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needle-stick injuries among healthcare workers&#44; and patient-to-patient transmission resulting from poor infection control practices&#46; Other risk factors include having been born to an HCV-infected mother&#44; having been incarcerated&#44; and having received a tattoo in an unregulated setting&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Risk factors for HCV infection in Mexican population in addition to those mentioned are prior heroin users &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;8&#44; 95&#37; CI &#40;2&#46;1&#8211;41&#46;4&#41;&#93;&#44; living alone &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;6&#44; 95&#37; CI &#40;1&#46;1&#8211;5&#46;9&#41;&#93;&#44; being a widower &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;2&#44; 95&#37; CI &#40;1&#46;1&#8211;4&#46;3&#41;&#93; and northern region residence &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;9&#44; 95&#37; CI &#40;1&#46;1&#8211;3&#46;2&#41;&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> HCV testing is recommended in select populations based on demographics&#44; prior exposure&#44; high-risk behaviors&#44; and medical conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk of infection in RA depends in three different situations&#58; RA itself as a chronic disorder with immunological dysfunctions&#44; immunocompromising comorbidities&#44; and the use of potent immunomodulatory drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> International<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and Mexican rheumatoid arthritis &#40;RA&#41; guidelines recommend testing for hepatitis B and C in high-risk patients &#40;level of evidence&#58; 4&#59; grade of recommendation&#58; D&#41; before the use of non-biologic and biologic disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Although patients with a higher risk profile for HCV have been defined by the Mexican National Health Survey<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> and the Centers for Disease Control and Prevention&#44; RA patients are not in this epidemiological group&#46; Therefore&#44; implementation of the recommendations for HCV testing in this population has not been clearly accomplished&#46; The aim of the study is to describe the characteristics of HCV testing in patients with RA in three different medical care settings in a non-endemic area&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a retrospective study based on clinical medical records&#46; RA patients who fulfilled the American College of Rheumatology &#40;ACR&#41; 1987 and&#47;or the ACR&#47;European League Against Rheumatism &#40;EULAR&#41; 2010 classification criteria were included&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7&#44;8</span></a> The patients were from three different health systems from Mexico&#58; Popular Health Insurance at the UANL University Hospital&#44; PHI&#59; the Mexican Social Security Institute for private sector workers &#40;Instituto Mexicano del Seguro Social&#44; IMSS&#41;&#44; SSI&#59; and Private health insurance at the Arthritis and Rheumatism Specialist Center &#40;Centro de Especialistas en Artritis y Reumatismo CEAR&#41; and Hospital Central &#8220;Dr&#46; Ignacio Morones Prieto&#8221;&#44; PrHI&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We describe the indications for HCV testing and its overall prevalence&#46; This study was approved by the local Institutional Review Board with registration no&#46; RE-13010&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis using the following variables&#58; age&#44; gender&#44; time since RA diagnosis&#44; treatment&#44; risk factors for HCV&#44; hepatitis B virus &#40;HBV&#41; and HIV&#44; including&#58; tattoo&#44; marital status&#44; prior blood transfusion and prior illicit drug&#46; Also&#44; we evaluated liver function tests and HCV result by ELISA&#46; In addition&#44; we determined the main reasons for HCV testing&#46; Results were reported as mean and standard deviation for continuous variables and percentages for categorical variables&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 960 patients were evaluated&#59; 312 &#40;32&#46;5&#37;&#41; were from PHI&#44; 380 &#40;39&#46;5&#37;&#41; from SSI&#44; and 268 &#40;27&#46;9&#37;&#41; from the PrHI&#46; Eight hundred eighty-five &#40;92&#37;&#41; and mean age was 51&#46;6 years &#40;SD 12&#46;99&#41;&#46; The mean time since RA diagnosis to testing was 9&#46;8 years &#40;SD 8&#46;2&#41;&#46; Rheumatoid factor was positive in 554 &#40;67&#46;6&#37;&#41; of 819 patients and anti-cyclic citrullinated peptide &#40;anti-CCP&#41; antibody in 239 &#40;69&#46;8&#37;&#41; of 342 patients&#46; Two hundred and seventy-three &#40;28&#46;4&#37;&#41; patients were using biologic agents for RA treatment and the rest were on synthetic DMARDs&#46; The mean value for transaminases was normal&#46; Alanine transaminase &#40;ALT&#41; had a mean of 29<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;SD 12&#46;8&#41; and aspartate transaminase &#40;AST&#41; a mean of 25<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;SD 10&#46;7&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The HCV testing was performed in 28&#46;6&#37; &#40;275&#47;960&#41;&#46; HCV testing was as follows&#58; PHI 4&#47;312 patients &#40;1&#46;49&#37;&#41;&#44; SSI 3&#47;380 &#40;0&#46;79&#37;&#41; patients&#44; and PrHI 268&#47;268 &#40;100&#37;&#41; patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The main reasons for HCV testing at PHI and SSI are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The only reason for requesting HCV testing at PrHI was prior to the beginning of biological therapy&#46; The overall frequency of HCV was 0&#46;36&#37; &#40;1&#47;275&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">We found that only 28&#46;6&#37; of patients were screened for HCV and this depended on the medical care setting&#44; and not necessarily represent the adherence to clinical practice guidelines&#46; It is well known that the main reasons for requesting HCV testing are the following&#58; before starting biological agents&#44; as a differential diagnosis in patients with acute polyarthritis&#44; the presence abnormal liver function tests&#44; and&#47;or belonging to HCV high risk groups &#40;previous use of illicit drugs&#44; transfusions before 1965&#44; etc&#46;&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the PrHI&#44; the main reason for HCV testing was the starting of biological agents for RA treatment &#40;surpassing the other risk factors&#41;&#44; as stated in international recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In PHI and SSI we observed different reasons for testing&#44; such as differential diagnosis&#44; abnormal liver function tests&#44; and the beginning of biologic treatment&#46; Since most patients already had confirmed and established RA&#44; additional testing for differential diagnosis without HCV risk factors was not made&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Previously&#44; Valdespino et al&#46; described the risk factors associated with a high HCV prevalence in Mexico&#46; The area where the study was conducted is associated with a higher prevalence compared to other areas of the country &#91;OR 1&#46;9&#44; 95&#37; CI &#40;1&#46;1&#8211;3&#46;2&#41;&#93;&#46; The age &#91;50&#8211;59 years-old&#44; OR 1&#46;3&#44; 95&#37; CI &#40;0&#46;8&#8211;2&#46;1&#41;&#93; and gender &#91;OR 1&#46;1&#44; 95&#37; CI &#40;0&#46;8&#8211;1&#46;5&#41;&#93; of our patients were not associated with an increased risk of HCV infection according to prior study&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We emphasized that HCV infection frequency is low in our RA patients living in northern Mexico&#46; We observed that the only risk factor in our patients was the geographical location&#44; although other risk factors as&#58; living alone and widower was not assessed&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The Global Burden of Diseases&#44; Injuries&#44; and Risk Factors 2010 &#40;GBD2010&#41; is an international collaborative effort to estimate the burden of disease using available parameters&#46; Anti-HCV seroprevalence was estimated by GBD as high &#40;&#62;3&#46;5&#37;&#41;&#44; moderate &#40;1&#46;5&#8211;3&#46;5&#37;&#41;&#44; and low &#40;&#60;1&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Although anti-HCV positivity in this cohort was 0&#46;36&#37;&#44; which is considered low&#44; it could not be clarified with this study design&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This study represents three main different medical settings &#40;PHI&#44; SSI and PrHI&#41; for a global view in Mexican population&#46; The Mexican health system comprises two sectors&#44; public and private&#46; Within the public sector are social security institutions&#58; IMSS&#44; Institute for Social Security and ISSSTE&#44; Social Security Services for Civil Servants&#44; Petroleos Mexicanos&#44; the Ministry of Defense&#44; the Secretary of the Navy&#44; and others&#46; Institutions and programs serving the population without social security are the Health Secretariat&#44; State Health Services&#44; the IMSS-Oportunidades Program and PHI&#46; The private sector includes insurance companies and service providers in offices&#44; clinics and private hospitals&#44; and providers of alternative medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The low pre-test probability in this population with a low prevalence of HCV justifies testing personalization&#46; This is the opposite of published by Conway et al&#46; that evaluated 100 medical records of RA patients and retrospectively analyzed testing for hepatitis B virus and HCV&#46; They recommended testing for HCV even in non-endemic population&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> We differ from the Conway statement because we believe that medicine should be predictive&#44; personalized&#44; preventive&#44; and participatory &#40;P4 medicine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> P4 medicine includes &#8220;personalized&#8221; medicine because it is based on genetic information of each individual&#46; It should be &#8220;predictive&#8221; because this personalized information will determine the risk of certain diseases in each individual&#46; It should be &#8220;preventive&#8221; because by predicting a certain risk&#44; prophylactic measures may be established to decrease it and finally&#44; it is &#8220;participatory&#8221; because many of these prophylactic interventions require patient participation&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> P4 medicine may reduce disease and therefore improve well-being&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The reasons for not doing HCV testing in the other patients were not evaluated&#46; Maybe&#44; the patient characteristics analyzed in this study &#40;as female gender and age&#41;&#44; are not considered high risk factors for HCV infection based on local epidemiology&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">According to the frequency of HIV infection&#44; the risk&#44; including the administration of anti-TNF drugs in a patient with chronic infection&#44; appears to be low&#46; Previously&#44; Brunasso et al&#46; studied the safety of the administration of anti-TNF drugs in patients with chronic HCV infection and inflammatory diseases&#44; such as RA&#46; They found that of 153 cases&#44; only 2 patients worsened under this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Actually&#44; it is reported that the anti-TNF drugs may participate in the pathogenesis of HCV reducing inflammation by inhibiting TNF&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">One of the limitations of the study is that we did not evaluate a priori other risk factors of the population studied&#46; Although the study was made in three different medical settings which represent a 64&#46;1&#37; of the medical insurance in our country&#44; we did not include other medical institutions&#46; In the case of IMSS the approbation of the use of biologics agents in RA patients&#44; now has been changed and all the patients even if they not have risk factors for HCV is necessary perform the screening&#46; RA patients from a non-endemic HCV population are screened for HCV in a 28&#46;6&#37;&#44; probably because particularities of the population&#46; For patients from PrHI&#44; we did not evaluate other factors &#40;other than the indication of the beginning of biological drugs&#41; that may contribute to HCV screening application&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We conclude that a cost-benefit testing HCV and other viruses &#40;HIV&#44; HBV&#41; should be according to the personalization of the population&#44; i&#46;e&#46;&#44; the prevalence of the disease in a particular geographical location&#44; the individual risk factors&#44; and the risk of the drug serious side-effects &#40;HCV activation&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest or financial disclosures&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In Mexico&#44; other risk factors are associated with hepatitis C virus &#40;HCV&#41;&#58; prior heroin users&#44; living alone&#44; widower&#44; and northern region residence&#46; Rheumatoid arthritis &#40;RA&#41; patients are considered immunosuppressed and HCV testing is recommended before treatment&#46; The aim of the study was to describe the characteristics of HCV testing in RA patients in three different medical care settings in a non-endemic area&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study was performed using medical records from 960 RA patients describing the indications for HCV testing&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The test was performed in 28&#46;6&#37; and the HCV overall frequency was 0&#46;36&#37;&#46; Population characteristics were not associated with an increased risk of HCV infection&#59; therefore&#44; anti-HCV positivity was low&#46; The main reason for testing was before starting biological agents&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Due to the low pre-test probability&#44; testing for HCV infection should be personalized&#59; i&#46;e&#46;&#44; according to disease prevalence in a particular geographical location and the individual risk factors&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En M&#233;xico&#44; se han descrito factores de riesgo para virus de hepatitis C &#40;VHC&#41;&#44; adem&#225;s de los conocidos como&#58; consumo de hero&#237;na&#44; individuos que viven solos&#44; ser viudo y residencia en el norte del pa&#237;s&#46; Los pacientes con artritis reumatoide &#40;AR&#41; son considerados inmunodeprimidos y se recomienda realizar pruebas de VHC antes del inicio del tratamiento&#46; El objetivo fue describir las caracter&#237;sticas de pacientes con AR a quienes se realizaron pruebas de VHC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo de 960 registros m&#233;dicos donde se describieron las indicaciones para las prueba de VHC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La prueba se realiz&#243; en el 28&#46;6&#37; y la frecuencia global de VHC fue de 0&#46;36&#37;&#46; Las caracter&#237;sticas de la poblaci&#243;n no se asociaron con un mayor riesgo de infecci&#243;n&#44; por lo tanto la presencia de anti-VHC fue baja&#46; La principal raz&#243;n para realizar la prueba fue el inicio de tratamiento biol&#243;gico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Debido a la baja probabilidad pre-test&#44; las pruebas para el VHC deben ser personalizadas&#44; es decir&#44; seg&#250;n la prevalencia de la enfermedad de acuerdo a la zona geogr&#225;fica y los factores de riesgo individuales&#46;</p></span>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">268 patients belong to PrHI were screening prior use of biologic treatment&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">HCV&#44; hepatitis C virus&#59; PHI&#44; public health insurance&#59; SSI&#44; Social Security Institute&#59; PrHI&#44; private health insurance&#59; aLFT&#44; abnormal liver function test&#59; DD&#44; differential diagnosis&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Marital status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior blood transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior illicit drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tattoo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main reason for HCV screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">aLFT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">aLFT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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Brief Report
Are RA patients from a non-endemic HCV population screened for HCV? A cross-sectional analysis of three different settings
¿Debe de realizarse un tamizaje de VHC en pacientes con artritis reumatoide pertenecientes a un área no-endémica? Estudio transversal en tres diferentes sistemas de salud
Cassandra Michelle Skinner-Taylora, Alejandro Erhard-Ramíreza, Mario Alberto Garza-Elizondoa, Jorge Antonio Esquivel-Valerioa,
Corresponding author
jesquive@yahoo.com

Corresponding author.
, Carlos Abud-Mendozab, Marco Ulises Martínez-Martínezb, David Vega-Moralesa,c, Ana Arana-Guajardoa
a Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Mexico
b Hospital Central “Dr. Ignacio Morones Prieto”, y Facultad de Medicina Universidad Autónoma de San Luis, Potosí, Mexico
c Hospital General de Zona No. 17, Instituto Mexicano del Seguro Social, Mexico
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needle-stick injuries among healthcare workers&#44; and patient-to-patient transmission resulting from poor infection control practices&#46; Other risk factors include having been born to an HCV-infected mother&#44; having been incarcerated&#44; and having received a tattoo in an unregulated setting&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Risk factors for HCV infection in Mexican population in addition to those mentioned are prior heroin users &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;8&#44; 95&#37; CI &#40;2&#46;1&#8211;41&#46;4&#41;&#93;&#44; living alone &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;6&#44; 95&#37; CI &#40;1&#46;1&#8211;5&#46;9&#41;&#93;&#44; being a widower &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;2&#44; 95&#37; CI &#40;1&#46;1&#8211;4&#46;3&#41;&#93; and northern region residence &#91;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;9&#44; 95&#37; CI &#40;1&#46;1&#8211;3&#46;2&#41;&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> HCV testing is recommended in select populations based on demographics&#44; prior exposure&#44; high-risk behaviors&#44; and medical conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk of infection in RA depends in three different situations&#58; RA itself as a chronic disorder with immunological dysfunctions&#44; immunocompromising comorbidities&#44; and the use of potent immunomodulatory drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> International<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and Mexican rheumatoid arthritis &#40;RA&#41; guidelines recommend testing for hepatitis B and C in high-risk patients &#40;level of evidence&#58; 4&#59; grade of recommendation&#58; D&#41; before the use of non-biologic and biologic disease-modifying anti-rheumatic drugs &#40;DMARDs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Although patients with a higher risk profile for HCV have been defined by the Mexican National Health Survey<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> and the Centers for Disease Control and Prevention&#44; RA patients are not in this epidemiological group&#46; Therefore&#44; implementation of the recommendations for HCV testing in this population has not been clearly accomplished&#46; The aim of the study is to describe the characteristics of HCV testing in patients with RA in three different medical care settings in a non-endemic area&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a retrospective study based on clinical medical records&#46; RA patients who fulfilled the American College of Rheumatology &#40;ACR&#41; 1987 and&#47;or the ACR&#47;European League Against Rheumatism &#40;EULAR&#41; 2010 classification criteria were included&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7&#44;8</span></a> The patients were from three different health systems from Mexico&#58; Popular Health Insurance at the UANL University Hospital&#44; PHI&#59; the Mexican Social Security Institute for private sector workers &#40;Instituto Mexicano del Seguro Social&#44; IMSS&#41;&#44; SSI&#59; and Private health insurance at the Arthritis and Rheumatism Specialist Center &#40;Centro de Especialistas en Artritis y Reumatismo CEAR&#41; and Hospital Central &#8220;Dr&#46; Ignacio Morones Prieto&#8221;&#44; PrHI&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We describe the indications for HCV testing and its overall prevalence&#46; This study was approved by the local Institutional Review Board with registration no&#46; RE-13010&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis using the following variables&#58; age&#44; gender&#44; time since RA diagnosis&#44; treatment&#44; risk factors for HCV&#44; hepatitis B virus &#40;HBV&#41; and HIV&#44; including&#58; tattoo&#44; marital status&#44; prior blood transfusion and prior illicit drug&#46; Also&#44; we evaluated liver function tests and HCV result by ELISA&#46; In addition&#44; we determined the main reasons for HCV testing&#46; Results were reported as mean and standard deviation for continuous variables and percentages for categorical variables&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 960 patients were evaluated&#59; 312 &#40;32&#46;5&#37;&#41; were from PHI&#44; 380 &#40;39&#46;5&#37;&#41; from SSI&#44; and 268 &#40;27&#46;9&#37;&#41; from the PrHI&#46; Eight hundred eighty-five &#40;92&#37;&#41; and mean age was 51&#46;6 years &#40;SD 12&#46;99&#41;&#46; The mean time since RA diagnosis to testing was 9&#46;8 years &#40;SD 8&#46;2&#41;&#46; Rheumatoid factor was positive in 554 &#40;67&#46;6&#37;&#41; of 819 patients and anti-cyclic citrullinated peptide &#40;anti-CCP&#41; antibody in 239 &#40;69&#46;8&#37;&#41; of 342 patients&#46; Two hundred and seventy-three &#40;28&#46;4&#37;&#41; patients were using biologic agents for RA treatment and the rest were on synthetic DMARDs&#46; The mean value for transaminases was normal&#46; Alanine transaminase &#40;ALT&#41; had a mean of 29<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;SD 12&#46;8&#41; and aspartate transaminase &#40;AST&#41; a mean of 25<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;SD 10&#46;7&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The HCV testing was performed in 28&#46;6&#37; &#40;275&#47;960&#41;&#46; HCV testing was as follows&#58; PHI 4&#47;312 patients &#40;1&#46;49&#37;&#41;&#44; SSI 3&#47;380 &#40;0&#46;79&#37;&#41; patients&#44; and PrHI 268&#47;268 &#40;100&#37;&#41; patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The main reasons for HCV testing at PHI and SSI are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The only reason for requesting HCV testing at PrHI was prior to the beginning of biological therapy&#46; The overall frequency of HCV was 0&#46;36&#37; &#40;1&#47;275&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">We found that only 28&#46;6&#37; of patients were screened for HCV and this depended on the medical care setting&#44; and not necessarily represent the adherence to clinical practice guidelines&#46; It is well known that the main reasons for requesting HCV testing are the following&#58; before starting biological agents&#44; as a differential diagnosis in patients with acute polyarthritis&#44; the presence abnormal liver function tests&#44; and&#47;or belonging to HCV high risk groups &#40;previous use of illicit drugs&#44; transfusions before 1965&#44; etc&#46;&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the PrHI&#44; the main reason for HCV testing was the starting of biological agents for RA treatment &#40;surpassing the other risk factors&#41;&#44; as stated in international recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In PHI and SSI we observed different reasons for testing&#44; such as differential diagnosis&#44; abnormal liver function tests&#44; and the beginning of biologic treatment&#46; Since most patients already had confirmed and established RA&#44; additional testing for differential diagnosis without HCV risk factors was not made&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Previously&#44; Valdespino et al&#46; described the risk factors associated with a high HCV prevalence in Mexico&#46; The area where the study was conducted is associated with a higher prevalence compared to other areas of the country &#91;OR 1&#46;9&#44; 95&#37; CI &#40;1&#46;1&#8211;3&#46;2&#41;&#93;&#46; The age &#91;50&#8211;59 years-old&#44; OR 1&#46;3&#44; 95&#37; CI &#40;0&#46;8&#8211;2&#46;1&#41;&#93; and gender &#91;OR 1&#46;1&#44; 95&#37; CI &#40;0&#46;8&#8211;1&#46;5&#41;&#93; of our patients were not associated with an increased risk of HCV infection according to prior study&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We emphasized that HCV infection frequency is low in our RA patients living in northern Mexico&#46; We observed that the only risk factor in our patients was the geographical location&#44; although other risk factors as&#58; living alone and widower was not assessed&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The Global Burden of Diseases&#44; Injuries&#44; and Risk Factors 2010 &#40;GBD2010&#41; is an international collaborative effort to estimate the burden of disease using available parameters&#46; Anti-HCV seroprevalence was estimated by GBD as high &#40;&#62;3&#46;5&#37;&#41;&#44; moderate &#40;1&#46;5&#8211;3&#46;5&#37;&#41;&#44; and low &#40;&#60;1&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Although anti-HCV positivity in this cohort was 0&#46;36&#37;&#44; which is considered low&#44; it could not be clarified with this study design&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This study represents three main different medical settings &#40;PHI&#44; SSI and PrHI&#41; for a global view in Mexican population&#46; The Mexican health system comprises two sectors&#44; public and private&#46; Within the public sector are social security institutions&#58; IMSS&#44; Institute for Social Security and ISSSTE&#44; Social Security Services for Civil Servants&#44; Petroleos Mexicanos&#44; the Ministry of Defense&#44; the Secretary of the Navy&#44; and others&#46; Institutions and programs serving the population without social security are the Health Secretariat&#44; State Health Services&#44; the IMSS-Oportunidades Program and PHI&#46; The private sector includes insurance companies and service providers in offices&#44; clinics and private hospitals&#44; and providers of alternative medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The low pre-test probability in this population with a low prevalence of HCV justifies testing personalization&#46; This is the opposite of published by Conway et al&#46; that evaluated 100 medical records of RA patients and retrospectively analyzed testing for hepatitis B virus and HCV&#46; They recommended testing for HCV even in non-endemic population&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> We differ from the Conway statement because we believe that medicine should be predictive&#44; personalized&#44; preventive&#44; and participatory &#40;P4 medicine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> P4 medicine includes &#8220;personalized&#8221; medicine because it is based on genetic information of each individual&#46; It should be &#8220;predictive&#8221; because this personalized information will determine the risk of certain diseases in each individual&#46; It should be &#8220;preventive&#8221; because by predicting a certain risk&#44; prophylactic measures may be established to decrease it and finally&#44; it is &#8220;participatory&#8221; because many of these prophylactic interventions require patient participation&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> P4 medicine may reduce disease and therefore improve well-being&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The reasons for not doing HCV testing in the other patients were not evaluated&#46; Maybe&#44; the patient characteristics analyzed in this study &#40;as female gender and age&#41;&#44; are not considered high risk factors for HCV infection based on local epidemiology&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">According to the frequency of HIV infection&#44; the risk&#44; including the administration of anti-TNF drugs in a patient with chronic infection&#44; appears to be low&#46; Previously&#44; Brunasso et al&#46; studied the safety of the administration of anti-TNF drugs in patients with chronic HCV infection and inflammatory diseases&#44; such as RA&#46; They found that of 153 cases&#44; only 2 patients worsened under this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Actually&#44; it is reported that the anti-TNF drugs may participate in the pathogenesis of HCV reducing inflammation by inhibiting TNF&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">One of the limitations of the study is that we did not evaluate a priori other risk factors of the population studied&#46; Although the study was made in three different medical settings which represent a 64&#46;1&#37; of the medical insurance in our country&#44; we did not include other medical institutions&#46; In the case of IMSS the approbation of the use of biologics agents in RA patients&#44; now has been changed and all the patients even if they not have risk factors for HCV is necessary perform the screening&#46; RA patients from a non-endemic HCV population are screened for HCV in a 28&#46;6&#37;&#44; probably because particularities of the population&#46; For patients from PrHI&#44; we did not evaluate other factors &#40;other than the indication of the beginning of biological drugs&#41; that may contribute to HCV screening application&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We conclude that a cost-benefit testing HCV and other viruses &#40;HIV&#44; HBV&#41; should be according to the personalization of the population&#44; i&#46;e&#46;&#44; the prevalence of the disease in a particular geographical location&#44; the individual risk factors&#44; and the risk of the drug serious side-effects &#40;HCV activation&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest or financial disclosures&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In Mexico&#44; other risk factors are associated with hepatitis C virus &#40;HCV&#41;&#58; prior heroin users&#44; living alone&#44; widower&#44; and northern region residence&#46; Rheumatoid arthritis &#40;RA&#41; patients are considered immunosuppressed and HCV testing is recommended before treatment&#46; The aim of the study was to describe the characteristics of HCV testing in RA patients in three different medical care settings in a non-endemic area&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study was performed using medical records from 960 RA patients describing the indications for HCV testing&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The test was performed in 28&#46;6&#37; and the HCV overall frequency was 0&#46;36&#37;&#46; Population characteristics were not associated with an increased risk of HCV infection&#59; therefore&#44; anti-HCV positivity was low&#46; The main reason for testing was before starting biological agents&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Due to the low pre-test probability&#44; testing for HCV infection should be personalized&#59; i&#46;e&#46;&#44; according to disease prevalence in a particular geographical location and the individual risk factors&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En M&#233;xico&#44; se han descrito factores de riesgo para virus de hepatitis C &#40;VHC&#41;&#44; adem&#225;s de los conocidos como&#58; consumo de hero&#237;na&#44; individuos que viven solos&#44; ser viudo y residencia en el norte del pa&#237;s&#46; Los pacientes con artritis reumatoide &#40;AR&#41; son considerados inmunodeprimidos y se recomienda realizar pruebas de VHC antes del inicio del tratamiento&#46; El objetivo fue describir las caracter&#237;sticas de pacientes con AR a quienes se realizaron pruebas de VHC&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo de 960 registros m&#233;dicos donde se describieron las indicaciones para las prueba de VHC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La prueba se realiz&#243; en el 28&#46;6&#37; y la frecuencia global de VHC fue de 0&#46;36&#37;&#46; Las caracter&#237;sticas de la poblaci&#243;n no se asociaron con un mayor riesgo de infecci&#243;n&#44; por lo tanto la presencia de anti-VHC fue baja&#46; La principal raz&#243;n para realizar la prueba fue el inicio de tratamiento biol&#243;gico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Debido a la baja probabilidad pre-test&#44; las pruebas para el VHC deben ser personalizadas&#44; es decir&#44; seg&#250;n la prevalencia de la enfermedad de acuerdo a la zona geogr&#225;fica y los factores de riesgo individuales&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Marital status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior blood transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prior illicit drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tattoo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main reason for HCV screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Married&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 21735743
Original language: English
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Idiomas
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