In 1995, the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) developed guidelines for preventing opportunistic infections (OIs) among persons infected with human immunodeficiency virus (HIV); these guidelines were updated in 1997 and 1999. This fourth edition of the guidelines, made available on the Internet in 2001, is intended for clinicians and other health-care providers who care for HIV-infected persons. The goal of these guidelines is to provide evidence-based guidelines for preventing OIs among HIV-infected adults and adolescents, including pregnant women, and HIV-exposed or infected children. Nineteen OIs, or groups of OIs, are addressed, and recommendations are included for preventing exposure to opportunistic pathogens, preventing first episodes of disease by chemoprophylaxis or vaccination (primary prophylaxis), and preventing disease recurrence (secondary prophylaxis). Major changes since the last edition of the guidelines include 1) updated recommendations for discontinuing primary and secondary OI prophylaxis among persons whose CD4+ T lymphocyte counts have increased in response to antiretroviral therapy; 2) emphasis on screening all HIV-infected persons for infection with hepatitis C virus; 3) new information regarding transmission of human herpesvirus 8 infection; 4) new information regarding drug interactions, chiefly related to rifamycins and antiretroviral drugs; and 5) revised recommendations for immunizing HIV-infected adults and adolescents and HIV-exposed or infected children.

We read with great interest and enthusiasm the updated American Association for the Study of Liver Diseases practice guidelines, "Diagnosis, Management, and Treatment of Hepatitis C" by Strader et al., who comprehensively reviewed the current status and pointed out areas requiring more studies. 1 Unfortunately, a group of hepatitis C patients-those with hepatitis B virus (HBV) coinfection-were not addressed at all. In most countries, hepatitis C patients usually have only one hepatotropic virus infection. However, in areas where HBV infection is endemic, such as Southeast Asia, Far East and southern Europe, the number of subjects infected with both hepatitis C and B is substantial. 2,3 More specifically, antibody to hepatitis C virus (anti-HCV) was present in 7% to 11% of patients with HBV-related chronic liver diseases. 2,3 If the prevalence of anti-HCV positivity is around 1% to 2% in the general population, then the number of HCV/HBV coinfection worldwide will be around 3 million to 7 million among the 350 million HBV carriers. Moreover, the HCV-and HBV-coinfected patients have been shown to carry a significantly higher risk of developing cirrhosis or hepatocellular carcinoma than those with HCV or HBV infection alone. 4 -6 Therefore, patients dually infected with hepatitis C and B need more attention from the medical profession, and they should be urgently treated with effective regimens. At present, unfortunately, hepatitis C and B coinfected patients are frequently neglected.Nevertheless, some regimens have been used to treat dual chronic hepatitis C and B. A recent study reported that standard interferon 9 million units thrice weekly for 6 months could clear HCV in 31% of these patients. 7 We have treated hepatitis C and B dually infected patients in a pilot study by using standard interferon in combination with ribavirin for 6 months. 8 We found that a sustained HCV clearance rate in hepatitis C and B dually infected patients could be achieved to an extent comparable to that in hepatitis C alone. After a follow-up of Ն2 years, HCV RNA remained undetectable in 89% of patients, with sustained clearance of serum HCV RNA 6 months posttreatment. To our surprise, 21% of these patients lose serum hepatitis B surface antigen. We anticipate that the efficacy may be enhanced by pegylated interferon, and therefore we propose using pegylated interferon plus ribavirin to treat the dually infected patients. Accordingly, a multicenter clinical trial is being undertaken at present in Taiwan, and we hope our results can culminate in a better treatment for hepatitis C patients coinfected with HBV. HCV Carriers With Persistently Normal Aminotransferase LevelsTo the Editor:We read with great interest the AASLD Practice Guideline 1 on the diagnosis, management and treatment of hepatitis C (HCV). However, we have some concerns about the definition of HCV carriers with normal alanine aminotransferase (ALT) given by Strader et al. 1 In this paper, a person is considered to have normal ALT levels when "there have been two ...

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Background Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients. Objectives To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions. Data sources Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence. Review methods Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis. Findings A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’s d = –0.51, 95% confidence interval –0.78 to –0.24; p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’s d = –1.04, 95% confidence interval –1.55 to –0.53; p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive. Limitations Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis. Conclusions Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known. Future work Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes. Study registration This study is registered as PROSPERO CRD42017080637. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Much has been written about prisoner research and the controversies surrounding prisoners as human subjects. The Institute of Medicine recently released a report addressing some of these issues. This report, which generated further controversy, needs to be fully discussed in the literature and certain aspects are examined in this work. Further, in the body of literature there has been little acknowledgement of the concept of the right of prisoners to be involved in research. This needs to be pursued from an ethical perspective and eventually a legal one. This paper explores that concept and documents some facilities in which a prisoner's right to research has occurred.