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Background Nonalcoholic fatty liver disease (NAFLD) is strongly associated with obesity and is the most common liver disease in the developed world. In children with suspected NAFLD, present guidelines suggest consideration of alternative diagnoses via extensive blood testing, though the yield of this work up is unknown. Furthermore, the gold standard diagnostic test for NAFLD remains liver biopsy, making the development of non-invasive tests critically important. Objectives Our objectives are: 1) to determine the accuracy of elastography and multiple serum biomarkers – each assessed individually and as algorithms (including those previously tested in adults) – for the diagnosis of nonalcoholic steatohepatitis (NASH) and early fibrosis in children and (2) to examine the utility of extensive testing for rare alternative diagnoses in overweight or obese children with elevated alanine aminotransferase (ALT) suspected to have NAFLD. Design This is an ongoing, cross-sectional study in children 2–18 years of age with up to 2 years of prospective follow up. Eligible patients are asymptomatic, overweight or obese, and have an ALT ≥35 U/L upon enrollment. Two forms of elastography are obtained serially along with anthropometric data and routine laboratory tests. Elastography and serum biomarkers are also performed immediately prior to any clinically-indicated biopsy. Methods Between April 2015 and April 2018, 193 children have been enrolled in this ongoing study and 71 have undergone liver biopsy. Here we carefully report the rationale, methodology, and preliminary data for this study.

Background Current US cervical cancer screening guidelines recommend screening cessation at the age of 65 years provided women have adequate previous screening and no history of precancer. Women living with HIV are at higher risk of cervical cancer than women living without HIV. Furthermore, limited data exists to quantify the risk of cervical cancer among women who otherwise would qualify for screening cessation. Objective This study aimed to determine whether guidelines recommending women to discontinue cervical cancer screening at the age of 65 years are appropriate for women living with HIV. Study Design Semiannual Papanicolaou testing was performed as part of surveillance visits in the Women’s Interagency HIV Study. Launched in October 1994, the Women’s Interagency HIV Study is a federally funded US multisite cohort study that has enrolled 3678 women living with HIV and 1304 women living without HIV; we included data throughout September 2019 onward. Conventional Papanicolaou tests were collected at scheduled 6-month visits and read centrally according to the 1991 Bethesda System criteria. Results were analyzed among women at least 65 years of age. The primary endpoint was high-grade cytology, including high-grade squamous intraepithelial lesions; atypical glandular cells; atypical squamous cells, cannot exclude high-grade lesions; and malignant cytology. Wilcoxon rank-sum tests were used to compare the continuous variables, and Chi-square tests or the Fisher exact tests were used to compare the categorical variables. The Kaplan-Meier method was used to calculate the cumulative incidence. Poisson regression was used to compare 2 incidence rates. Results Of 169 eligible women (121 women living with HIV and 48 women living without HIV) who contributed 678.4 person-years of observation after reaching the age of 65 years, 2.2% had high-grade cytologic abnormalities. However, no cancer was found. Furthermore, 20 women had previous precancer results, and 74 women had abnormal Papanicolaou test results in the previous decade. Among 50 women (38 women living with HIV and 12 women living without HIV) with a previous hysterectomy and no history of cervical precancer, the cumulative incidence rates of high-grade squamous intraepithelial lesions were 0.6 (95% confidence interval, 0.0–3.2) per 100 person-years for women living with HIV and 0.0 (95% confidence interval, 0.0–8.1) per 100 person-years for women living without HIV (P=.61). Only 48 women (27 women living with HIV and 21 women living without HIV) had cervices and met the current guidelines to discontinue screening; their risk of experiencing high-grade squamous intraepithelial lesions was 2.2 (95% confidence interval, 0.6–5.5) per 100 person-years overall and did not vary by HIV status (2.3 [95% confidence interval, 0.5–6.8] per 100 person-years for women living with HIV and 1.8 [95% confidence interval, 0.0–9.8] per 100 person-years for women living without HIV; P=.81). Conclusion Most women living with HIV do not meet the criteria for cervical cancer screening cessation and will need to continue screening over the age of 65 years; however, women who meet the criteria for screening cessation have risks of high-grade squamous lesions similar to women living without HIV and may choose to discontinue.

Introduction Human Papillomavirus (HPV) 16 E6 serum antibodies are common in people with HPV-related oropharyngeal cancers (HPV-OPC), but not the general population. We explored HPV16 seroprevalence in people with and without oral HPV16 infection, the cause of HPV-OPC. Methods Oral rinse samples were collected semiannually and tested for 36 types of HPV DNA by PCR. HPV16 E6 serum antibodies were tested at the visit of first oral HPV detection in participants with prevalent (n = 54), or incident (n = 39) oral HPV16 DNA; or at baseline in matched participants with no oral HPV16 DNA (n = 155) using multiplex serology assay. Predictors of seropositivity were examined using logistic regression. Results HPV16 E6 seropositivity (7.5% vs 0.7%; p = 0.005) but not seropositivity to the other HPV16 antigens, was significantly more common in those with than without oral HPV16 infection. There were only 8 HPV16 E6 seropositive participants, but oral HPV16 DNA remained a strong predictor of E6 seropositivity after adjustment for other risk factors (aOR = 14.6 95%CI, 1.7–122.5). Seroprevalence was similar in those with prevalent (7.4%; 4/54), and incident (7.7%; 3/39) oral HPV16 infection (p = 1.00). E6 seroprevalence was associated with reduced oral HPV16 clearance, but was not statistically significant (HR = 0.65 95% CI, 0.16–2.70). Seropositive participants were primarily male (87.5%), HIV-positive (75.0%; median CD4 cell-count of 840) and had oral HPV16 DNA (87.5%). History of an HPV-related cancer (0/8) or HPV-related anogenital dysplasia (1/8) was rare, and 4 participants had recent screening showing no anogenital dysplasia. Discussion HPV16 E6 seropositivity was higher among people with than without oral HPV16 infection, despite no known anogenital disease in these participants.

Objective Levels of insulin-like growth factor (IGF) proteins are associated with the risk of cancer and mortality. IGF assays produced by Diagnostic Systems Laboratories (DSL) were widely used in epidemiological studies, were not calibrated against recommended standards and are no longer commercially available. Design In a split sample study among 1471 adults participating in the Cardiovascular Health Study, we compared values obtained using DSL assays with alternative assays for serum IGF-I (Immunodiagnostic Systems, IDS), IGFBP-1 (American Laboratory Products Company, ALPCO) and IGFBP-3 (IDS). Results Results were compared using kernel density estimation plots, quartile analysis with weighted kappa statistics and linear regression models to assess the concordance of data from the different assays. Participants had a mean age of 77years. Results between alternative assays were strongly correlated (IGF-I, r =0.93 for DSL versus IDS; log-IGFBP-1, r =0.90 for DSL versus ALPCO; IGFBP-3, r =0.92 for DSL versus IDS). Cross tabulations showed that participants were usually in the same quartile categories regardless of the assay used (overall agreement, 74% for IGF-I, 64% for IGFBP-1, 71% for IGFBP-3). Weighted kappa also showed substantial agreement between assays (k w , 0.78 for IGF-I, 0.69 for IGFBP-1, 0.76 for IGFBP-3). Regressions of levels obtained with DSL assays (denoted X) to alternative assays were, IGF-I: 0.52X+15.2ng/ml, log-IGFBP-1: 1.01X−1.73ng/ml IGFBP-3: 0.87X+791.1ng/ml. Serum values of IGF-I, IGFBP-1 and IGFBP-3 measured using alternative assays are moderately correlated. Conclusions Care is needed in the interpretation of data sets involving IGF analytes if assay methodologies are not uniform.

Background Monitoring cancer risk among HIV-infected people in the modern antiretroviral therapy (ART) era is critical given their elevated risk for many cancers and prolonged survival with immunosuppression, ART exposure, and aging. Our study described cancer risk in HIV-infected people in the United States relative to the general population. Methods Utilizing data from linked population-based HIV and cancer registries (nine areas; 1996–2012), we calculated standardized incidence ratios (SIRs). We tested SIR differences by AIDS status and over time using Poisson regression. Findings Among 448,258 HIV-infected people, risk was elevated (p

Background & Aims Genetic polymorphisms within the interferon lambda (IFN-λ) region are strongly associated with hepatitis C virus (HCV) clearance; the IFNL4 -ΔG/TT (rs368234815) polymorphism, which controls the generation of IFN-λ4 protein, is more strongly associated with HCV clearance than rs12979860 (the ‘IL28B variant'). An IFNL3 3′ untranslated region polymorphism (rs4803217) has been proposed as a causal variant that may affect HCV clearance by altering IFNL3 mRNA stability. Methods We compared IFNL4 -ΔG/TT and rs4803217 for association with response to pegylated-IFN-α/ribavirin in the VIRAHEP-C and HALT-C trials, and spontaneous HCV clearance in the ALIVE, UHS and WIHS studies. Genotyping was performed with TaqMan assays. We compared differences in mean reduction in HCV RNA levels by genotype and haplotype. For HCV clearance, we calculated p -values comparing c-statistics for IFNL4 -ΔG/TT and rs4803217 genotypes by a bootstrap approach. Results Among European Americans, linkage disequilibrium between IFNL4 -ΔG/TT and rs4803217 was strong (r 2 =0.89–0.99) and there were no significant differences between the variants. In African American (AA) individuals enrolled in VIRAHEP-C, HCV RNA at treatment day 28 was more strongly associated with IFNL4 -ΔG/TT than rs4803217 ( p =0.003); the IFNL4 -ΔG:rs4803217-G haplotype, which includes the putatively favorable IFNL3 allele, was actually associated with the poorest day 28 response ( p =0.03, comparison to IFNL4 -ΔG:rs4803217-T haplotype). Among AA participants, associations were stronger for IFNL4 -ΔG/TT than rs4803217 for undetectable HCV RNA at week 24 in Virahep-C ( p =0.03) and week 20 in HALT-C ( p =0.03), as well as for spontaneous HCV clearance ( p =0.048). Conclusion IFNL4 -ΔG/TT is the primary IFN-λ region polymorphism for impaired HCV clearance.

Circulating free insulin-like growth factor (IGF)-I and its binding proteins, most notably, IGFBP-1 and IGFBP-2, have been prospectively associated with incident type 2 diabetes in women. However, little is known regarding the factors that may influence these IGF-axis protein levels. The aim is to study the relation of IGF-axis protein levels with adipcytokines, macronutrient consumption, and other factors related to diabetes.Fasting plasma from 558 controls enrolled in a nested case-control study within the Nurses' Health Study of incident type 2 diabetes in women was tested for: IGF-axis proteins (free and total IGF-I, IGFBP-1, IGFBP-2, IGFBP-3), adipocytokines (leptin, adiponectin, resistin), soluble leptin receptor (sOB-R), inflammatory factors (IL-18 and C-reactive protein (CRP)), insulin, and glycated hemoglobin (HbA1C).In multivariate models, each 1% increase in sOB-R (mean 34.9ng/mL, standard deviation (SD) ±11.3) was associated with -0.20% total IGF-I (P=0.0003) and -0.42% free IGF-I (P=0.002), as well as 0.73% higher IGFBP-1 (P0.0001) and 0.27% IGFBP-2 (P=0.003). For example, a one SD change from the mean sOB-R level was associated with 11% lower free IGF-I. Insulin levels (mean 6.8μU/mL±5.3) were inversely and adiponectin (mean 18.3μg/mL±7.4) positively associated with IGFBP-1 and IGFBP-2 (all P0.01). Consumption of dairy protein, monounsaturated fats, and saturated fats, was also correlated with IGF-axis protein levels (all P0.05).Several molecular factors and macronutrients were independently associated with plasma IGF-axis protein levels. Which of these, if any, reflect biologic relationships that can be intervened upon to influence IGF-axis protein concentrations warrants further investigation.

Objectives Studies to evaluate clinical screening tests often face the problem that the “gold standard” diagnostic approach is costly and/or invasive. It is therefore common to verify only a subset of negative screening tests using the gold standard method. However, undersampling the screen negatives can lead to substantial overestimation of the sensitivity and underestimation of the specificity of the diagnostic test. Our objective was to develop a simple and accurate statistical method to address this “verification bias.” Study Design and Setting We developed a weighted generalized estimating equation approach to estimate, in a single model, the accuracy (eg, sensitivity/specificity) of multiple assays and simultaneously compare results between assays while addressing verification bias. This approach can be implemented using standard statistical software. Simulations were conducted to assess the proposed method. An example is provided using a cervical cancer screening trial that compared the accuracy of human papillomavirus and Pap tests, with histologic data as the gold standard. Results The proposed approach performed well in estimating and comparing the accuracy of multiple assays in the presence of verification bias. Conclusion The proposed approach is an easy to apply and accurate method for addressing verification bias in studies of multiple screening methods.

The insulin-like growth factor (IGF) system is highly conserved across species and plays a central role in cellular differentiation, cellular proliferation, apoptosis, metabolism, wound repair, and somatic growth (1–6). IGF-I, the main effector peptide of the IGF system and the principal mediator of growth hormone (GH) effects, may influence the development of age-related cardiovascular diseases (7–11). A report from the Framingham Heart Study identified low IGF-I as a risk factor for incident congestive heart failure (CHF) in the elderly (7). IGF binding proteins (IGFBPs) modulate IGF-I activity and may also have IGF-I-independent effects. Circulating IGFBP-3, like IGF-I, is responsive to GH status (12) and in older adults IGFBP-3 and IGF-I decline in concert with decreased GH. Most IGF-I in circulation is bound to IGFBP-3, suggesting a role of IGFBP-3 in determining the circulating half-life of IGF-I and its delivery to target tissues. IGFBP-1 is less abundant than IGFBP-3, but appears particularly important in regulating IGF-I bioavailability, with strong inverse correlations between circulating IGFBP-1 and free IGF-I (13) (14). IGFBP-1 has a very different system of regulation than IGFBP-3, with hepatic IGFBP-1 production strongly (inversely) regulated by insulin. Aging, cachectic conditions, malnutrition, inflammatory cytokines, and oxidative stress all increase IGFBP-1 expression (15–21), which may in turn lead to inhibition of anabolic IGF-I effects by IGFBP-1 during catabolic states. High circulating IGFBP-1 levels predict cardiovascular events after myocardial infarction (22) and cardiovascular mortality among apparently healthy older men (23). Prior data also indicate increased IGFBP-1 levels in CHF patients (24) which suggests that high circulating IGFBP-1 levels may be a CHF risk factor, although no prior studies of IGFBP-1 and incident CHF are available. We assessed the association between fasting IGF-I, IGFBP-1, IGFBP-3, and insulin levels and incident CHF among older adults in the Cardiovascular Health Study (CHS).

Background Co-infection with hepatitis C virus (HCV) is common among HIV-infected women. Objective To further our understanding of the risk factors for HCV viremia and the predictors of HCV viral load among women. Study design We investigated sociodemographic, immunologic, and virologic factors associated with presence and level of HCV viremia among 1049 HCV-seropositive women, 882 of whom were HIV-infected and 167 HIV-uninfected at their entry into the Women's Interagency HIV Study. Results Plasma HCV RNA was detected in 852 (81%) of these 1049 women (range: 1.2–7.8 log 10 copies/ml). HCV-viremic women were more likely to have an HIV RNA level >100,000 copies/ml ( P = 0.0004), to have reported smoking ( P = 0.01), or to be Black ( P = 0.005). They were less likely to have current or resolved hepatitis B infection. HCV RNA levels were higher in women who were >35 years old, or HIV-infected. Current smoking and history of drug use (crack/freebase cocaine, marijuana, amphetamines, or heroin) were each associated with both presence and level of viremia. Conclusions Substance abuse counseling aimed at eliminating ongoing use of illicit drugs and tobacco may reduce clinical progression, improve response to treatment, and decrease HCV transmission by lowering levels of HCV viremia in women.

Increasing evidence suggests that the insulin-like growth factor (IGF)-system may play a role in glucose metabolism and may also be associated with systemic inflammation. The aim of this study was to evaluate the association of insulin-like growth factor-1 (IGF-I) and its binding proteins, IGFBP-1 and IGFBP-3, with glucose intolerance and inflammation among older adults. We conducted a cross-sectional analysis in a in a random subsample (n=922) of the Cardiovascular Health Study (CHS), a prospective cohort of men and women ≥65 years. Mean IGFBP-1 levels were significantly lower in older adults with impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and diabetes compared to those with normal fasting and post-load glucose. High IGFBP-1 was associated with a reduced prevalence of IGT and IFG; the multivariable OR between extreme quartiles of IGFBP-1 was 0.60 (95% CI: 0.37, 0.95; p-trend: 0.03) for IGT and 0.41 (95% CI: 0.26, 0.64; p-trend

An increasing number of epidemiologic studies are investigating the relationship between serum levels of insulin-like growth factor-I (IGF-I) and IGF binding proteins (IGFBPs) and risk of cancer, cardiovascular disease, and other diseases. However, little is known regarding the effects of blood specimen processing time on measured levels of total and free IGF-I, and on IGFBP-3, the major binding protein.Two serum separation tubes were collected from each of 12 subjects. One tube was centrifuged as soon as possible following blood collection (a mean of 47 min; range=30-80 min), and serum aliquots were placed into -70 degrees C storage either shortly after centrifugation, or following 2, 4, 10, or 24 h at ambient temperature (measured from the time of blood draw). The second serum separation tube was maintained at ambient temperature for 24h before centrifugation and freezing. Total IGF-I, free IGF-I, and IGFBP-3 levels were determined using commercial enzyme linked immunosorbent assays (ELISAs) commonly employed in epidemiologic studies. The effects of time until centrifugation and freezing on seroassay results were evaluated using generalized estimating equation (GEE) linear regression models and Spearman correlation.Total IGF-I and IGFBP-3 levels did not vary significantly with the amount of time at ambient temperature following centrifugation, even up to 24 h, in blood specimens that were centrifuged soon after collection (all pchi2). However, free IGF-I levels increased significantly with increasing time intervals between centrifugation and freezing in these same specimens (ptrend0.001). Total IGF-I/IGFBP-3 molar ratio, a crude measure of free IGF-I levels, showed no clear association. In blood specimens that were not centrifuged for 24h, total IGF-I, free IGF-I, and IGFBP-3 were each significantly elevated (each pchi2) compared with results in blood specimens that were centrifuged and frozen soon after collection, whereas the total IGF-I/IGFBP-3 molar ratio was decreased pchi2. Nonetheless, all total IGF-I, free IGF-I, IGFBP-3, and total IGF-I/IGBFBP-3 molar ratio values altered by delays in processing were highly correlated with the values in specimens processed as soon as possible (all Spearman rank correlation coefficients 0.84).Total IGF-I and IGFBP-3 can be fairly stably measured in serum with commonly used commercial assays regardless of the interval between blood collection and freezing, up to at least 24 h, as long as centrifugation and serum aliquoting take place shortly after blood collection. Free IGF-I levels, however, increase steadily with the time interval until freezing, even if serum separation has been completed soon after blood collection. Because the altered serum values are highly correlated with the referent values, analysis of total IGF-I, free IGF-I, IGFBP-3, and total IGF-I/IGFBP-3 molar ratio data by quartile might help mitigate concerns regarding the effects of delays in processing time.

The purpose of this study was to determine the incidence and predictors of genital warts and vulvar intraepithelial neoplasia among women with the human immunodeficiency virus.This was a multicenter prospective cohort study comprised of women without warts or vulvar intraepithelial neoplasia at baseline who underwent CD4 count, human immunodeficiency virus RNA measurement, examination, Papanicolaou test, and biopsy, as indicated, every 6 months. Human papillomavirus DNA typing was examined at baseline.The incidence of warts among women who were human immunodeficiency virus seronegative was 1.31 versus 5.01 per 100 person-years among women who were seropositive (P.001). Incidence of vulvar intraepithelial neoplasia among women who were seronegative was 1.31 versus 4.67 per 100 person-years among women who were seropositive (P.001). In multivariable analysis, warts were associated with highly active antiretroviral therapy (relative hazard, 0.76), CD4 count (relative hazard, 0.91/100 cell/cm(2) increase), acquired immunodeficiency syndrome (relative hazard, 1.25), abnormal Papanicolaou test results (relative hazard, 2.18), high- or medium-risk human papillomavirus types (relative hazard, 1.91), low-risk human papillomavirus types (relative hazard, 1.48), smoking (relative hazard, 1.43), having 1 child (relative hazard, 1.54), and age (relative hazard, 0.74/10 years). Vulvar intraepithelial neoplasia was linked to highly active antiretroviral therapy (relative hazard, 0.65), CD4 count (relative hazard, 0.92), abnormal Papanicolaou test results (relative hazard, 16.03), high- or medium-risk human papillomavirus types (relative hazard, 1.37), and age (relative hazard, 0.85/10 years).Warts and vulvar intraepithelial neoplasia are common among women with human immunodeficiency virus. Highly active antiretroviral therapy decreases their incidence.

Estimating human immunodeficiency virus (HIV) prevalence from sentinel seroprevalence studies is difficult. We characterize these studies and show that most are investigations of incompletely defined (hypothetical) cohorts and are usually based on nonprobability samples. Prevalence in HIV sentinel serosurveys is also time-averaged and vulnerable to several time-dependent sources of bias (e.g., migration, deaths, and changes in incidence). Assumptions must be made that these time-dependent biases did not meaningfully affect the data, and this can be helped by reducing the period of investigation. Furthermore, we show that “reliability” can not be adequately measured by standard error, that “internal validity” is vulnerable to self-selection bias and laboratory problems, and that “generalizability” is limited. We propose that what is needed is a procedure (like formal metaanalysis methods) incorporating information from several separate HIV sentinel seroprevalence studies, in a manner that is reproducible and can take into consideration the differences between studies.

1 ALTERED HCV SPECIFIC T CELL IMMUNITY VERY EARLY IN INTERFERON FREE HCV DAA THERAPY L. Barrett, G. Shivasabesan, C. Wang, A. Osinusi, A. Kohli, E.G. Meissner, L. Heytens, A. Nelson, M.A. Polis, H. Masur, W. Symonds, J. McHutchinson, S. Kottilil. Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, SAIC-Frederick Inc, Frederick, CCMD, CC, National Institutes of Health, Bethesda, MD, Gilead Sciences, Inc., Foster City, CA, USA E-mail: barrettl@niaid.nih.gov