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An in-depth report on the causes, diagnosis, treatment, and prevention of hepatitis.
Hepatitis C Screening for "Baby Boomers"
The U.S. Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force (USPSTF) now recommend that everyone born from 1945 - 1965 (the "baby boom" generation) get a one-time test for hepatitis C:
- People bornbetween 1945- 1965 comprise 25% of the U.S. population but account for 75% of adults infected with HCV. They are 5 times more likely than other American adults to be infected with HCV.
- Most patients with hepatitis C do not experience symptoms and are unaware they are infected. Chronic hepatitis C can be present for decades and liver damage can occur before people experience symptoms.
- Compared to other Americans, people of the baby boom generation face an increased risk of dying from hepatitis C-related illnesses such as liver cancer and cirrhosis. A CDC study found that deaths from hepatitis C have been increasing steadily in recent years, especially among middle-aged people.
- Testing can help prevent deaths. Advances in treatment with new drug therapies are saving many lives.
Vaccines are available to prevent hepatitis A and B. There is no vaccine for hepatitis C.
New Drug Treatments for Hepatitis C
In 2011, the Food and Drug Administration (FDA) approved two new drugs, telaprevir (Incivek) and boceprevir (Victrelis), for treatment of adult patients with genotype 1 chronic hepatitis C infection. Genotype 1 is the most common type of hepatitis C virus and is the most difficult to treat. Patients take either telaprevir or boceprevir as daily pills in combination with peginterferon alfa and ribavirin, the standard hepatitis C drug regimen. These new drugs marked a breakthrough for hepatitis C treatment by dramatically improving outcomes and cure rates.
In 2013, the FDA approved two more new drugs, sofosbuvir and simeprevir, which promise even better cure rates and potentially shorter treatment times:
- Simeprevir (Olysio) is, like telaprevir and boceprevir, a protease inhibitor drug used to treat genotype 1.
- Sofosbuvir (Sovaldi) is a nucleotide analog inhibitor. It has shown excellent cure rates when used in combination with pegylated interferon and ribavirin for treating genotype 1. Most significantly, sofosbuvir offers the first interferon-free regimen for treating genotypes 2 and 3. For these genotypes, sofosbuvir is given in combination with ribavirin alone.
- Sofosbuvir and simeprevir are taken as once-daily pills.
Hepatitis means "inflammation of the liver." It is a disorder in which viruses or otherfactors produce inflammation in liver cells, resulting in their injury or destruction.
The Liver
The liver is the largest internal organ in the body, occupying the upper right area of the abdomen. It performs over 500 vital functions. Some of its key roles are:
- The liver processes all of the nutrients the body requires, including proteins, glucose, vitamins, and fats.
- The liver is the body's "factory" where many important proteins are made. The blood protein albumin is one example that is often under-produced in patients with cirrhosis.
- The liver manufactures bile, the greenish fluid stored in the gallbladder that helps digest fats.
- One of the liver's major contributions is to render harmless potentially toxic substances, including alcohol, ammonia, nicotine, drugs, and harmful by-products of digestion.
- Damage to the liver can impair these and many other processes.
Types of Hepatitis
Hepatitis can occur from many different causes:
- Viral hepatitis is the most common kind of hepatitis. Many types of viruses can damage the liver. Hepatitis caused by the viruses A, B, and C are the focus of this report.
- Hepatitis can also result from an autoimmune condition, in which abnormally targeted immune factors attack the body's own liver cells.
- Hepatitis can also occur from medical problems, drugs, alcoholism, chemicals, and environmental toxins.
Acute and Chronic Hepatitis
Hepatitis can be either acute (short-term) or chronic (long-term):
- Acute hepatitis lasts less than than 6 months. It usually causes only minimal liver damage. All hepatitis viruses can cause an acute form of liver disease. Hepatitis A and E viruses only cause acute hepatitis; they do not cause chronic disease.
- Chronic hepatitis lasts more than 6 months. It may progress slowly and cause minimal liver damage, or it can progress aggressively and cause extensive damage. Chronic hepatitis can result from specific hepatitis viruses (B, C, and D) or some non-viral forms of hepatitis.
Although chronic hepatitis is generally considered more serious than acute hepatitis, patients with either condition can have varying degrees of severity.
Viral Hepatitis
Most cases of hepatitis are caused by viruses that infect liver cells and begin multiplying. They are identified by the letters A through G:
- Hepatitis A, B, and C are the most common viral forms of hepatitis and are the primary focus of this report.
- Hepatitis D and E are less common hepatitis viruses. Hepatitis D is a serious form of hepatitis that can be chronic. It is associated with hepatitis B because the D virus relies on the B virus to replicate. (Therefore, hepatitis D cannot exist without the B virus also being present.) Hepatitis E, like hepatitis A, is an acute form of hepatitis that is transmitted by contact with contaminated food or water.
- Researchers are investigating additional viruses that may be implicated in hepatitis unexplained by the currently known viruses.
The name of each type of viral hepatitis condition corresponds to the virus that causes it. For example, hepatitis A is caused by hepatitis A virus (HAV), hepatitis B is caused by hepatitis B virus (HBV), and hepatitis C is caused by hepatitis C virus (HCV).
Scientists do not know exactly how these viruses actually cause hepatitis. As the virus reproduces in the liver, several proteins and enzymes, including many that attach to the surface of the viral protein, are also produced. Some of these may be directly responsible for liver inflammation and damage.
Non-Viral Hepatitis
Non-viral forms of hepatitis are less common than viral hepatitis.
Autoimmune Hepatitis. Autoimmune hepatitis is a rare form of chronic hepatitis. Like other autoimmune disorders, its exact cause is unknown. Autoimmune hepatitis may develop on its own or it may be associated with other autoimmune disorders, such as systemic lupus erythematosus. In autoimmune disorders, a misdirected immune system attacks the body's own cells and organs (in this case the liver).
Alcoholic Hepatitis. About 20% of heavy drinkers develop alcoholic hepatitis, usually between the ages of 40 - 60 years. In the body, alcohol breaks down into various chemicals, some of which are very toxic to the liver. After years of drinking, liver damage can be very severe, leading to cirrhosis. Although heavy drinking itself is the major risk factor for alcoholic hepatitis, genetic factors may play a role in increasing a person's risk for alcoholic hepatitis. Women who abuse alcohol are at higher risk for alcoholic hepatitis and cirrhosis than are men who drink heavily.
Nonalcoholic Fatty Liver Disease (NAFLD). NAFLDaffects 10 - 24% of the population. It covers several conditions, including nonalcoholic steatohepatitis (NASH). NAFLD has features similar to alcoholic hepatitis, particularly a fatty liver, but it occurs in individuals who drink little or no alcohol. Severe obesity and diabetes are the major risk factors for NAFLD and they also increase the likelihood of complications from NAFLD. NAFLD is usually benign and very slowly progressive. In certain patients, however, it can lead to cirrhosis, liver failure, or liver cancer.
Drug-Induced Hepatitis. Because the liver plays such a major role in metabolizing drugs, hundreds of medications can cause reactions that are similar to those of acute viral hepatitis. Symptoms can appear any time after starting drug treatment. In most cases, they disappear when the drug is withdrawn, but in rare circumstances they may progress to serious liver disease. Drugs most associated with liver interactions include halothane, isoniazid, methyldopa, phenytoin, valproic acid, and sulfonamide drugs. Very high doses of acetaminophen (Tylenol, generic) can cause severe liver damage and even death, particularly when used with alcohol.
Toxin-Induced Hepatitis. Certain types of plant and chemical toxins can cause hepatitis. They include toxins found in poisonous mushrooms, and industrial chemicals such as vinyl chloride.
Metabolic-Disorder Associated Hepatitis. Hereditary metabolic disorders, such as hemochromatosis (accumulation of iron in the body) and Wilson's disease (accumulation of copper in the body) can cause liver inflammation and damage.
Risk Factors and Transmission
Depending on the type of hepatitis virus, there are different ways that people can acquire hepatitis. In the United States, the main ways that people contract hepatitis are:
- Hepatitis A. Through contaminated food and water
- Hepatitis B. Through sexual contact or contaminated blood or body fluids
- Hepatitis C. Through contact with infected blood, usually by sharing drug injection needles and syringes and in rare cases through sexual contact
Hepatitis A
The hepatitis A virus is excreted in feces and transmitted by ingesting contaminated food or water. An infected person can transmit hepatitis to others if they do not take strict sanitary precautions, such as thoroughly washing hands before food preparation
People can become infected with hepatitis A by:
- Eating or drinking food or water contaminated with hepatitis A virus. Contaminated fruits, vegetables, shellfish, ice, and water are common sources of hepatitis A transmission.
- Engaging in unsafe sexual practices (oral-anal contact).
People at high risk for hepatitis A infection include:
- International travelers. Hepatitis A is the hepatitis strain people are most likely to encounter in the course of international travel to developing countries.
- Day care employees and children. Many cases of hepatitis A occur among day care employees and children who attend day care. Risks can be reduced if hygienic precautions are used, particularly when changing and handling diapers.
- People living in a household with someone who has hepatitis A
- Men who have sex with men
- Users of illegal drugs
Hepatitis B
The hepatitis B virus is transmitted through blood, semen, and vaginal secretions. Situations that can cause hepatitis B transmission include:
- Sexual contact with an infected person (using a condom can help reduce risk)
- Sharing needles and drug injection equipment
- Sharing personal items, (such as toothbrushes, razors, and nail clippers), with an infected person
- Having direct contact with blood of an infected person, through needlestick injury or bytouching open wounds
- During childbirth, an infected mother can transmit the hepatitis B virus to her baby.
The CDC recommends routine testing for chronic hepatitis B virus (HBV) infection for the following high risk groups:
- People born in regions with high rates of hepatitis B infection. Hepatitis B is very common in Asian and Pacific Island countries. In the United States, 1 in 10 Asian Americans are chronically infected with the hepatitis B virus. Other regions with high rates of HBV prevalence include Africa, the Middle East, Eastern Europe, South and Central America, and the Caribbean. US-born people not vaccinated as infants whose parents were born in these regions should also be screened for HBV.
- People who use injected drugs or who share needles
- Men who have sex with men
- People receiving chemotherapy or immunosuppressive therapy for certain medical conditions including cancer, organ transplantation, or rheumatologic or intestinal disorders
- Donors of blood, organs, or semen
- Hemodialysis patients
- All pregnant women and infants born to mothers infected with HBV; pregnant women should be screened for HBV at their first neonatal visit
- People who have sex with an infected person or who live in a household with an infected person
- Health care workers and others at risk of exposure to blood products and needlestick injuries
- People infected with HIV
Other people at high risk for hepatitis B virus infection include:
- People who have multiple sex partners
- International travelers to countries with high rates of hepatitis B
- People who received a blood transfusion or received a blood clotting product prior to 1987, when better procedures were implemented to screen donors and blood products for the hepatitis B virus.
Hepatitis C
The hepatitis C virus is transmitted by contact with infected human blood.
- Most people are infected through sharing needles or other drug injection equipment.
- Less commonly, hepatitis C is spread through sexual contact (only rarely), sharing household items such as razors or toothbrushes, or through birth to a mother infected with hepatitis C.
The CDC recommends hepatitis C virus (HCV) testing for:
- People bornfrom 1945- 1964. The Centers for Disease Control and Prevention (CDC) recommends one-time testing for everyone who was born during these years. "Baby boomers" account for nearly 75% of all HCV infections in the United States. Most people with chronic HCV do not realize they are infected. Middle-aged people are at the greatest risk for developing and dying from liver cancer and other serious HCV-related illnesses. Advances in drug treatments are now helping cure or stop disease progression for many people with HCV. For these reasons, the CDC advocates HCV screening for people of this generation.
- Current and former drug injection users. Even if it has been many years since you injected drugs, you should get tested.
- People who received a blood transfusion, blood product, or organ before 1992 when procedures were implemented to screen blood for hepatitis C
- People who received a blood clotting product prior to 1987, when screening procedures were implemented
- People who have liver disease or who have had abnormal liver test results
- Hemodialysis patients
- Healthcare workers who mayget exposed through aneedlestick injury
- People infected with HIV
Other people at high risk for HCV infection include:
- People who have had tattooing or body piercing performed with non-sterile instruments
- Children born to mothers infected with hepatitis C
Prevention of Hepatitis A
Vaccination. Hepatitis A is preventable by vaccination. Two vaccines (Havrix, Vaqta) are available, both very safe and effective. They are given in 2 shots, 6 months apart. A combination Hep A - Hep B vaccine (Twinrix) that contains both Havrix and Engerix-B (a hepatitis B vaccine) is also available for people age 18 years and older. It is given as 3 shots over a 6-month period.
The CDC recommend hepatitis A vaccination for:
- Children at age 1 year (12 - 23 months)
- Travelers to countries where hepatitis A is prevalent; they should receive the hepatitis A vaccine at least 2 weeks prior to departure.
- Men who have sex with other men
- Users of illegal drugs, especially those who inject drugs
- People with chronic liver diseases, such as hepatitis B or C
Others who may benefit include:
- People who have chronic liver disease
- People who receive clotting factor concentrate to treat hemophilia or other clotting disorders
- Military personnel
- Employees of child day-care centers
- People who care for institutionalized patients
Prevention after Exposure to Hepatitis A. Unvaccinated people who have recently been exposed to hepatitis A may be able to prevent hepatitis A by receiving injection with immune globulin (IG) or the hepatitis A vaccine. These shots must be given within 2 weeks after exposure to be effective. In the past, immune globulin was the standard postexposure prophylaxis (preventive treatment after exposure) for hepatitis A. However, recent studies have indicated that the hepatitis A vaccine provides as good protection as immune globulin. The CDC's Advisory Committee on Immunization Practices now recommends the vaccine for postexposure prophylaxis for healthy individuals between the ages of 1 - 40 years. Others should be given immune globulin if warranted.
Lifestyle Measures for Hepatitis A Prevention. Frequent handwashing after using the bathroom or changing diapers is important for preventing transmission of hepatitis A. International travelers to developing countries should use bottled or boiled water for brushing teeth and drinking, and avoid ice cubes. It is best to eat only well-cooked heated food and to peel raw fruits and vegetables.
Prevention of Hepatitis B
Vaccination. Hepatitis B is preventable by vaccination. There are several inactivated virus vaccines, including Recombivax HB and Engerix-B. A combination vaccine (Twinrix) that contains Engerix-B and Havrix, a hepatitis A vaccine, is also available. The hepatitis B vaccine is usually given as a series of 3 - 4 shots over a 6-month period.
The CDC recommends hepatitis B vaccination for:
- All children should receive their first dose of hepatitis B vaccine at birth and complete their vaccination series by 6 - 18 months. Children younger than age 19 who were not vaccinated should receive "catch-up" doses.
- People who live in a household with or who have sexual relations with a person with chronic hepatitis B
- People with multiple sex partners
- People who have a sexually transmitted disease
- Men who have sex with men
- People who share drug-injection needles and equipment
- Healthcare workers at risk for exposure to blood
- People with diabetes
- People with end-stage renal disease who are on dialysis (hemodialysis or peritoneal dialysis)
- People with chronic liver disease
- People infected with HIV
- Residents and staff of institutions for the developmentally disabled
- Travelers to regions that have moderate-to-high rates of hepatitis B infection
Prevention After Exposure to Hepatitis B. The hepatitis B vaccine or a hepatitis B immune globulin (HBIG) shot may help prevent hepatitis B infection if given within 24 hours of exposure.
Lifestyle Measures for Hepatitis B Prevention. The following are some precautions for preventing the transmission of hepatitis B (and hepatitis C):
- Use a condom and practice safe sex.
- Avoid sharing personal items such as razors or toothbrushes.
- Do not share drug needles or other drug paraphernalia (such as straws for snorting drugs).
- Clean blood spills with a solution containing 1 part household bleach to 10 parts water.
Hepatitis B (and hepatitis C) viruses cannot be spread by casual contact such as holding hands, sharing eating utensils or drinking glasses, breastfeeding, kissing, hugging, coughing or sneezing.
Prevention of Hepatitis C
There is no vaccine for hepatitis C prevention. Lifestyle precautions are similar to those for hepatitis B. People who are infected with the hepatitis C virus should avoid drinking alcohol as this can accelerate the liver damage associated with hepatitis C. People who are infected with hepatitis C should receive vaccinations for hepatitis A and B.
Hepatitis A
Hepatitis A is the least serious of the common hepatitis viruses. It only has an acute (short-term) form that can last from several weeks to up to 6 months. It does not have a chronic form. Most people who have hepatitis A recover completely. Once people recover, they are immune to the hepatitis A virus.
In very rare cases, hepatitis A can cause liver failure (fulminant hepatic failure) but this usually occurs in people who already have other chronic liver diseases, such as hepatitis B or C.
Hepatitis B
Hepatitis B can have an acute (limited) or chronic (long-term) form. Infants and young children are at much higher risk than adults for developing the chronic form. The vast majority (95%) of adults who are infected with hepatitis B have the acute form, recover spontaneously (without drug treatment) within a few months, and develop immunity to the virus. People who develop immunity are not infectious and cannot pass the virus on to others. Still, blood banks will not accept donations from people who test positive for the presence of HBV antibodies.
About 5% ofadults develop a chronic form of hepatitis B. People who have chronic hepatitis B remain infectious and are considered carriers of the disease, even if they do not have any symptoms. Some patients with chronic hepatitis B may need drug treatment. Drug treatment can stop the virus from replicating and reduce the risk for cirrhosis and liver damage.
Liver disease, especially liver cancer, is the main cause of death in people with chronic hepatitis B. In fact, hepatitis B is the leading cause of liver cancer worldwide.
Patients with hepatitis B who are co-infected with hepatitis D may develop a more severe form of acute infection than those who have only hepatitis B. Co-infection with hepatitis B and D increases the risk of developing acute liver failure. Patients with chronic hepatitis B who develop chronic hepatitis D also face high risk for cirrhosis. Hepatitis D occurs only in people who are already infected with hepatitis B.
Hepatitis C
Hepatitis C has an acute and chronic form but most people (75 - 85%) who are infected with the virus develop chronic hepatitis C. Chronic hepatitis C poses a risk for cirrhosis, liver cancer, or both.
The prognosis for hepatitis C depends in part on the genotype. There are six distinct genotypes of hepatitis C. Some (such as genotypes 2 and 3) respond better to drug therapy than others (such as genotype 1). The good news is that researchers are making great progress in developing new treatments for chronic hepatitis C. Over the past several years,many new drugs have been approved and other new therapies are being investigated.
Patients with chronic hepatitis C are considered cured if they have an undetectable amount of virus in their blood 6 months after completing drug treatment. Successful treatment for hepatitis C can help reduce the risk for cirrhosis and liver cancer.
Symptoms of Hepatitis A
Symptoms of hepatitis A are usually mild, especially in children, and generally appear between 2 - 6 weeks after exposure to the virus. Adult patients are more likely to have fever, jaundice, nausea, fatigue, and itching that can last up to several months. Stools may appear chalky grey and urine will appear darkened.
Symptoms of Hepatitis B
Acute Hepatitis B. Many people with acute hepatitis B have few or no symptoms. If symptoms appear, they tend to occur 6 weeks to 6 months (most commonly 3 months) after exposure and be mild and flu-like. Symptoms may include mild fever, nausea, vomiting, loss of appetite, fatigue, or muscle or joint aches. Some patients develop dark urine and jaundice (yellowish tinge to skin).
Symptoms of acute hepatitis B can last from a few weeks to 6 months. Even if people infected with hepatitis B have no symptoms, they can still spread the virus.
Chronic Hepatitis B. While some people with chronic hepatitis B have symptoms similar to those of the acute form, many people can have the chronic form for decades and show no symptoms. Liver damage may eventually be detected when blood tests for liver function are performed (see Diagnosis section).
Symptoms of Hepatitis C
Most patients with hepatitis C do not experience symptoms. Chronic hepatitis C can be present for 10 - 30 years, and cirrhosis or liver failure can sometimes develop before patients experience any clear symptom. Signs of liver damage may first be detected when blood tests for liver function are performed.
If initial symptoms do occur, they tend to be very mild and resemble the flu with fatigue, nausea, loss of appetite, fever, headaches, and abdominal pain. People who have symptoms usually tend to experience them about 6 - 7 weeks after exposure to the virus. Some people may not experience symptoms for up to 6 months after exposure. People who have hepatitis C can still pass the virus on to others even if they do not have symptoms.
Doctors diagnose hepatitis based on a physical examination and the results of blood tests. In addition to specific tests for hepatitis antibodies, doctors will order other types of blood tests to evaluate liver function.
Specific Tests for Hepatitis A
Blood tests are used to identify IgM anti-HAV antibodies, substances that the body produces to fight hepatitis A infection.
Specific Tests for Hepatitis B
There are many different blood tests for detecting the hepatitis B virus. Standard tests include:
- Hepatitis B surface antigen (HBsAg). A positive result indicates active infection, either acute or chronic.
- Hepatitis B surface antibody (HBsAb, also called anti-HBs). A positive result indicates an immune response to hepatitis B, either from previous infection with the virus or from having received the vaccine.
- Antibody to hepatitis B core antigen (HBcAb, also called anti-HBc). A positive result indicates either recent infection or previous infection.
- Hepatitis B envelope antigen (HBeAg) indicates that someone with a chronic infection is actively contagious.
- Antibody to HBeAg (Anti-HBeAg) usually indicates recovery from chronic hepatitis.
- Hepatitis B DNA (HBV DNA) detects hepatitis B viral genetic material. It can detect an active HBV infection. It is primarily used to monitor response to antiviral treatment in patients with chronic hepatitis B.
Specific Tests for Hepatitis C
Tests to Identify the Virus. The standard first test for diagnosing hepatitis C is an enzyme immunoassay (EIA), which is used to test for hepatitis C antibodies. Antibodies can usually be detected by EIA 4 - 10 weeks after infection.
Tests to Identify Genetic Types and Viral Load. Additional tests called hepatitis C virus RNA assays may be used to confirm the diagnosis. They use a polymerase chain reaction (PCR) to detect the RNA (the genetic material) of the virus. Such tests should be used if EIA results show positive HCV antibody and may be performed if there is some doubt about a diagnosis but the doctor still believes the virus is present. HCV RNA can be detected through blood tests as early as 2 - 3 weeks after infection.
Hepatitis C RNA assays also determine virus levels (called viral load). Such levels do not reflect the severity of the condition or speed of progression, as they do for other viruses, such as HIV. However, high viral loads may suggest a poorer response to treatment with interferon drugs.
Tests for Genotype. Patients with detectable viral loads should have HCV genotyping performed. Knowing the specific genotype of the virus is helpful in determining a treatment approach. There are six main genetic types of hepatitis C and more than 50 subtypes. They do not appear to affect the rate of progression of the disease itself, but they can differ significantly in their effects on response to treatment.
Specific genotypes vary in prevalence around the world. Genotype 1 is the most difficult to treat and is the cause of up to 75% of the cases in the U.S and Europe. The other common genetic types in the U.S. are types 2 (15%) and 3 (7%), which are more responsive to treatment than genotype 1. Genotype 4 is more common in the Middle East and Africa. Genotype 5 is limited mainly to South Africa and genotype 6 is prevalent throughout Southeast Asia.
People with hepatitis C need to have their genotype tested so that doctors can make appropriate treatment recommendations. Researchers are working on developing a genetic test to identify which patients with chronic hepatitis C are most at risk of developing cirrhosis.
Liver Biopsy. Liver biopsy may be helpful both for diagnosis and for determining treatment decisions. Only a biopsy can determine the extent of injury in the liver. Some doctors recommend biopsies only for patients who do not have genotypes 2 or 3 (as these genotypes tend to respond well to treatment). A liver biopsy in patients with other genotypes may help clarify risk for disease progression and allow doctors to reserve treatment for patients with moderate-to-severe liver scarring (fibrosis). Even in patients with normal alanine aminotransferase (ALT) liver enzyme levels, a liver biopsy can reveal significant damage.
Tests for Liver Function
In people suspected of having or carrying viral hepatitis, doctors will measure certain substances in the blood.
- Bilirubin. Bilirubin is one of the most important factors indicative of hepatitis. It is a red-yellow pigment that is normally metabolized in the liver and then excreted in the urine. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise. (High levels of bilirubin cause the yellowish skin tone known as jaundice.)
- Liver Enzymes (Aminotransferases). Enzymes known as aminotransferases, including aspartate (AST) and alanine (ALT), are released when the liver is damaged. Measurements of these enzymes, particularly ALT, are the most important tests for detecting hepatitis and monitoring treatment effectiveness. Enzyme levels vary, however, and are not always an accurate indicator of disease activity. (For example, they are not useful in detecting progression to cirrhosis.)
- Alkaline Phosphatase (ALP). High ALP levels can indicate bile duct blockage.
- Serum Albumin Concentration. Serum albumin measures protein in the blood (low levels indicate poor liver function).
- Prothrombin Time (PT). The PT test measures in seconds the time it takes for blood clots to form (the longer it takes the greater the risk for bleeding).
Liver Biopsy
A liver biopsy may be performed for acute viral hepatitis caught in a late stage or for severe cases of chronic hepatitis. A biopsy helps determine treatment possibilities, the extent of damage, and the long-term outlook.
A biopsy involves a doctor inserting a biopsy fine needle, guided by ultrasound, to remove a small sample of liver tissue. Local anesthetic is used to numb the area. Patients may feel pressure and some dull pain. The procedure takes about 20 minutes to perform.
Treatment for Hepatitis A
Hepatitis A usually clears up on its own and does not require treatment. Patients should make sure to get plenty of rest and avoid drinking any alcohol until they are fully recovered.
Treatment for Hepatitis B
Most adult patients with hepatitis B have an acute (self-limiting) form that clears up on its own within 1 - 2 months. There are no medications for treating acute hepatitis B. Doctors usually recommend that patients get plenty of bed rest, drink plenty of fluids, and get adequate nutrition.
A small percentage of adult patients with hepatitis B develop the chronic form of hepatitis B. Infants and young children who have hepatitis B have a higher risk of developing the chronic form. Several types of antiviral drugs are used to treat chronic hepatitis B, although not all patients need medication.
It is not always clear which patients with chronic hepatitis B should receive drug therapy and when drug therapy should be started. Therapy is generally indicated for patients who have experienced a rapid deterioration in liver function or who have signs of long-term liver damage. Patients should seek the advice of an internal medicine doctor (internist) or another specialist (a gastroenterologist, hepatologist, or infectious disease doctor) who has experience treating hepatitis B.
Patients with chronic hepatitis B should receive regular monitoring to evaluate any signs of disease progression, liver damage, or liver cancer. It is also important that patients with chronic hepatitis B abstain from alcohol as it may accelerate liver damage. Patients should check with their doctors before taking any over-the-counter or prescription medications or herbal supplements. Some medications (such as high doses of acetaminophen) and herbal products (kava) can increase the risk of liver damage.
If the disease progresses to liver failure, liver transplantation may be an option. It is not foolproof, however. In patients with hepatitis B, the virus often recurs in the new liver after transplantation. However, regular, lifelong injections of hepatitis B immune globulin (HepaGam B) can reduce the risk for re-infection following liver transplantation.
Treatment for Hepatitis C
Antiviral drug therapy is used to treat both acute and chronic forms of hepatitis C. Most people infected with hepatitis C virus develop the chronic form of the disease.
While all patients with chronic hepatitis C are potential candidates for treatment, doctors usually decide whether treatment is appropriate based on many different factors including:
- Active virus. Detectable virus levels as measured by an HCV RNA test usually indicate the patient requires treatment, but other factors are also considered.
- Age. Treatment is generally recommended for those over age 18. Elderly patients may not be good candidates.
- Disease progression. Hepatitis C usually progresses slowly. Patients who have had the disease for many years and who show minimal signs of liver damage may not need treatment. Patients who have very advanced cirrhosis or liver cancer are unlikely to benefit from treatment.
- Liver damage or scarring. Patients who show signs of active liver damage or scarring should be considered for treatment. They have increased risk for developing cirrhosis.
- Alcohol and drug use. Patients who actively abuse drugs or alcohol may not be appropriate candidates.
- Other disease conditions. Patients who have other serious disease conditions may not be appropriate candidates.
Until recently, the standard treatment for chronic hepatitis C was dual combination therapy with the antiviral drugs pegylated interferon and ribavirin. In 2011, two new protease inhibitor drugs (telaprevir and boceprevir) were approved for treatment of patients with genotype 1 HCV. These new drugs significantly improved cure rates. Since then, triple combination therapy with a protease inhibitor, plus pegylated interferon and ribavirin has become the new standard of care for patients with genotype 1. In 2013, other new oral antiviral drugs were approved that may offer even more effective treatments for genotype 1 HCV as well as interferon-free regimens for other genotypes.
Patients with chronic hepatitis C should receive genotype testing to determine the treatment approach. There are six types of hepatitis C genotypes and patients have different responses to drugs depending on their genotype. For example, patients with genotypes 2 or 3 are three times more likely to respond to treatment than patients with genotype 1. The recommended length of drug treatment also depends on genotype. Patients with genotype 2 or 3 usually have a 24-week course of treatment with pegylated interferon plus ribavirin, whereas a 48-week course is recommended for patients with genotype 1. Patients who take triple combination therapy that includes a protease inhibitor undergo 24 weeks of treatment.
Patients are considered cured when they have had a "sustained virologic response" and there is no evidence of hepatitis C on lab testing. A sustained virologic response (SVR) means that the hepatitis C virus becomes undetectable during treatment and remains undetectable for at least6 months after treatment has been completed. A SVR indicates that the treatment was successful and that the patient has been cured of hepatitis C. For most patients who have a response, viral loads remain undetectable indefinitely. However, some patients can become re-infected or infected with a different genotype strain.
Patients who develop cirrhosis or liver cancer from chronic hepatitis C may be candidates for liver transplantation. Unfortunately, hepatitis C usually recurs after transplantation, which can lead to cirrhosis of the new liver in at least 25% of patients 5 years after transplantation. The issue of retransplantation for patients with recurrent hepatitis C is a matter of debate.
Patients with chronic hepatitis C should abstain from alcoholbecause it can speed cirrhosis and end-stage liver disease. Patients should also check with their doctors before taking any non-prescription or prescription medications, or herbal supplements. It is also important that patients who are infected with HCV be tested for HIV, as patients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone.
Herbal Remedies and Liver Disease
Popular herbal remedies for hepatitis include ginseng, glycyrrhizin (a compound in licorice), catechin (found in green tea), and silymarin (found in milk thistle). However, there is no evidence that these herbs are helpful for hepatitis or other liver diseases.
Milk thistle is the most studied of these herbs and evidence of its benefit has been mixed. Some small older studies indicated that milk thistle may help improve liver enzyme levels. However, recent rigorous reviews and better designed studies have found that the herb is ineffective for treating liver disease caused by hepatitis B or C.
Patients with hepatitis should be aware that some herbal remediesand dietary supplements can cause liver damage. In particular, kava (an herb promoted to relieve anxiety and tension) is dangerous for people with chronic liver disease. Other herbs associated with liver damage include chaparral, kombucha mushroom, mistletoe, pennyroyal, and some traditional Chinese herbs.
Liver Transplantation
Liver transplantation may bean optionfor patients with severe cirrhosis or for patients with liver cancer that has not spread beyond the liver.
Current 5-year survival rates after liver transplantation are 55 - 80%, depending on different factors. Patients report improved quality of life and mental functioning after liver transplantation.
Patients should consider medical centers that have performed more than 50 transplants per year and produced better-than-average results. Unfortunately, there are far more people waiting for liver transplants than there are available organs.
Medications for Chronic Hepatitis B
Seven drugs are currently approved in the United States for treatment of chronic hepatitis B:
- Peginterferon alfa-2a (Pegasys)
- Interferon-alfa-2b (Intron A)
- Entecavir (Baraclude)
- Lamivudine (Epivir-HBV)
- Telbivudine (Tyzeka)
- Tenofovir (Viread)
- Adefovir (Hepsera)
These drugs do not cure hepatitis B but they can block the replication of hepatitis B virus (HBV) and lower the amount of HBV in the body. They may also help prevent the development of progressive liver disease (cirrhosis and liver failure) and the development of liver cancer.
Peginterferon alfa-2a, entecavir, and tenofovir are currently the preferred drugs for first-line, long-term treatment. They have shown better results and less likelihood for drug resistance than the other approved medications.
Peginterferon alfa-2a. Peginterferon alfa-2a (Pegasys) is also called pegylated interferon. It is given as a weekly injection. Interferon alfa-2b is an older injectable interferon drug that used to be the standard treatment for hepatitis B but is no longer commonly used.
Common side effects include flu-like symptoms, such as fever, chills, muscle aches, joint pains, and headaches. The drug can also cause depression, anxiety, irritability, and insomnia and should be used with caution in patients with a history of mental illness. Peginterferon alfa-2a can also increase the risk for infections, heart problems, stroke, and autoimmune disorders, as well as other serious conditions.
Entecavir. Entecavir (Baraclude) is an oral drug that is taken once daily. Entecavir is a nucleoside analog drug. Lamivudine (Epivir-HBV) and telvibudine (Tyzeka) are also nucleoside analogs, but they tend to have higher rates of drug resistance than entecavir. For this reason, entecavir is the preferred nucleoside analog drug for treatment of chronic hepatitis B. Common side effects of entecavir and other nucleoside analogs include headache, fatigue, dizziness, and nausea.
Tenofovir. Tenofovir (Viread) is an oral drug that is taken once daily. It belongs to a class of antiviral drugs called nucleotide analogs. Adefovir (Hepsera) is an older drug of this class but it is not used as commonly as tenofovir. Common side effects of these drugs include weakness, headache, stomach pain, and itching.
Serious Side Effects of Entecavir and Tenofovir. Patients who take entecavir or tenofovir (or a similar antiviral drug) should be aware that:
- Stopping the drug can increase the risk for severe and sudden worsening of hepatitis B. Patients who discontinue drug therapy should be closely monitored for several months after stopping treatment. In some cases, drug treatment may need to be reinstated.
- Lactic acidosis (buildup of acid in the blood) is a serious complication of these drugs. Signs and symptoms of lactic acidosis include feeling extremely tired, unusual muscle pain, difficulty breathing, stomach pain with nausea and vomiting, feeling cold (especially in the arms and legs), feeling dizzy or light-headed, or a fast or irregular heartbeat. Immediately contact your doctor if you experience these symptoms.
- Liver hepatotoxicity (liver damage) is another serious complication. Signs and symptoms include yellowing of skin or white part of eyes (jaundice), dark urine, light-colored stool, or lower stomach pain. Immediately contact your doctor if you experience these symptoms.
- Kidney damage (nephrotoxicity) may occur, particularly in people who already have kidneyproblems.
Medications for Chronic Hepatitis C
Pegylated interferon (Pegasys or Peg-Intron) combined with the nucleoside analog drug ribavirin (Copegus) used to be the gold standard treatment for chronic hepatitis C.In recent years, new drugs have dramatically changed hepatitis C treatment regimens and improved outcomes:
- In 2011, the FDA telaprevir (Incivek) and boceprevir (Victrelis). In 2013, the FDA approved simeprevir (Olysio), and sofosbuvir (Sovaldi). All four of these medications are oral drugs. Telaprevir, boceprevir, and simeprevir are protease inhibitors. Sofosbuvir is a nucoleotide analog inhibitor.
- Most patients with genotype 1 now receive triple combination therapy with pegylated interferon, ribavirin, and a protease inhibitor drug. Sofosbuvir is also used in combination with pegylated interferon and ribavirin to treat genotype 1.
- Some patients with genotype 1 do not take a protease inhibitor. Instead, they receive dual combination therapy with pegylated interferon and ribavirin.
- Patients with hepatitis C genotypes 2 or 3 generally receive dual pegaylated interferon-ribavirin. Sofosbuvir plus ribavirin is the first interferon-free drug regimen approved for genotype 2.
Genotype 1 is the most common type of hepatitis C and is more difficult to treat than genotypes 2 and 3. The introduction of new oral drugs has represented a significant breakthrough for hepatitis C treatment.
Pegylated Interferon and Ribavirin. Pegylated interferon [Pegasys (Peginteferon alfa-2a) or Peg-Intron (Peginterferon alfa-2b)] is given as an injection once a week. Ribavirin (Copegus) is taken as a pill twice a day. Treatment generally lasts 24 - 48 weeks.
Common side effects of peginterferon-ribavirin treatment include fatigue, stomach upset, and flu-like symptoms. More serious side effects may include:
- Depression, anxiety, insomnia, and other mental health problems (caused by peginterferon)
- Decrease in white blood cell count (caused by peginterferon) and decrease in red blood cell count (caused by ribavirin)
- Skin rash, cough, shortness of breath (caused by ribavirin)
- Risk for birth defects (associated with ribavirin)
Telaprevir and Boceprevir. Telaprevir (Incivek) and boceprevir (Victrelis) belong to a class of drugs called protease inhibitors, which work by preventing the virus from multiplying. Neither telaprevir nor boceprevir can be used alone. Either one must be used in combination with both peginterferon alfa and ribavirin.
In clinical trials, the three-drug combination cured hepatitis C in about 75% of patients who took telaprevir and about 67% of patients who took boceprevir. In contrast, only 45% of patients with genotype 1 are successfully treated by peginterferon alfa and ribavirin combination therapy.
Telaprevir is taken as 2 pills three times a day in combination with ribavirin and pegylated interferon, for 12 weeks. After the triple therapy is completed, the patient has another 12 weeks of dual therapy with ribavirin and pegylated interferon. Boceprevir is taken as 4 pills three times a day, in combination with ribavirin and pegylated interferon, with treatment lasting 24- 48 weeks.
In addition to the side effects caused by combination peginterferon-ribavirin therapy, telaprevir and boceprevir may:
- Increase the risks of birth defects or death of unborn baby. These drugs can prevent hormonal contraceptives (birth control pills, vaginal rings, implants, injections) from working well. Patients (both men and women) who take telaprevir or boceprevir should use two non-hormonal forms of contraception during treatment and for6 months after treatment.
- Interact with many types of medications including statin drugs, anti-seizure drugs, and drugs used to treat HIV. Make sure your doctor knows all medications or herbal supplements you are taking. Herbs such as St. John's wort should not be taken with these drugs.
- Telaprevir may cause a severe and life-threatening skin rash. Patients must immediately stop telaprevir treatment if they experience this type of rash.
Sofosbuvir and Simeprevir. In late 2013, the FDA approved two new once-daily oral medications for hepatitis C, which promise even better cure rates and shorter treatment times than telaprevir and boceprevir.
Sofosbuvir (Sovaldi) is a nucleotide analog inhibitor that has shown cures rates of 90% for treating genotype 1 hepatitis C when combined with ribavirin and pegylated interferon. It is also used in combination with ribavirin –without pegylated interferon -- for treating genotypes 2 and 3. Sofosbuvir offers the first all-oral drug treatment for genotypes 2 and 3, as well as a considerably shorter treatment time for genotype 1. However at $1000/pill, it is extremely expensive. A 12- 24 week treatment course could cost about $80,000- 170,000. Common side effects include fatigue, headache, nausea, insomnia, and anemia.
Simeprevir (Olysio) is another protease inhibitor drug. In clinical trials, it showed cure rates of 80% in treating patients with hepatitis C genotype 1 who had not previously been treated with interferon. Simeprevir is taken as a single pill once a day for 24 weeks, along with ribavirin and pegylated interferon, instead of the 6- 12 pills per day required for telaprevir and boceprevir. Rash, including serious sensitivity to light (photosensitivity), is a common side effect as are itching and nausea. Patients should limit sun exposure and be sure to use sun protection measures while taking this drug.
- www.cdc.gov/hepatitis -- U.S. Centers for Disease Control and Prevention
- www.aasld.org -- American Association for the Study of Liver Diseases
- www.hepfi.org -- Hepatitis Foundation International
- www.hepb.org -- Hepatitis B Foundation
- www.liverfoundation.org -- American Liver Foundation
- www2.niddk.nih.gov -- National Institute of Diabetes and Digestive and Kidney Diseases
- www.unos.org -- United Network for Organ Sharing
Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2007 Oct 19;56(41):1080-4.
American Academy of Pediatrics Committee on Infectious Diseases. Hepatitis A vaccine recommendations. Pediatrics. 2007 Jul;120(1):189-99.
Bacon BR, Gordon SC, Lawitz E, Marcellin P, Vierling JM, Zeuzem S, et al. Boceprevir for previously treated chronic HCV genotype 1 infection. N Engl J Med. 2011 Mar 31;364(13):1207-17.
Centers for Disease Control and Prevention (CDC). Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011 Dec 23;60(50):1709-11.
Chou R, Hartung D, Rahman B, Wasson N, Cottrell EB, Fu R. Comparative effectiveness of antiviral treatment for hepatitis C virus infection in adults: a systematic review. Ann Intern Med. 2013 Jan 15;158(2):114-23.
Cooke GS, Main J, Thursz MR. Treatment for hepatitis B. BMJ. 2010 Jan 5;340:b5429.
Dienstag JL. Hepatitis B virus infection. N Engl J Med. 2008 Oct 2;359(14):1486-500.
Fried MW, Navarro VJ, Afdhal N, Belle SH, Wahed AS, Hawke RL, et al. Effect of silymarin (milk thistle) on liver disease in patients with chronic hepatitis C unsuccessfully treated with interferon therapy: a randomized controlled trial. JAMA. 2012 Jul 18;308(3):274-82.
Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009 Apr;49(4):1335-74.
Jacobson IM, Gordon SC, Kowdley KV, Yoshida EM, Rodriguez-Torres M, Sulkowski MS, et al.
Sofosbuvir for hepatitis C genotype 2 or 3 in patients without treatment options. N Engl J Med. 2013 May 16;368(20):1867-77
Jensen DM. A new era of hepatitis C therapy begins. N Engl J Med. 2011 Mar 31;364(13):1272-4.
Jacobson IM, McHutchison JG, Dusheiko G, Di Bisceglie AM, Reddy KR, Bzowej NH, et al. Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med. 2011 Jun 23;364(25):2405-16.
Lawitz E, Mangia A, Wyles D, Rodriguez-Torres M, Hassanein T, Gordon SC, et al. Sofosbuvir for previously untreated chronic hepatitis C infection. N Engl J Med. 2013 May 16;368(20):1878-87. Epub 2013 Apr 23.
Ly KN, Xing J, Klevens RM, Jiles RB, Ward JW, Holmberg SD. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med. 2012 Feb 21;156(4):271-8.
Morgan RL, Baack B, Smith BD, Yartel A, Pitasi M, Falck-Ytter Y. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma: a meta-analysis of observational studies. Ann Intern Med. 2013 Mar 5;158(5 Pt 1):329-37.
Moyer VA; U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive services task force recommendation statement. Ann Intern Med. 2013 Sep 3;159(5):349-57.
Poordad F, McCone J Jr, Bacon BR, Bruno S, Manns MP, Sulkowski MS, et al. Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med. 2011 Mar 31;364(13):1195-206.
Rosen HR. Clinical practice. Chronic hepatitis C infection. N Engl J Med. 2011 Jun 23;364(25):2429-38.
Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo CG, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012 Aug 17;61(RR-4):1-32.
Sorrell MF, Belongia EA, Costa J, Gareen IF, Grem JL, Inadomi JM, et al. National Institutes of Health Consensus Development Conference Statement: management of hepatitis B. Ann Intern Med. 2009 Jan 20;150(2):104-10. Epub 2009 Jan 5.
U.S. Preventive Services Task Force. Screening for hepatitis B virus infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009 Jun 16;150(12):869-73, W154.
Victor JC, Monto AS, Surdina TY, Suleimenova SZ, Vaughan G, Nainan OV, et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med. 2007 Oct 25;357(17):1685-94. Epub 2007 Oct 18.
Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008 Sep 19;57(RR-8):1-20.
Woo G, Tomlinson G, Nishikawa Y, Kowgier M, Sherman M, Wong DK, et al. Tenofovir and entecavir are the most effective antiviral agents for chronic hepatitis B: a systematic review and Bayesian meta-analyses. Gastroenterology. 2010 Oct;139(4):1218-29. Epub 2010 Jun 20.
Zeuzem S, Andreone P, Pol S, Lawitz E, Diago M, Roberts S, et al. Telaprevir for retreatment of HCV infection. N Engl J Med. 2011 Jun 23;364(25):2417-28.
Review Date: 12/23/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, In-Depth Reports; Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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All signs continue to point toward the eventual divorce between Carmelo Anthony and the Denver Nuggets.
League sources say it is now a matter of when, not if, Anthony and the Nuggets will go their separate ways.
Sources: Split between Carmelo Anthony and Denver Nuggets likely - ESPN
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Since 1980, we've collaborated with governments to responsibly grow lottery businesses.
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For most of the day it was a two-man race at the FedEx 400 in Dover. Carl Edwards and Jimmie Johnson combined to lead 324 of the 400 laps. But, in the end, another Roush driver, Matt Kenseth, crossed the finish line first for the victory.
Matt Kenseth wins FedEx 400 At Dover
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Enrollment 1-2-3
Three resolutions for enrollment marketing professionals in the New Year. GUEST COLUMN | by Gil Rogers Every year in January, it's the same story: resolving to get in shape, give up sweets, be better about our work life balance — … Continue reading
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Efficient use of online outreach at UWG. GUEST COLUMN | by Justin Barlow The University of West Georgia is a public institution with an undergraduate student population of approximately 9,000 students. Located in Carrollton, Georgia, UWG offers endless opportunities for … Continue reading
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Arts groups prepare to fight for funds
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The revolt against the Australia Council's planned restructure is gaining momentum, as arts alliances form to stop the council dissolving its community cultural development and new-media arts boards.
Artspeak, a body bringing together major performing arts groups, writers, musicians and artists, is preparing a detailed criticism of the plans.
State-based groups are protesting against what they fear is a reduction in peer assessment and a move to judge arts bodies on their business plans rather than their artistic expertise.
The reorganisation, announced in December, aims to make the federal funding and advocacy body into an "arts catalyst" that sets directions for the arts. The two boards would be abolished and a new Key Organisations department would handle the council's relationships with the 120 small-to-medium organisations that receive triennial grants.
The council itself would decide on funding for strategic projects, rather than leaving it to the boards of individual art forms.
The council has faced outrage from staff and arts organisations about the lack of consultation on the changes.
The manager of the council's Community Cultural Development Board, Bernice Gerrand, has resigned, and the board's chairman, museum director Chris Tassell, said in an open letter that the plan was "unexpected".
In a closed workshop with the five-member taskforce that devised the plan, 30 community cultural development groups were asked on Monday if they supported the changes. Not a hand was raised.
The taskforce - including management consultants Terrey Arcus and Adam Lewis, arts administrators Michael Snelling and Ian McRae, and the council's general manager, Jennifer Bott - will meet next week to consider its next move.
Today the council will post models on the internet of how the scheme might work. But community groups were unwilling to debate those details until the taskforce produced the research behind the proposals.
Victoria Keighery, from Regional Arts NSW, said the new, unnamed alliance of community cultural development groups wanted a "proper review", on par with the Nugent review into performing arts or the Myer review into visual arts and crafts. Otherwise, she said, the council appeared to be cutting costs by targetting groups with the least tangible infrastructure.
The community alliance is convened by the chief executive of Community Cultural Development NSW, Frank Panucci. He said the council had to provide data that could be used to measure the effects of the restructure.
The new-media sector is also marshalling forces. Last week, seven of Australia's largest new-media groups created a lobby group called New Media Arts Australia.
The director of dLux media arts, David Cranswick, was among about 30 people at the council's workshop with new-media groups on Monday. He warned that without more meaningful consultation, "there's a train wreck coming".
The sector is particularly concerned about funding for new-media projects being quarantined. New-media funding will now be assigned to the Visual Arts and Crafts board (85 per cent), and the Music board (15 per cent), who will farm out the money to projects.
The editor of RealTime magazine, Keith Gallasch, was also concerned about lack of new-media expertise in the reorganisation, where the plan is for one new-media representative to sit on each board. "We fear a loss of identity, that new media will be devalued and erased," he said.
Last night, Bott said the taskforce "to date has decided not to have a moratorium" and planned to introduce the changes by mid-year. The taskforce was taking the feedback from the workshops seriously, she said, and the models had been tweaked accordingly. "Our plan is to do more and do it better" in community and new media arts, "because they are such important areas".
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Commercial Leasing in Residential Real Estate
Better Homes and Gardens Real Estate Metro Brokers
Monday, March 11, 2013 from 10:00 AM to 1:15 PM (EDT)
Event Details
Gain a basic understanding of commercial leasing and increase your ability to have a knowledgeable discussion of commercial leasing with clients and colleagues.
Course Topics will Include:
- What is a Commercial Lease?
- Areas of Leasing
- Leasing Economics
- Leasing Terminology
- Lease Rates
- Commission
- Sources of Information
- Getting Business
- Expand Your Knowledge
- Case Studies
For any questions, contact the Metro Brokers Academy at 404.836.4040.
View all Atlanta Real Estate Events and Classes
Continuing Education Provided By:
Metro Brokers Academy of Real Estate
School Code: 1018
School Approval Expires: 12/31/2015
Recruiting is prohibited on the school premises. Report any recruiting efforts to the school director at 404.836.4040
When & Where
5775-D Glenridge Drive
Second Floor
Monday, March 11, 2013 from 10:00 AM to 1:15 PM (EDT)
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Better Homes and Gardens Real Estate Metro Brokers
Better Homes and Gardens Real Estate Metro Brokers is a full-service real estate brokerage with more than 1700 sales associates, each with access to 25 offices throughout metro Atlanta and North Georgia. The company commits its resources to providing the finest environment for its real estate agents including technology, training and marketing.


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The following page is a two column layout with a global navigation. Page sections are identified with headers. The footer contains update information.
Professor William Whiting, PhD (Kinesiology) has been named the 2010-11 CSUN Research Fellow from the College of Health and Human Development. Nine research fellowships are awarded to faculty across campus each academic year to support research and academic development.
Throughout his career, Whiting has consistently focused on the well being of people of all ages and abilities. In his fellowship year he will perform research to better understand the relationship between fatigue and injury. The resulting information can benefit a range of people from young athletes to the elderly.
We all know that when we're tired or fatigued, concentration and dexterity are compromised and that the more complex the movement, the more likely we are to make a mistake. "But," says Whiting, "the fact that has eluded us is exactly how fatigue affects the reliability of multi-joint movements, especially in the lower extremities."
Whiting's research project: "Limiting factors in human performance: Biomechanical assessment of joint-specific fatigue characteristics," will measure kinetic force and torque at the hip, knee and ankle joints to identify the point of fatigue where risk of injury may become a concern. "We want to understand the neuromuscular relationship," Whiting says. "Understanding how fatigue builds and functions will lead us to ways to increase strength and stamina to help maintain well being."
The risk of falling is greater in older adults because of the compromised balance, sensory perception, muscle strength, coordination and reflexes that can accompany aging. Hip fractures are a high risk among the elderly – and they are all too often the result of a simple fall. Because healing calls for immobility and can take months, a fracture can lead to fatality. The study will provide valuable information for falls prevention. "What we want to find out," Whiting says, "is where is the discernible point of fatigue that makes the difference between continuing an activity safely or where changes in behavior can keep a person safer."
The study will also look at fatigue characteristics in healthy athletes. "I'm very interested in solving problems associated with a common knee injury – damage to the ACL [anterior cruciate ligament]. ACL injury is becoming increasingly common," Whiting says. "There are several hundred thousand ACL injuries in the US every year. And it's worse in females than males. So far, we don't know exactly why a female college soccer player is about three times more likely to get an ACL tear than a male of the same age in the same sport." Recent evidence suggests that neuromuscular recruitment and joint movement patterns play a primary role, and fatigue affects these patterns.
"For the study, we're going to recruit healthy adults who meet specific criteria, including no recent injury that would affect participation," Whiting says. The Biomechanics Laboratory in the Department of Kinesiology is well equipped to help the scholars collect the research data. "Basically we're going to work the subjects to fatigue through jumping and walking exercises, and then measure the effect of fatigue on an array of biomechanical variables." Proper training for athletes can definitely build strength and stamina. "But," says Whiting, "we need to understand how fatigue negatively alters the way people move – and generally, where their coordination is compromised. There are joint-specific fatigue patterns we'll be examining."
Conclusions of the study may influence the design of training programs to decrease injury risk and enhance performance." Whiting's research will also involve graduate students as researchers for credit toward their degrees. Traditionally the fellowship involves a mentorship component that teaches graduate students the protocols of research while strengthening the university as a center for research and new scholarly information.
Over the past thirty years, Dr. Whiting has authored several textbooks and presented numerous articles and papers exploring the biomechanics of performance enhancement and musculoskeletal injury.
The fellowship was created in 2007 and is funded collaboratively by the Office of the Provost, the Colleges and the Library.
-Jean O'Sullivan


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Average grade: 9.2 %
Length: 4.96 km
Altitude start: 1172 m
Altitude top: 1633 m
Ascent: 461 m
Maximum: 14 %
Cote de Serre-Eyraud rankings
Difficulty ranking world: 3125 (all)
Ranking France: 721 (all)
Difficulty score: 72.72 what?
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The Cote de Serre-Eyraud is situated in Provence-Alpes-Cote d'Azur.
Starting from Les Ricoux,
the Cote de Serre-Eyraud ascent is 4.96 km long. Over this distance, you climb 461 heightmeters.
The average percentage thus is 9.2 %.
The maximum slope is 14 %.
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Good day!
Breezy Friday with rain and a thunderstorm possible. Highs near 70. Details on page A-8.
Safety tip
In observance of April being National Sexual Assault Awareness Month, the Haven of Hope offers the following tip: If you are being followed drive to the nearest police department or crowded place for help. Do not stop your car. For information contact the Haven of Hope, 439-SAFE.
Road closing
The Guernsey County Highway Department will be closing Reservoir Road (Center TR 452) between Leatherwood Road (SR 265) and Byesville Road (CR 35). This section of Reservoir Road will close at 8 a.m. on Monday, April 7 and remain closed for an indefinite length of time for bridge repair.
Square dance
A square dance hosted by the Red Barn, 18362 Easton Road, and featuring the band "Deep Down Country" will begin at 7 p.m. Saturday. Free admission and food with a 50/50 drawing and cake walk fund-raiser. Call 489-5799 for additional information.
Antrim Mennonite Church will host a spaghetti supper from 5 to 7:30 p.m. Friday. Proceeds will benefit the Antrim Mennonite Christian Church.
Cyril Burkhart, Lewisville
Leonard Carpenter, Marietta
David Wehr, Beallsville
I will praise Thee; for I am fearfully and wonderfully made. Psalm 139:14


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I have a "go get it" type of personality and love to sometimes do things on a moment's notice.
I love my family and making sure that the people around me know that I care for them. I try to always be upbeat and am always trying to make people around me laugh.
I am looking for a person that enjoys going out for dinner, movies, coffee, and whatever strikes us as fun for that moment, but that would also love to curl up on the couch and watch a movie and relax.
I love being outdoors and taking the top off my jeep and letting the wind blow through my hair. I love white water rafting and camping. I love sports, especially college football (War Eagle!). I have traveled a lot and would love someone who loves to see this great country of ours, not just from a plane, but from road trips. I love all kinds of music. I love everything from country, rock, and metal, to classical and jazz.
I workout 5 to 6 days a week and love staying in shape. I would love to find some that is interested in that part of my life and have us be in shape together.
I also have a belief in God and am a saved Christian. Noticed I didn't say that I was a perfect Christian because I've never personal met one of those myself. I don't judge people, I leave that to the big guy upstairs, he's much better at it than I can ever be.
I also do have a want to have kids in my future. It will give me a chance to be the kind of father that I learned from. My parents have been married for almost 45 years and I want someone that is willing to fight for a relationship to work and not jump ship when things go a little astray!
If you've read this far, don't just go away....say hi, worst case, we might end up friends!!
It was almost 14 years ago when I put on my Superman suit and blue spandex to try to save the world, I'm ready to try to do that again.
2. movies
3. friends and family
4. Laughter
5. Guns
6. my Jeep


text: Posted March 26, 2014 http://billvoth.com/5-takeaways-dave-gettlemans-nfl-meetings-media-briefing/ Voth seems to know his stuff this offseason, so there's no reason to doubt him at this point, for me. Nothing groundbreaking here, but he interprets what he believes is the heart of the "issues."Panthers general manager Dave Gettleman, in Orlando at the NFL owners meetings, made his first extended public comments since last month's Combine on Tuesday. While he didn't accidentally drop hints about upcoming bombshells like he did in Indy, he did share a handful of useful nuggets. As always, there's more to be gleaned from much of what he said, so here are five take-aways: 7 people like this Share this post Link to post Share on other sites


text: HondaPower - Unregistered October 16, 2012 2:14 PM Sorry, but Lorenzo will have to ride to his max, and Dani needs some problems with the bike, the Honda is just too strong at this stage. Cornering the same, straights too fast ... Don't see Lorenzo winning soon. 10 agree 2 disagree


text: I was wondering what peoples view is on wearing shoes without socks. Obviously it depends on the entire outfit too but say for example a Navy sportcoat/casual blazer with sand chinos and Navy or dark brown suede casual shoes?? The Chinos are tapered and slim fit and don't end like regular trousers/jeans, instead they are like elasticated type cuff around the ankles. What do you think?


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For your convenience, we have provided every piece of line art from Biochemistry, Third Edition, Volume I and II for use in PowerPoint ®, Web Site pages, or importing into course management systems such as WebCT or Blackboard.
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Note About ImagesThese images are intended only for use in lectures and presentations. For other purposes, please contact the publisher about obtaining permission to use the images.
Chapter MenuChapter 1: Life
Chapter 2: Aqueous Solutions
Chapter 3: Thermodynamic Principles: A Review
Chapter 4: Amino Acids
Chapter 5: Nucleic Acids, Gene Expression, and Recombinant DNA Technology
Chapter 6: Techniques of Proteins and Nucleic Acids
Chapter 7: Covalent Structures of Proteins and Nucleic Acids
Chapter 8: Three-Dimensional Structures of Proteins
Chapter 9: Protein Folding, Dynamics, and Structural Evolution
Chapter 10: Hemoglobin: Protein Function in Microcosm
Chapter 11: Sugars and Polysaccharides
Chapter 12: Lipids and Membranes
Chapter 13: Introduction to Enzymes
Chapter 14: Rates of Enzymatic Reactions
Chapter 15: Enzymatic Catalysis
Chapter 16: Introduction to Metabolism
Chapter 17: Glycolysis
Chapter 18: Glycogen Metabolism
Chapter 19: Signal Transduction
Chapter 20: Transport through Membranes
Chapter 21: Citric Acid Cycle
Chapter 22: Electron Transport and Oxidative Phosphorylation
Chapter 23: Other Pathways of Carbohydrate Metabolism
Chapter 24: Photosynthesis
Chapter 25: Lipid Metabolism
Chapter 26: Amino Acid Metabolism
Chapter 27: Energy Metabolism: Integration and Organ Specialization
Chapter 28: Nucleotide Metabolism
Chapter 29: Nucleic Acid Structures
Chapter 30: DNA Replication, Repair, and Recombination
Chapter 31: Transcription
Chapter 32: Translation
Chapter 33: Viruses: Paradigms for Cellular Function
Chapter 34: Eukaryotic Gene Expression
Copyright © 2004 John Wiley and Sons


text: [Federal Register: October 26, 2005 (Volume 70, Number 206)] [Notices] [Page 61828-61829] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr26oc05-106] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration Vaccines and Related Biological Products Advisory Committee; Notice of Meeting AGENCY: Food and Drug Administration, HHS. ACTION: Notice. ----------------------------------------------------------------------- This notice announces a forthcoming meeting of a public advisory committee of the Food and Drug Administration (FDA). At least one portion of the meeting will be closed to the public. Name of Committee: Vaccines and Related Biological Products Advisory Committee. General Function of the Committee: To provide advice and recommendations to the agency on FDA's regulatory issues. Date and Time: The meeting will be held on November 16, 2005, from 8:30 a.m. to 5:15 p.m. and on November 17, 2005, from 8:30 a.m. to 5:30 p.m. Location: Holiday Inn Select, 8120 Wisconsin Ave., Bethesda, MD. Contact Person: Christine Walsh or Denise Royster, Center for Biologics Evaluation and Research (HFM-71), Food and Drug Administration, 1401 Rockville Pike, Rockville, MD 20852, 301-827-0314, or FDA Advisory Committee Information Line, 1-800-741-8138 (301-443- 0572 in the Washington, DC area), code 3014512391. Please call the Information Line for up-to-date information on this meeting. Agenda: On November 16, 2005, the committee will hear presentations and discuss the use of Madin-Darby Canine Kidney Cells for manufacture of Inactivated Influenza Vaccines. On November 17, 2005, the committee will discuss developing new Pneumococcal Vaccines for U.S. licensure for adults. Procedure: On November 16, 2005, from 8:30 a.m. to 5:15 p.m. and on November 17, 2005, from 10 a.m. to 5:30 p.m., the meeting is open to the public. Interested persons may present data, information, or views, orally or in writing, on issues pending before the committee. Written submissions may be made to the contact person by November 9, 2005. Oral presentations from the public will be scheduled on November 16, 2005, between approximately 1:45 p.m. and 2:15 p.m. and on November 17, 2005, between approximately 1 p.m. and 1:30 p.m. Time allotted for each presentation may be limited. Those desiring to make formal oral presentations should notify the contact person before November 9, 2005, and submit a brief statement of the general nature of the evidence or arguments they wish to present, the names and addresses of proposed participants, and an indication of the approximate time requested to make their presentation. Closed Committee Deliberations: On November 17, 2005, from 8:30 a.m. to 9:55 a.m., the meeting will be closed to permit discussion and review of trade secret and/or confidential information (5 U.S.C. 552b(c)(4)). Persons attending FDA's advisory committee meetings are advised that the [[Page 61829]] agency is not responsible for providing access to electrical outlets. FDA welcomes the attendance of the public at its advisory committee meetings and will make every effort to accommodate persons with physical disabilities or special needs. If you require special accommodations due to a disability, please contact Christine Walsh or Denise Royster at least 7 days in advance of the meeting. Notice of this meeting is given under the Federal Advisory Committee Act (5 U.S.C. app. 2). Dated: October 18, 2005. Jason Brodsky, Acting Associate Commissioner for External Relations. [FR Doc. 05-21350 Filed 10-25-05; 8:45 am] BILLING CODE 4160-01-S


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MANAGER Tom Killick welcomed the opportunity for promotion-chasing Poole to turn on the style on one of the division's slickest surfaces at St Neots.
Having had four of their past five league matches washed out, Killick was confident Dolphins would finally have a taste of the action tomorrow (3pm) after the Cambridgeshire club's facilities received a professional seal of approval.
Spurs legend Steve Perryman, now director of football at Exeter City, gave the Rowley Park pitch the thumbs up with the Tatnam boss hopeful his side's enforced lay-off would come to an end.
The weather-hit schedule has seen Dolphins drop out of the Southern Premier play-off places but Killick's men could jump back into the top five should they extend their five-match winning streak in the league.
And while Killick does not believe Poole will have things all their own way against Saints, he thinks his side can utilise the rare treat of playing on a stellar surface.
Killick told the Daily Echo: "Steve Perryman said Exeter had trained there in advance of one of their matches and commented on how good the pitch was.
"Apparently, it held up really well despite a lot of wet weather so, hopefully, we should get a game on this weekend.
"In this league, it is quite rare to have a very good pitch and that favours the home side because they are comfortable playing on it.
"Our pitch is very big and we use that to our advantage, so while we are looking forward to it, they frequently play and prepare on an immaculate surface.
"If a pitch has any unusual characteristics, whether it is very bumpy or near perfect, it tends to benefit the home side but we do have some very good footballers and one of our great strengths is the flexibility to our approach.
"We can be quite direct and physical when we need to be but the likes of Carl Pettefer and Steve Devlin, in particular, are very good technically and even our defenders are comfortable on the ball.
"The lads don't get the opportunity to play on a nice pitch very often and I am sure they will relish it."
Left-back Neil Martin serves a one-match ban, while goalkeeper Dan Thomas (shoulder) remains on the sidelines alongside striker Richard Gillespie.
Jon Davies and Sam Clarke are set to return while Keith Emmerson is available. Cherries loanee Benji Buchel will play in goal.
Dolphins: (from) Buchel, Clarke, Emmerson, Spetch, Whisken, Pettefer, Davies, Elliott, Devlin, Brooks, Preston, Charles, Cann, Byerley, Dibba, Lowes, Davis.
- In Southern South & West, Wimborne travel to Stratford without Jamie Davidson (injured) and James Stokoe (suspended).
Magpies: (from) Harvell, Arnold, Wilson, Oliver, Costello, Middleton, Blake, Sainsbury, Maybury, Webb, Kemble, Gamble, Griffin, Burton-Hemmings, Donachy, Roast, Ackerman.


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Home > Community > Health Library > Placenta Previa
Normally, the placenta is attached to the uterus away from the cervix. When
the placenta blocks the cervix, it is called placenta previa. The amount
of cervix covered by the placenta may be slight (marginal), moderate (partial),
or complete (total). This picture shows a complete placenta previa.
ByHealthwise StaffPrimary Medical ReviewerSarah Marshall, MD - Family MedicineAdam Husney, MD - Family MedicineSpecialist Medical ReviewerWilliam Gilbert, MD - Maternal and Fetal Medicine
Current as ofMay 30, 2016
Current as of:
May 30, 2016
Healthwise Staff
Medical Review:
Sarah Marshall, MD - Family Medicine & Adam Husney, MD - Family Medicine & William Gilbert, MD - Maternal and Fetal Medicine
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Updated May 9, 2012 7:27 AM ET
During Week 13 of the 2011 NFL campaign, the Giants and Packers went at it in MetLife Stadium in what ended up being one of the best regular-season games of the entire year.
While watching that NFL on FOX game from my couch, I flipped over to CBS to see which game that network was airing in the New York market. Turned out that there was none. Rather, CBS was re-airing a broadcast of something called "The 2011 Deer Valley Celebrity Skifest."
I was ready to change it back immediately, when I saw the list of "celebrities" blobbing along, downhill on the slopes — "Party of Five" star Scott Wolf, hair-gel guy Paul Mitchell, and … Terrell Owens.
It was an NFL Sunday, 24 teams were still in playoff contention and a possible Hall of Fame receiver was yukking it up on the slopes alongside Hollywood's B-list in some bad version of the old "Superstars" show. I tweeted about it. I wrote, at 5:04 pm EST on Sunday, Dec. 4, "Big NFL Sunday and we've got our first T.O. sighting of the year! He's skiing ... Yes, T.O. has seen better days."
On Tuesday afternoon, I sat on that very same couch, flipping the channels with the same remote control, when I saw T.O. on TV yet again. This time, he was seated on a director's chair in front of three women — three of his kids' mothers — and Dr. Phil McGraw.


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this is my husbands and my 2nd year at VICG. and we wouldn't trade our time here for the world. Just when life gets crazy (crazier) there is still a little slice of heaven here at the campgrounds. Randy and Lisa are so very helpful...More
Getting you more information on this room
Getting you more information on this room
"know your physical capabilities. and know you're not going for pampering. this is eco-friendly, outdoor..."
"Private Island Campgrounds + Open Cabins with Tarp + Not on St. Thomas! Ferry cost $10pp round trip..."
"When full, cabin 1 - which we loved and has excellent wifi -- might not be ideal as it's by the community..."


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Back in 1997 it was big news when James Cameron spent $200 million on his sinking-ship movie; then Titanic grossed $1.8 billion worldwide, and all was forgiven. Today Hollywood sees a $200 million budget as an acceptable gamble for a picture with blockbuster hopes. As often as not, the bet pays off. Transformers: Revenge of the Fallen cost that much, but has earned $826 million worldwide; Harry Potter and the Half-Blood Prince came in at $250 million and has taken in $868 million. The one semifizzle among superpricey films: Terminator Salvation, whose $370 million worldwide gross means that, after costs, it will just about make back its $200 million budget.
Five other films in the summer's top 10 domestic winners Up, Star Trek, X-Men Origins: Wolverine, Night at the Museum: Battle of the Smithsonian and Angels & Demons had budgets of at least $150 million. Their sponsors must have been pleased, since each of the five earned more than $350 million worldwide. The only real bargains were the two comedies, The Hangover ($35 million budget, $268 million domestic gross) and Sandra Bullock's The Proposal ($40 million, $159 million domestic gross), and the animated feature Ice Age: Dawn of the Dinosaurs. Costing $90 million, about half the budget of Up, it has registered a foreign gross nearly six times that of the Pixar film. That's money well spent.
Next Ignore the Grownups


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Hobbico HydriMax NiMH 5C 6V 2000mAh AA Flat Receiver U
Hobbico HydriMax NiMH 5C 6V 2000mAh AA Flat Receiver U - HCAM6351
HydriMax Ultra NiMH 6V 2000mAh Flat Receiver Battery Pack w/Universal Connector.
- Capacity: 2000mAh
- Number of Cells in Series: 5
- Rated Voltage: 6V
- Min. Discharge Voltage: 4.5V
- Maximum Recommended Charge Current: 1.4A
- Lead: 20AWG 5.9" (150mm) long wire w/Universal connector and gold plated terminals
- Pack Dimensions: 72x53x15mm (2.8x2.1x.6 in)
- Weight: 152g (5.4oz)
- Number of Welds Per Connection: 6
- Cell Size: AA


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Cenovus 2012 Oil Production Anticipated to Grow 21%
Cenovus Energy Inc. (NYSE: CVE) plans to make substantial investments in its oil assets next year to support the company's growth strategy established in its long range business plan. The 2012 capital budget of between $3.1 billion and $3.4 billion is about 23% higher than planned 2011 capital spending.
Cenovus is anticipating strong cash flow for 2012 of between $2.9 billion and $3.5 billion. The range is similar to expected cash flow for 2011. While the company anticipates lower operating cash flow from its refining and natural gas operations in 2012, it expects increased operating cash flow from its oil projects due to higher volumes and prices.
© 2017 Benzinga.com. Benzinga does not provide investment advice. All rights reserved.


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Is an "award" ticket a real airline ticket — or something else?
It's not just me asking; so is Greg Ho, an elite-level United Airlines customer (he's a 1K, if you must know) who recently discovered a missing flight segment.
He needed our help recovering it.
Ho's route was a combination of United and Ethiopian Airlines from Portland, Ore., to Seychelles. Both airlines are codeshare partners via the Star Alliance, meaning they share routes, flights and have reciprocal frequent flier benefits.
"All is well until last week when I discovered our last segment — from Addis Ababa to Seychelles — was missing from my United.com itineraries," he says. "Apparently, Ethiopian canceled their flight and I was not notified by either airline."
If this were a "real" ticket, United would have to find a replacement flight or offer a full refund. But, since Ho paid for it with miles, are his rights any different? The Transportation Department suggests award tickets should be treated as if they were actual tickets, with all the rights and privileges thereto pertaining. Review its helpful Fly Rights brochure, which deals, for example, with denied boarding compensation and award tickets.
But that's not what happened to Ho.
"I tried to call their elite desk and contacted their corporate and they are all telling me my only option is to cancel the trip or visit somewhere else," he says.
Ho understands that flights get canceled, but he's looking for a solution.
"I realize it is Ethiopian Airline's fault for canceling their flight, but since my ticket is booked on United.com using the miles that I earned from them, I have to think they would step up and get me to my destination even if this means they need to seek other alliances to get us there to fulfill their obligation," he says.
That sounded reasonable to us. While usually we will not get involved with award point disputes, this one was different in several ways. Travel was booked in advance, and the consumer was never notified of the change.
I reached out to my contact at United, and to my surprise, he sent a message back to me almost immediately to let me know he would look into it.
Problem solved? Not quite.
Fast forward two weeks. I received another message from Ho letting me know that no one at United ever contacted him. So I followed up again with my United contact, and once again I got a response saying that he will look into it. But as of today, another two weeks have passed, and Ho has still heard nothing from United.
At this point, I'm not sure what else we can do for Ho. With his travel date quickly approaching, and still has no way to reach his destination, and United ignoring his requests — and apparently, ours — what's our next move?
William Leeper is a fire safety equipment inspector who has been with Elliott.org since 2012. He actively mediates consumer cases and manages internal workflows. William lives with his wife and daughters in rural Western Arkansas.


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Cox Remote Codes
In order to program your Cox remote control, you will need to find the correct Cox remote codes. These kinds of remote codes will help when you need to program your remote control for better functionality. If you are not well acquainted with the codes, or if your home entertainment equipment is malfunctioning, then you will need to follow a few steps to eliminate the problems. Sometime your remote control may not response to the Cox remote codes, even after you have tried your very best to apply all of them. Below are a few steps that can offer you help. These steps can offer you proper guidance to make the Cox remote codes programming work:
1) First of all you need to turn on your home entertainment system. This can be your (AUX), (VCR), (DVD), (TV), or (CABLE) box. After you choose a device you want to program, you'll need to enter a sequence of steps before entering the Cox remote codes. Use our remote codes lists, locate the correct codes for your device brand (example: Sony, Denon, Panasonic, etc.)
2) Push and hold either (AUX), (VCR), (DVD), (TV), or (CABLE) button, located at the top of your remote control. Hold the button up to 60 seconds or until the preferred mode key winks twice.
3) Next, push the (SETUP) button.
4) Use the number keys located on your remote control to enter your Cox remote codes. Enter the first code for selected device brand. Each code is separated by a comma, enter ONLY ONE code at a time.
5) Point the remote control in front of the chosen device and push the (POWER) key once. The device should turn off if the correct Cox remote code was entered.
If the device does not turn off, then repeat the above steps. In the event that none of the listed codes work skip step 4, and use the (CHANNEL+) button. Push the (CHANNEL+) button once and then push the power button. Repeat this step until the device turns off. Once the correct Cox remote code is found and device turns off, continue to step 6.
6) Push down the SETUP push button to lock the code within the remote control. You will notice that the selected mode button will blink twice.
7) Repeat the above, to program additional devices.
From the above mentioned it is clear that having the correct Cox remote codes are essential when programming your Cox remote control. You can now start enjoying your freshly programmed Cox remote control. Thanks to Cox remote codes.


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Friday, August 17, 2007
Another Idiotic Environmentalist OpinionI don't usually use words like "idiotic," even when appropriate, but this gentleman's correspondence makes the word especially apt. Our position on invasive species legislation, as shown here, is that it "should be case-specific, weigh species' benefits against costs, and... be based on peer-reviewed scientific evidence." To this I believe reasonable position, a Frank Friedrich Kling (or some very mean person, impersonating him), writes:
Do you stupid [expletive deleteds] have any idea how much money invasive species are costing farmers, taxpayers, and the average American? I live on a farm and am in a constant battle with non-native species like crab grass, kudzu, pig weed,purple loosestrife, green borer beetles, and now a newly introduced species of bettle that is destroying this country's Ash trees.Mr. Kling does not mention if his farm raises pigs. Pigs are an invasive species.
You neo-con [expletive deleteds] are so caught up with George Bush and allowing corporations to do any [expletive deleted] thing they want that not only the environment but people suffer from your misguided positions. Why do you hate anything that benefits the environment. The Passenger pigeon, Carolina Parakeet, Ivory billed woodpecker and many other now extinct and soon to be extinct species thank you for their destruction. God, do I hope you have your day of reckoning with the good Lord.
These and other invasive species are destroying this country's landscape and cost billions and billions to TRY and control.
Get a life and come live in the real world.
"The good Earth - we could have saved it, but we were too damn cheap and lazy."
Frank Friedrich Kling
[address removed]
Woodstock, Illinois
P.S. The only corporate interactions we've had on the invasive species issue are from those who sell pesticides. They weighed in, as corporations often do, with the environmentalists.
Labels: Environment, Invasive Species, Liberals
Posted by Amy Ridenour at 1:45 PM


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Household inflation experiences in the U.S.: a comprehensive approach
We present new measures of household-specific inflation experiences based on comprehensive information from the Consumer Expenditure Survey (CEX). We match households in the Interview and the Diary Surveys from the CEX to produce both complete and detailed pictures of household expenditures. The resulting household inflation measures are based on a more accurate and detailed description of household expenditures than those previously available. We find that our household-based inflation measures track aggregate measures such as the CPI-U quite well and that the addition of Diary Survey data induces small but significant differences in the measurement of household inflation. The distribution of inflation experiences across households exhibits a large amount of dispersion over the entire sample period. In addition, we uncover a significantly negative relationship between mean inflation and inflation inequality across households.
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References listed on IDEAS
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- Bart Hobijn & David Lagakos, 2005.
"Inflation Inequality In The United States,"
Review of Income and Wealth,
International Association for Research in Income and Wealth, vol. 51(4), pages 581-606, December.
- Bart Hobijn & David Lagakos, 2003. "Inflation inequality in the United States," Staff Reports 173, Federal Reserve Bank of New York.
- Pollak, Robert A, 1980. "Group Cost-of-Living Indexes," American Economic Review, American Economic Association, vol. 70(2), pages 273-278, May.
- Hamilton, Bruce W., 2001. "Black-White Differences in Inflation: 1974-1991," Journal of Urban Economics, Elsevier, vol. 50(1), pages 77-96, July. Full references (including those not matched with items on IDEAS)
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