Using survival analysis to predict septic shock onset in ICU patients.

PURPOSE: To determine the efficacy of survival analysis for predicting septic shock onset in ICU patients. MATERIALS AND METHODS: We performed a retrospective analysis on ICU cases from Mercy Hospital St. Louis from 2012 to 2016. As part of the procedure for inclusion in the Apache Outcomes database, each case is reviewed by critical care clinicians to identify septic shock patients as well as the time of septic shock onset. We used survival analysis to predict septic shock onset in these cases and employed lagging to compensate for uncertainties in septic shock onset time. RESULTS: Survival analysis was highly effective at predicting septic shock onset, producing AUC values of >0.87. The methodology was robust to lag times as well as the specific method of survival analysis used. CONCLUSIONS: This methodology has the potential to be implemented in the ICU for real time prediction and can be used as a building block to expand the approach to other hospital wards or care environments.

Incident CTS in a large pooled cohort study: associations obtained by a Job Exposure Matrix versus associations obtained from observed exposures.

BACKGROUND: There is growing use of a job exposure matrix (JEM) to provide exposure estimates in studies of work-related musculoskeletal disorders; few studies have examined the validity of such estimates, nor did compare associations obtained with a JEM with those obtained using other exposures. OBJECTIVE: This study estimated upper extremity exposures using a JEM derived from a publicly available data set (Occupational Network, O*NET), and compared exposure-disease associations for incident carpal tunnel syndrome (CTS) with those obtained using observed physical exposure measures in a large prospective study. METHODS: 2393 workers from several industries were followed for up to 2.8 years (5.5 person-years). Standard Occupational Classification (SOC) codes were assigned to the job at enrolment. SOC codes linked to physical exposures for forceful hand exertion and repetitive activities were extracted from O*NET. We used multivariable Cox proportional hazards regression models to describe exposure-disease associations for incident CTS for individually observed physical exposures and JEM exposures from O*NET. RESULTS: Both exposure methods found associations between incident CTS and exposures of force and repetition, with evidence of dose-response. Observed associations were similar across the two methods, with somewhat wider CIs for HRs calculated using the JEM method. CONCLUSION: Exposures estimated using a JEM provided similar exposure-disease associations for CTS when compared with associations obtained using the 'gold standard' method of individual observation. While JEMs have a number of limitations, in some studies they can provide useful exposure estimates in the absence of individual-level observed exposures.

Tumor Necrosis Factor Inhibition and Head and Neck Cancer Recurrence and Death in Rheumatoid Arthritis.

The objective of this retrospective cohort study was to determine the effect of tumor necrosis factor inhibitor (TNFi) therapy on the risk of head and neck cancer (HNC) recurrence or HNC-attributable death in patients with rheumatoid arthritis (RA). RA patients with HNC were assembled from the US national Veterans' Affairs (VA) administrative databases, and diagnoses confirmed and data collected by electronic medical record review. The cohort was divided into those treated with non-biologic disease-modifying anti-rheumatic drugs (nbDMARDs) versus TNF inhibitors (TNFi) after a diagnosis of HNC. Likelihood of a composite endpoint of recurrence or HNC-attributable death was determined by Cox proportional hazards regression. Of 180 patients with RA and HNC, 31 were treated with TNFi and 149 with nbDMARDs after the diagnosis of HNC. Recurrence or HNC-attributable death occurred in 5/31 (16.1%) patients in the TNFi group and 44/149 (29.5%) patients in the nbDMARD group (p = 0.17); it occurred in 2/16 (13%) patients who received TNFi in the year prior to HNC diagnosis but not after. Overall stage at diagnosis (p = 0.03) and stage 4 HNC (HR 2.49 [CI 1.06-5.89]; p = 0.04) were risk factors for recurrence or HNC-attributable death; treatment with radiation or surgery was associated with a lower risk (HR 0.35 [CI 0.17-0.74]; p = 0.01 and HR 0.39 [CI 0.20-0.76]; p = 0.01 respectively). Treatment with TNFi was not a risk factor for recurrence or HNC-attributable death (HR 0.75; CI 0.31-1.85; p = 0.54). We conclude that treatment with TNFi may be safe in patients with RA and HNC, especially as the time interval between HNC treatment and non-recurrence increases. In this study, TNF inhibition was not associated with an increase in recurrence or HNC-attributable death.

General population job exposure matrix applied to a pooled study of prevalent carpal tunnel syndrome.

A job exposure matrix may be useful for the study of biomechanical workplace risk factors when individual-level exposure data are unavailable. We used job title-based exposure data from a public data source to construct a job exposure matrix and test exposure-response relationships with prevalent carpal tunnel syndrome (CTS). Exposures of repetitive motion and force from the Occupational Information Network were assigned to 3,452 active workers from several industries, enrolled between 2001 and 2008 from 6 studies. Repetitive motion and force exposures were combined into high/high, high/low, and low/low exposure groupings in each of 4 multivariable logistic regression models, adjusted for personal factors. Although force measures alone were not independent predictors of CTS in these data, strong associations between combined physical exposures of force and repetition and CTS were observed in all models. Consistent with previous literature, this report shows that workers with high force/high repetition jobs had the highest prevalence of CTS (odds ratio = 2.14-2.95) followed by intermediate values (odds ratio = 1.09-2.27) in mixed exposed jobs relative to the lowest exposed workers. This study supports the use of a general population job exposure matrix to estimate workplace physical exposures in epidemiologic studies of musculoskeletal disorders when measures of individual exposures are unavailable.

Comparison of automated versus traditional nerve conduction study methods for median nerve testing in a general worker population.

OBJECTIVE: To investigate the validity of automated nerve conduction studies compared to traditional electrodiagnostic studies (EDS) for testing median nerve abnormalities in a working population. DESIGN: Agreement study and sensitivity investigation from 2 devices. SETTING: Field research testing laboratory. PARTICIPANTS: Active workers from several industries participating in a longitudinal study of carpal tunnel syndrome. METHODS: Sixty-two subjects received bilateral median and ulnar nerve conduction testing across the wrist with a traditional device and the NC-stat automated device. We compared the intermethod agreement of analogous measurements. MAIN OUTCOME MEASUREMENT: Nerve conduction study parameters. RESULTS: Median motor and sensory latency comparisons showed excellent agreement (intraclass correlation coefficients 0.85 and 0.80, respectively). Areas under the receiver operating characteristic curves were 0.97 and 0.96, respectively, using the optimal thresholds of 4.4-millisecond median motor latency (sensitivity 100%, specificity 86%) and 3.9-millisecond median sensory latency (sensitivity 100%, specificity 87%). Ulnar nerve testing results were less favorable. CONCLUSION: The automated NC-stat device showed excellent agreement with traditional EDS for detecting median nerve conduction abnormalities in a general population of workers, suggesting that this automated nerve conduction device can be used to ascertain research case definitions of carpal tunnel syndrome in population health studies. Further study is needed to determine optimal thresholds for defining median conduction abnormalities in populations that are not seeking clinical care.

Self-reported physical work exposures and incident carpal tunnel syndrome.

BACKGROUND: To prospectively evaluate associations between self-reported physical work exposures and incident carpal tunnel syndrome (CTS). METHODS: Newly employed workers (n = 1,107) underwent repeated nerve conduction studies (NCS), and periodic surveys on hand symptoms and physical work exposures including average daily duration of wrist bending, forearm rotation, finger pinching, using vibrating tools, finger/thumb pressing, forceful gripping, and lifting >2 pounds. Multiple logistic regression models examined relationships between peak, most recent, and time-weighted average exposures and incident CTS, adjusting for age, gender, and body mass index. RESULTS: 710 subjects (64.1%) completed follow-up NCS; 31 incident cases of CTS occurred over 3-year follow-up. All models describing lifting or forceful gripping exposures predicted future CTS. Vibrating tool use was predictive in some models. CONCLUSIONS: Self-reported exposures showed consistent risks across different exposure models in this prospective study. Workers' self-reported job demands can provide useful information for targeting work interventions.

The effectiveness of post-offer pre-placement nerve conduction screening for carpal tunnel syndrome.

OBJECTIVE: We evaluated post-offer pre-placement (POPP) nerve conduction studies (NCS) for carpal tunnel syndrome (CTS), testing diagnostic yield and cost-effectiveness. METHODS: A total of 1027 newly hired workers underwent baseline NCS and were followed for an average of 3.7 years for diagnosed CTS. Measures of diagnostic yield included sensitivity, specificity, and positive predictive value (PPV). Cost-effectiveness of POPP screening was evaluated using a range of inputs. RESULTS: Abnormal NCS was strongly associated with future CTS with univariate hazard ratios ranging from 2.95 to 11.25, depending on test parameters used. Nevertheless, PPV was poor, 6.4% to 18.5%. Cost-effectiveness of POPP varied with CTS case costs, screening costs, and NCS thresholds. CONCLUSIONS: Although abnormal NCS at hire increases risk of future CTS, the PPV is low, and POPP screening is not cost-effective to employers in most scenarios tested.

Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans.

BACKGROUND: Antibiotics may interact with warfarin, increasing the risk for significant bleeding events. METHODS: This is a retrospective cohort study of veterans who were prescribed warfarin for 30 days without interruption through the US Department of Veterans Affairs between October 1, 2002 and September 1, 2008. Antibiotics considered to be high risk for interaction with warfarin include: trimethoprim/sulfamethoxazole (TMP/SMX), ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin, and clarithromycin. Low-risk antibiotics include clindamycin and cephalexin. Risk of bleeding event within 30 days of antibiotic exposure was measured using Cox proportional hazards regression, adjusted for demographic characteristics, comorbid conditions, and receipt of other medications interacting with warfarin. RESULTS: A total of 22,272 patients met inclusion criteria, with 14,078 and 8194 receiving high- and low-risk antibiotics, respectively. There were 93 and 36 bleeding events in the high- and low-risk groups, respectively. Receipt of a high-risk antibiotic (hazard ratio [HR] 1.48; 95% confidence interval [CI], 1.00-2.19) and azithromycin (HR 1.93; 95% CI, 1.13-3.30) were associated with increased risk of bleeding as a primary diagnosis. TMP/SMX (HR 2.09; 95% CI, 1.45-3.02), ciprofloxacin (HR 1.87; 95% CI, 1.42-2.50), levofloxacin (HR 1.77; 95% CI, 1.22-2.50), azithromycin (HR 1.64; 95% CI, 1.16-2.33), and clarithromycin (HR 2.40; 95% CI, 1.16-4.94) were associated with serious bleeding as a primary or secondary diagnosis. International normalized ratio (INR) alterations were common; 9.7% of patients prescribed fluconazole had INR value >6. Patients who had INR performed within 3-14 days of co-prescription were at a decreased risk of serious bleeding (HR 0.61; 95% CI, 0.42-0.88). CONCLUSIONS: Warfarin users who are prescribed high-risk antibiotics are at higher risk for serious bleeding events. Early INR evaluation may mitigate this risk.

Using job-title-based physical exposures from O*NET in an epidemiological study of carpal tunnel syndrome.

OBJECTIVE: We studied associations between job-title-based measures of force and repetition and incident carpal tunnel syndrome (CTS). BACKGROUND: Job exposure matrices (JEMs) are not commonly used in studies of work-related upper-extremity disorders. METHOD: We enrolled newly hired workers in a prospective cohort study. We assigned a Standard Occupational Classification (SOC) code to each job held and extracted physical work exposure variables from the Occupational Information Network (O*NET). CTS case definition required both characteristic symptoms and abnormal median nerve conduction. RESULTS: Of 1,107 workers, 751 (67.8%) completed follow-up evaluations. A total of 31 respondents (4.4%) developed CTS during an average of 3.3 years of follow-up. Repetitive motion, static strength, and dynamic strength from the most recent job held were all significant predictors of CTS when included individually as physical exposures in models adjusting for age, gender, and BMI. Similar results were found using time-weighted exposure across all jobs held during the study. Repetitive motion, static strength, and dynamic strength were correlated, precluding meaningful analysis of their independent effects. CONCLUSION: This study found strong relationships between workplace physical exposures assessed via a JEM and CTS, after adjusting for age, gender, and BMI. Though job-title-based exposures are likely to result in significant exposure misclassification, they can be useful for large population studies where more precise exposure data are not available. APPLICATION: JEMs can be used as a measure of workplace physical exposures for some studies of musculoskeletal disorders.

Myocardial infarction risk among patients with fractures receiving bisphosphonates.

OBJECTIVE: To determine if bisphosphonates are associated with reduced risk of acute myocardial infarction (AMI). PATIENTS AND METHODS: A cohort of 14,256 veterans 65 years or older with femoral or vertebral fractures was selected from national administrative databases operated by the US Department of Veterans Affairs and was derived from encounters at Veterans Affairs facilities between October 1, 1998, and September 30, 2006. The time to first AMI was assessed in relationship to bisphosphonate exposure as determined by records from the Pharmacy Benefits Management Database. Time to event analysis was performed using multivariate Cox proportional hazards regression. An adjusted survival analysis curve and a Kaplan-Meier survival curve were analyzed. RESULTS: After controlling for atherosclerotic cardiovascular disease risk factors and medications, bisphosphonate use was associated with an increased risk of incident AMI (hazard ratio, 1.38; 95% CI, 1.08-1.77; P=.01). The timing of AMI correlated closely with the timing of bisphosphonate therapy initiation. CONCLUSION: Our observations in this study conflict with our hypothesis that bisphosphonates have antiatherogenic effects. These findings may alter the risk-benefit ratio of bisphosphonate use for treatment of osteoporosis, especially in elderly men. However, further analysis and confirmation of these findings by prospective clinical trials is required.

Increased body mass index is associated with improved survival in United States veterans with diffuse large B-cell lymphoma.

PURPOSE: Obesity increases the risk of death from many malignancies, including non-Hodgkin's lymphoma (NHL). In diffuse large B-cell lymphoma (DLBCL), the most common form of NHL, the association between body mass index (BMI) at diagnosis and survival is unclear. PATIENTS AND METHODS: We evaluated the association between BMI at diagnosis and overall survival in a retrospective cohort of 2,534 United States veterans diagnosed with DLBCL between October 1, 1998 and December 31, 2008. Cox modeling was used to control for patient- and disease-related prognostic variables. RESULTS: Mean age at diagnosis was 68 years (range, 20 to 100 years); 64% of patients were overweight (BMI, 25 to < 30) or obese (BMI, ≥ 30). Obese patients were significantly younger, had significantly fewer B symptoms, and trended toward lower-stage disease, compared with other BMI groups. Cox analysis showed reduced mortality in overweight and obese patients (overweight: hazard ratio [HR], 0.73; 95% CI, 0.65 to 0.83; obese: HR, 0.68; 95% CI, 0.58 to 0.80), compared with normal-weight patients (BMI, 18.5 to < 25). Treatment during the rituximab era reduced the risk of death without affecting the association between BMI and survival. Disease-related weight loss occurred in 29% of patients with weight data 1 year before diagnosis. Cox analysis based on BMI 1 year before diagnosis continued to demonstrate reduced risk of death in overweight and obese patients. CONCLUSION: Being overweight or obese at the time of DLBCL diagnosis is associated with improved overall survival. Understanding the mechanisms responsible for this association will require further study.

Mental health disorders and the risk of AIDS-defining illness and death in HIV-infected veterans.

OBJECTIVE: Mental health comorbidities are common in HIV-infected veterans and can impact clinical outcomes for HIV. We examined the impact of mental health diagnoses on progression to AIDS-defining illness (ADI) and death in a large cohort of HIV-infected veterans who accessed care between 2001 and 2006. DESIGN: Retrospective cohort study using the national Veterans Health Administration (VHA) HIV Clinical Case Registry. METHODS: We identified HIV-infected veterans initiating combination antiretroviral therapy (cART) within the VHA between 2000 and 2006. The prevalences of the following mental health diagnoses were examined: schizophrenia, bipolar disorder, depression, anxiety, and substance use disorder. Cox proportional hazards models were constructed to examine the relationship between mental health conditions and two outcomes, all-cause mortality and ADI. Models were computed before and after adjusting for confounding factors including age, race, baseline CD4 cell count, comorbidities and cART adherence. RESULTS: Among 9003 veterans receiving cART, 31% had no mental health diagnosis. Age, race, baseline comorbidity score, CD4, and cART adherence were associated with shorter time to ADI or death. All-cause mortality was more likely among veterans with schizophrenia, bipolar disorder and substance use, and ADI was more likely to occur among veterans with substance use disorder. CONCLUSIONS: Our results demonstrate the high prevalence of mental health diagnoses among HIV-infected veterans. In the era of highly active antiretroviral therapy, presence of psychiatric diagnoses impacted survival and development of ADI. More aggressive measures addressing substance abuse and severe mental illness in HIV-infected veterans are necessary.

Risk of non-melanoma skin cancer in a national cohort of veterans with rheumatoid arthritis.

OBJECTIVE: To determine the incidence of and risk factors for non-melanoma skin cancer (NMSC) in a national cohort of veterans with RA. METHODS: We examined skin cancer risk in a cohort of 20 648 patients with RA derived from the Department of Veterans' Affairs (VA) national administrative databases. The cohort was divided into two medication groups: patients treated with non-biologic and TNF-α antagonist DMARDs. We defined skin cancer as the first occurrence of an International Classification of Disease, Version 9, Clinical Modification (ICD-9-CM) code for NMSC after initiation of a DMARD. Outcome risk was described using hazard ratios (HRs) with Cox proportional hazards regression for time-to-event analysis and logistic regression. We performed medical record review to validate the diagnosis of NMSC. RESULTS: Incidence of NMSC was 18.9 and 12.7 per 1000 patient-years in patients on TNF-α antagonists and non-biologic DMARDs, respectively. Patients on TNF-α antagonists had a higher risk of developing NMSC (HR 1.42; 95% CI 1.24, 1.63). Risk factors for NMSC included older age, male gender, NSAID and glucocorticoid use and a history of prior malignancies. There was substantial agreement between ICD-9-CM diagnosis of NMSC and medical record validation (κ = 0.61). CONCLUSION: TNF-α antagonist therapy in veterans with RA may be associated with an increased risk of NMSC, compared with therapy with non-biologic DMARDs. Rheumatologists should carefully screen patients receiving TNF-α antagonists for pre-cancerous skin lesions and skin cancer.

Antidepressant drug compliance: reduced risk of MI and mortality in depressed patients.

BACKGROUND: The long-term risk of myocardial infarction (MI) associated with use of antidepressants is uncertain, especially for nontricyclic antidepressants. The present study uses a national Veterans Affairs cohort to test whether antidepressants increase or decrease risk of MI and all-cause mortality. METHODS: US Department of Veterans Affairs patient records were analyzed to identify a cohort free of cardiovascular disease in fiscal years 1999 and 2000, aged 25-80 years, who had an International Classification of Diseases, Ninth Revision, Clinical Modification code indicating an episode of depression (n=93,653). Incident MI and all-cause mortality were modeled in patients who received 12 weeks or more of antidepressant pharmacotherapy as compared with 0-11 weeks during follow-up. Age-adjusted Cox proportional hazard models were computed before and after adjusting for baseline sociodemographics and time-dependent covariates. RESULTS: Receipt of 12 or more weeks of continuous antidepressant therapy was associated with significantly reduced rates of incident MI across classes of antidepressants: selective serotonin reuptake inhibitor (SSRIs) (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.44-0.52), serotonin-norepinephrine reuptake inhibitors (SNRIs) (HR 0.35; 95% CI, 0.32-0.40), tricyclic antidepressants (TCAs) (HR 0.39; 95% CI, 0.34-0.44), and "Other" (HR 0.41; 95% CI, 0.37-0.45). Risk of all-cause mortality also was decreased with receipt of 12 weeks of pharmacotherapy with all classes of antidepressants (SSRI, SNRI, TCA, Other), with HRs ranging from 0.50 to 0.66. CONCLUSIONS: Across classes of antidepressants, 12 weeks of pharmacotherapy appears to be safe in terms of MI risk. Although the mechanism for this association remains uncertain, it is possible that compliance with pharmacotherapy for depression reflects compliance with cardiovascular medications. It also is possible that a direct drug effect or improved depressed mood may attenuate the risk of MI in depressed patients.

TNF-α antagonist use and risk of hospitalization for infection in a national cohort of veterans with rheumatoid arthritis.

Medications used to treat rheumatoid arthritis (RA) may confer an increased risk of infection. We conducted a retrospective cohort study of veterans with RA followed in the United States Department of Veterans Affairs health care system from October 1998 through September 2005. Risk of hospitalization for infection associated with tumor necrosis factor (TNF)-α antagonists therapy was measured using an extension of Cox proportional hazards regression, adjusting for demographic characteristics, comorbid illnesses, and other medications used to treat RA. A total of 20,814 patients met inclusion criteria, including 3796 patients who received infliximab, etanercept, or adalimumab. Among the study cohort, 1465 patients (7.0%) were hospitalized at least once for infection. There were 1889 hospitalizations for infection. The most common hospitalized infections were pneumonia, bronchitis, and cellulitis. Age and several comorbid medical conditions were associated with hospitalization for infection. Prednisone (hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.88-2.43) and TNF-α antagonist use (HR, 1.24; 95% CI, 1.02-1.50) were associated with hospitalization for infection, while the use of disease-modifying antirheumatic drugs (DMARDs) other than TNF-α antagonists was not. Compared to etanercept, infliximab was associated with risk for hospitalization for infection (HR, 1.51; 95% CI, 1.14-2.00), while adalimumab use was not (HR, 0.95; 95% CI, 0.68-1.33). In all treatment groups, rate of hospitalization for infection was highest in the first 8 months of therapy. We conclude that patients with RA who are treated with TNF-α antagonists are at higher risk for hospitalization for infection than those treated with other DMARDs. Prednisone use is also a risk factor for hospitalization for infection.

Tumor necrosis factor-α blockade, cardiovascular outcomes, and survival in rheumatoid arthritis.

The effect of TNF-α blockade on the risk of cardiovascular outcomes and long-term survival in patients with rheumatoid arthritis (RA) is not known. We assembled a cohort of 20,811 (75,329 person-years) U.S. veterans who were diagnosed with RA between October 1998 and September 2005, and who were treated with a disease-modifying anti-rheumatic drug (DMARD). Cox survival models were built to examine the effect of TNF-α antagonists on the risk of a composite endpoint of cardiovascular outcomes defined as the occurrence of atherosclerotic heart disease, congestive heart failure, peripheral artery disease, or cerebrovascular disease, and on the risk of death. Treatment with TNF-α antagonists was not associated with a significant effect on the composite endpoint of cardiovascular outcomes. When each outcome was examined separately, the use TNF-α antagonists was not associated with an increased risk of atherosclerotic heart disease, congestive heart failure, or peripheral artery disease, but it was associated with decreased risk of cerebrovascular disease (hazard ratio [HR] = 0.83; confidence interval [CI] = 0.70-0.98). The use of TNF-α antagonists did not affect the risk of death (HR = 0.99; CI = 0.87-1.14). In subgroup analyses, the use TNF-α antagonists was associated with a reduced risk of cardiovascular outcomes (HR = 0.90, CI = 0.83-0.98) in patients younger than the median age of our cohort (63 years). The use TNF-α antagonists was not associated with a change in the risk of death in any other subgroup. These results show that the risk of cardiovascular events and survival in patients who receive TNF-α antagonists is not different than those who receive other DMARDs.

Increasing prevalence of HCC and cirrhosis in patients with chronic hepatitis C virus infection.

BACKGROUND & AIMS: Patients with hepatitis C virus (HCV) infection are at risk for developing costly and morbid complications, although the actual prevalence of these complications is unknown. We examined time trends in the prevalence of cirrhosis and its related complications, such as hepatic decompensation and hepatocellular carcinoma (HCC). METHODS: We calculated the annual prevalence of cirrhosis, decompensated cirrhosis, and HCC in a national sample of veterans diagnosed with HCV between 1996 and 2006. Patients with HCV who had at least one physician visit in a given calendar year were included in the analysis of prevalence for that year. We used direct standardization to adjust the prevalence of cirrhosis and related complications for increasing age of the cohort as well as sex and changes in clinical characteristics. RESULTS: In this cohort, the number of individuals with HCV increased from 17,261 in 1996 to 106,242 in 2006. The prevalence of cirrhosis increased from 9% in 1996 to 18.5% in 2006. The prevalence of patients with decompensated cirrhosis doubled, from 5% in 1996 to 11% in 2006, whereas the prevalence of HCC increased approximately 20-fold (0.07% in 1996 to 1.3% in 2006). After adjustment, the time trend in the prevalence of cirrhosis (and its complications) was lower than the crude trend, although it still increased significantly. CONCLUSIONS: The prevalence of cirrhosis and HCC in HCV-infected patients has increased significantly over the past 10 years. An aging cohort of patients with HCV could partly explain our findings. Clinicians and health care systems should develop strategies to provide timely and effective care to this high-risk population of patients.