical therapy are fundamental to addressing ways to improve access to care, adherence, and overall survival in these at-risk groups. The review outlines racial/ethnic variations in the etiology, prognosis, and management with medical and device therapy for HF.     

Racial/Ethnic Differences in Multiple Self-Care Behaviors in Adults with Diabetes

Objective To assess racial/ethnic differences in multiple diabetes self-care behaviors. Design Cross-sectional study. Participants 21,459 participants with diabetes in the 2003 Behavioral Risk Factor Surveillance survey. Measurements The study assessed self-care behaviors including physical activity, fruits/vegetables consumption, glucose testing, and foot examination, as well as a composite of the 4 self-care behaviors across racial/ethnic groups. Multiple logistic regression was used to assess the independent association between race/ethnicity, the composite variable, and each self-care behavior controlling for covariates. STATA was used for statistical analysis. Results Overall, 6% engaged in all 4 self-care behaviors, with a range of 5% in non-insulin users to 8% in insulin users. Blacks were less likely to exercise (OR 0.63, 95% CI 0.51, 0.79), while Hispanics and “others” were not significantly different from whites. Hispanics (OR 0.64, 95% CI 0.49, 0.82) and others (OR 0.69, 95% CI 0.49, 0.96) were less likely to do home glucose testing, while blacks were not significantly different from whites. Blacks (OR 1.42, 95% CI 1.12, 1.80) were more likely to do home foot examinations, while Hispanics and others were not significantly different from whites. Blacks (OR 0.56, 95% CI 0.36, 0.87) were less likely to engage in all 4 behaviors, while Hispanics and others were not significantly different from whites. There were no significant racial/ethnic differences in fruit and vegetable consumption. Conclusions Few patients engage in multiple self-care behaviors at recommended levels, and there are significant racial/ethnic differences in physical activity, dietary, and foot care behaviors among adults with diabetes. Potential Financial Conflicts of Interest: The authors do not have any conflicts of interest to report.     

Racial and Ethnic Differences in the Use of Environmental Control Practices Among Children With Asthma

Objective. Minority children with asthma suffer a disproportionate burden of asthma morbidity. National asthma guidelines recommend use of environmental control practices (ECPs) as part of a comprehensive approach to asthma management. The purpose of this study was to examine use of ECPs among minority and nonminority children with asthma. Methods. The authors used data from the four state sample of the National Asthma Survey, a telephone survey conducted in 2003. The sample included Alabama, California, Illinois, and Texas. Parents provided responses for 2003 children ≤17 years of age with a diagnosis of asthma. The outcomes of interest were use of mattress covers, use of pillow covers, smoke avoidance, pet avoidance, and carpet removal. Univariate and multiple regression analyses were conducted to examine the rates of use of these ECPs among minority and nonminority children. Results. Black and Hispanic children with asthma were less likely to use mattress covers and pillow covers compared to white children in these four states. Smoking avoidance was less likely among black children but more likely among Hispanic children compared to white children. Both black and Hispanic children were more likely to live in a home without pets and without carpets compared to white children. Conclusions. These data illustrate that there are differences in the patterns of ECP use among minority and nonminority children with asthma in these four states. This information can help target physician counseling regarding ECP use in asthmatic children and should inform interventions to improve asthma management among minority children.