Birmingham Study Research Articles

Nutritional Risk and Body Mass Index Predict Hospitalization, Nursing Home Admissions, and Mortality in Community-Dwelling Older Adults: Results From the UAB Study of Aging With 8.5 Years of Follow-Up

Nutritional risk and low BMI are common among community-dwelling older adults, but it is unclear what associations these factors have with health services utilization and mortality over long-term follow-up. The aim of this study was to assess prospective associations of nutritional risk and BMI with all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality over 8.5 years. Data are from 1,000 participants in the University of Alabama at Birmingham Study of Aging, a longitudinal, observational study of older black and white residents of Alabama aged 65 and older. Nutritional risk was assessed using questions associated with the DETERMINE checklist. BMI was categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), class I obese (30.0-34.9), and classes II and III obese (≥35.0). Cox proportional hazards models were fit to assess risk of all-cause, nonsurgical, and surgical hospitalization; nursing home admission; and mortality. Covariates included social support, social isolation, comorbidities, and demographic measures. In adjusted models, persons with high nutritional risk had 51% greater risk of all-cause hospitalization (95% confidence interval: 1.14-2.00) and 50% greater risk of nonsurgical hospitalizations (95% confidence interval: 1.11-2.01; referent: low nutritional risk). Persons with moderate nutritional risk had 54% greater risk of death (95% confidence interval: 1.19-1.99). BMI was not associated with any outcomes in adjusted models. Nutritional risk was associated with all-cause hospitalizations, nonsurgical hospitalizations, and mortality. Nutritional risk may affect the disablement process that leads to health services utilization and death. These findings point to the need for more attention on nutritional assessment, interventions, and services for community-dwelling older adults.

Severity of Spatial Neglect During Acute Inpatient Rehabilitation Predicts Community Mobility After Stroke

To examine whether stroke survivors with more severe spatial neglect duringtheir acute inpatient rehabilitation had poorer mobility after returning to their communities. A prospective observational study. Acute inpatient rehabilitation and follow-up in the community. Thirty-one consecutive stroke survivors with right-brain damage (women, n= 15 [48.4%]), with the mean (standard deviation) age of 60 ± 11.5 years, were included in the study if they demonstrated spatial neglect within 2 months after stroke. Spatial neglect was assessed with the Behavioral Inattention Test (BIT) (range, 0-146 [a lower score indicates more severity]) and the Catherine Bergego Scale (range, 0-30 [a higher score indicates more severity]). A score of the Behavioral Inattention Test<129 or of the Catherine Bergego Scale >0 defined the presence of spatial neglect. The outcome measure is community mobility, defined by the extent and frequency of traveling within the home and in the community, and is assessed with the University of Alabama at Birmingham Study of Aging Life-Space Assessment (range, 0-120 [a lower score indicates less mobile]). This measure was assessed after participants returned home≥6 months after stroke. The covariates were age, gender, functional independence at baseline; follow-up interval; and depressed mood, which may affect the relationship between spatial neglect and community mobility. A lower Behavioral Inattention Test score was a significant predictor of a lower Life-Space Assessment score after controlling for all the covariates (β= 0.009 [95% confidence interval, 0.008-0.017]); P= .020). The proportion of participants unable to travel independently beyond their homes was 0%, 27.3%, and 72.7% for those with mild, moderate, and severe acute neglect, respectively (Catherine Bergego Scale range, 1-10, 11-20, and 21-30, respectively). Our result indicates that acute spatial neglect has a negative impact on regaining of functional mobility in the community. Specific screening and treatment of spatial neglect during acute stroke care may be necessary to improve long-term mobility recovery.

O conceito de classe social no marxismo: correntes e atualidade

This article discusses the relevance and importance of the current class concept and proposes to think about the concept of social class in some currents of marxism, from: i) Marx; ii) Nico Poulantzas; iii) Adam Przeworski; iv) Erik Olin Wright and Analytical Marxism; and v) Edward Palmer Thompson and Cultural Studies in Birmingham.

An integrated cellular automata evolutionary-based approach for evaluating future scenarios and the expansion of urban drainage networks

The paper describes and demonstrates an integrated cellular automata evolutionary-based approach for evaluating future scenarios including the expansion of urban drainage networks. The approach can be used to derive a drainage network layout based on future land use scenarios. Two techniques are used to derive the layout of the system: one using agent-based modelling and the other using similar principles built as a set of raster operations within ArcGIS. The tools and models are applied to a case study in Birmingham, UK. The results show that both techniques perform well for carrying out a scoping analysis at an urban scale. The case study shows that the application of the proposed approach for simulating urban growth processes and the consequent expansion of the drainage networks can achieve promising results. The interconnected drainage model for Birmingham shows that future developments will contribute further to flooding problems if no improvements are made to the existing drainage system. The same approach can be used to identify those drainage system elements that require immediate attention and which need to be replaced in order to improve the overall system performance.

Community Mobility Among Older Adults With Reduced Kidney Function: A Study of Life-Space

Life-Space Assessment captures community mobility and social participation and quantifies the distance, frequency, and independence obtained as an older adult moves through his or her environment. Reduced estimated glomerular filtration rate (eGFR) is associated with decline in activities of daily living among older adults, but less is known about the association of eGFR with restrictions in mobility. Prospective observational cohort study. Community-dwelling Medicare beneficiaries from the University of Alabama at Birmingham Study of Aging who had serum creatinine measured during a baseline in-home study visit and completed at least one telephone follow-up (N = 390). eGFR ≥ 60, 45-59, and <45 mL/min/1.73 m(2). Life-space mobility trajectory. Life-space mobility was evaluated by telephone every 6 months for up to 4.5 years using the previously validated Life-Space Assessment. Scores using this tool range from 0-120 (higher scores indicate greater mobility). Mean age of the 390 participants was 77.6 ± 5.8 (SD) years, 41% were African American, 50.5% were women; 30.0% had eGFR of 45-59 mL/min/1.73 m(2), and 20.2% had eGFR < 45 mL/min/1.73 m(2). Age-, race-, and sex-adjusted mean baseline life-space mobility scores were 64.8(95% CI, 62.0-67.6), 63.8 (95% CI, 60.3-67.4), and 58.3 (95% CI, 53.8-62.7) among those with eGFR categories ≥ 60, 45-59, and <45 mL/min/1.73 m(2), respectively. Compared with those with eGFRs ≥ 60 mL/min/1.73 m(2), a more rapid decline in life-space mobility was found among those with eGFRs < 45 mL/min/1.73 m(2), though this did not reach statistical significance (P=0.06); a similar effect was not seen among those with eGFRs of 45-59 mL/min/1.73 m(2) (P=0.3). Urinary albumin or longitudinal measures of eGFR were not available. eGFR < 45 mL/min/1.73 m(2) was associated with a trend toward a more rapid decline in life-space mobility among community-dwelling older adults. Findings should be confirmed in a larger population.

Life-Space Assessment scale to assess mobility: validation in Latin American older women and men

The Life-Space Assessment (LSA) instrument of the University of Alabama and Birmingham study is a useful and innovative measure of mobility in older populations. The purpose of this article was to assess the reliability, construct and convergent validity of the LSA in Latin American older populations. In a cross-sectional study, a total of 150 women and 150 men, aged 65-74 years, were recruited from seniors' community centers in Manizales, Colombia and Natal, Brazil. The LSA questionnaire summarizes where people travel (5 levels from room to places outside of town), how often and any assistance needed. Four LSA variables were obtained according to the maximum life space achieved and the level of independence. As correlates of LSA, education, perception of income sufficiency, depression, cognitive function, and functional measures (objective and subjectively measured) were explored. The possible modifying effect of the city on correlates of LSA was examined. Reliability for the composite LSA score was substantial (ICC = 0.70; 95 % CI 0.49-0.83) in Manizales. Average levels of LSA scores were higher in those with better functional performance and those who reported less mobility difficulties. Low levels of education, insufficient income, depressive symptoms, and low scores of cognitive function were all significantly related to lower LSA scores. Women in both cities were more likely to be restricted to their neighborhood and had lower LSA scores. This study provides evidence for the validity of LSA in two Latin American populations. Our results suggest that LSA is a good measure of mobility that reflects the interplay of physical functioning with gender and the social and physical environment.

Youth Cultures, Lifestyles and Social Class in Finnish Contexts

The purpose of this article is to analyse young people’s cultural practices and style seeking by utilizing certain notions of a theory promoted in the 1970s at CCCS (the Centre for Contemporary Cultural Studies in Birmingham), and especially the notions of ‘new studies’ on social class that refer to Pierre Bourdieu’s concepts. The article takes as its focus the lifestyles of young people in certain localities in Finland. Although the qualitative data from 39 interviews were collected in the Finnish cities of Helsinki and Kajaani, the main focus in this article is on different localities in Helsinki (33 interviews). It is suggested that young people’s styles vary within locations and the formation of (life)styles takes place partly within groups, which are connected to the local culture (area, school) as well as to social class (family, school). I argue that no one can, will or is able to manifest any kind of style wherever they wish. One’s (life)style is attached to locality, class, gender and ethnicity.

Nikolas Rose

Nikolas Rose

Factors Affecting Acceptance and Intention to Receive Pandemic Influenza A H1N1 Vaccine among Primary School Children: A Cross-Sectional Study in Birmingham, UK

UK pandemic influenza strategy focused on vaccination of high risk groups, although evidence shows that school-age children have the highest infection rates. Vaccination of children might be an additional strategy. We undertook a cross-sectional study amongst 149 parents of primary school children aged 4–7 years in Birmingham, UK to quantify intention to accept pandemic influenza vaccine and identify factors affecting uptake. Ninety-one (61.1%, 95% CI 52.8, 68.9) had or would accept vaccine for their child. The most common reasons for declining vaccine were concerns about safety (58.6% reported this), side effects (55.2%), or believing their child had already had swine flu (12.1%). Parents of nonwhite ethnicity (OR 2.4 (1.1, 5.0)) and with asthmatic children (OR 6.6 (1.4, 32.1)) were significantly more likely to accept pandemic vaccine, as were those whose children had ever received seasonal vaccine and those who believed swine flu to be a serious threat (OR 4.2 (1.9, 9.1)). Parents would be more likely to accept vaccination if they received a letter of invite, if the government strongly encouraged them, if it were administered at school, and if it were more thoroughly tested. Accurate media portrayal of safety of the vaccine during future pandemics will be essential.

Dietary patterns and diet quality among diverse older adults: the University of Alabama at Birmingham Study of Aging.

To characterize dietary patterns among a diverse sample of older adults (≥ 65 years). Cross-sectional. Five counties in west central Alabama. Community-dwelling Medicare beneficiaries (N=416; 76.8 ± 5.2 years, 56% female, 39% African American) in the University of Alabama at Birmingham (UAB) Study of Aging. Dietary data collected via three, unannounced 24-hour dietary recalls was used to identify dietary patterns. Foods were aggregated into 13 groups. Finite mixture modeling (FMM) was used to classify individuals into three dietary patterns. Differences across dietary patterns for nutrient intakes, sociodemographic, and anthropometric measurements were examined using chi-square and general linear models. Three dietary patterns were derived. A "more healthful" dietary pattern, with relatively higher intakes of fruit, vegetables, whole grains, eggs, nuts, legumes and dairy, was associated with lower energy density, higher quality diets as determined by healthy eating index (HEI)-2005 scores and higher intakes of fiber, folate, vitamins C and B6, calcium, iron, magnesium, and zinc. The "western-like" pattern was defined by an intake of starchy vegetables, refined grains, meats, fried poultry and fish, oils and fats and was associated with lower HEI-2005 scores. The "low produce, high sweets" pattern was characterized by high saturated fat, and low dietary fiber and vitamin C intakes. The strongest predictors of better diet quality were female gender and non-Hispanic white race. The dietary patterns identified may provide a useful basis on which to base dietary interventions targeted at older adults. Examination of nutrient intakes regardless of the dietary pattern suggests that older adults are not meeting nutrient recommendations and should continue to be encouraged to choose high quality diets.

Identifying the early adopters of alternative fuel vehicles: A case study of Birmingham, United Kingdom

The transport sector has been identified as a significant contributor to greenhouse gas emissions. As part of its emissions reduction strategy, the United Kingdom Government is demonstrating support for new vehicle technologies, paying attention, in particular, to electric vehicles.Cluster analysis was applied to Census data in order to identify potential alternative fuel vehicle drivers in the city of Birmingham, United Kingdom. The clustering was undertaken based on characteristics of age, income, car ownership, home ownership, socio-economic status and education. Almost 60% of areas that most closely fitted the profile of an alternative fuel vehicle driver were found to be located across four wards furthest from Birmingham city centre, while the areas with the poorest fit were located towards the centre of Birmingham. The paper demonstrates how Census data can be used in the initial stages of identifying potential early adopters of alternative vehicle drivers. It also shows how such research can provide scope for infrastructure planning and policy development for local and national authorities, while also providing useful marketing information to car manufacturers.

British Generalship during the Great War: The Military Career of Sir Henry Horne (1861–1929). By Simon Robbins. Birmingham Studies in First World War History. Edited by John Bourne. Farnham: Ashgate, 2010. Pp. xxx+321. $124.95.

Previous articleNext article No AccessBook ReviewsBritish Generalship during the Great War: The Military Career of Sir Henry Horne (1861–1929). By Simon Robbins. Birmingham Studies in First World War History. Edited by John Bourne. Farnham: Ashgate, 2010. Pp. xxx+321. $124.95.David FrenchDavid FrenchUniversity College London Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by The Journal of Modern History Volume 84, Number 2June 2012The Jew in the Modern European Imaginary Article DOIhttps://doi.org/10.1086/664650 Views: 18Total views on this site © 2012 by The University of Chicago. All rights reserved. For permission to reuse, please contact [email protected]PDF download Crossref reports no articles citing this article.

Food access, diet and health in the UK: an empirical study of Birmingham

PurposeThis paper aims to investigate the statistical and geographical links between the prevalence of obesity and a range of socio‐economic indicators in a major UK cityDesign/methodology/approachThe geographical pattern of fresh fruit and vegetable retailing was mapped across Birmingham (UK), and this data was combined with UK census data from Neighbourhood Statistics to investigate possible correlations between obesity and the social geography of this city. To further elicit the varying underlying links between obesity and social conditions, a methodology of partial correlations was used to create “social transects” across Birmingham so the operational effects of social conditions upon poor diet could be investigated across a range of Birmingham neighbourhood types.FindingsAcross Birmingham as a whole, people whose ethnic or social make‐up did not fit the dominant group in their neighbourhood were more likely to be obese than those of the majority socio‐ethnic group for that area. The level of qualifications was the dominant influencer on obesity and diet. Particularly, less wealthy people in the more affluent areas of Birmingham were likely to suffer financial difficulties in eating healthily. However, in less affluent areas, being in (low‐paid) work actually increased the chances of being obese, as compared to being unemployed in these districts.Research limitations/implicationsChanges in the pattern of retailing or changes in individual's social status over the period of this research may confound the results; however the research may be regarded as a snapshot of conditions in Birmingham in ca.2006. The areal analysis may be confounded by the MAUP problem, although as distance to shops does not emerge as a major predictor of obesity, the results are still valid. The research applies to only one city (Birmingham), although a wide range of neighbourhood types typical of other British cities are covered.Practical implicationsTime limitations emerge as a significant factor in diet, especially in the less‐affluent areas of Birmingham. The significance of a range of social indicators upon diet is greatly affected by the range of neighbourhood types sampled. Factors barring access to a healthy diet can vary upon very small scales, even down to the individual household. Distance to shops has an effect upon diet, but only as a “moderating factor” acting in conjunction with a wider range of economic and social factors.Social implicationsThe effects of poverty, and especially unemployment, have very different effects upon diet and obesity in poor as compared to affluent areas; and in poorer areas, time limitations upon households operate so as to worsen the diet of those in low‐paid work. This implies that dietary improvement initiatives aimed at the less well off should aim for a compromise between health and convenience; otherwise such initiatives will merely widen health inequalities. Minority groups in all areas, whether a minority by ethnicity, age, or wealth, need special attention by dietary investigators.Originality/valueThe use of partial correlations to elicit the different responses to socio‐economic conditions as regards diet has not been applied before to a major UK city. The distance to shops for all residential areas for a major UK city has not been previously mapped.

Wearing the Garment of Widowhood: Variations in Time Since Spousal Loss Among Community-Dwelling Older Adults

We examine how the passage of time since spousal loss varies by social and demographic characteristics, using data from the University of Alabama at Birmingham Study of Aging. In multivariate analyses, African American race, female sex, lower income, and higher risk of social isolation had significant and independent associations with variation in time since spousal loss. African American women were at highest risk for long-term widowhood. Accurate characterizations of widowhood among community-dwelling older adults must consider variation in the length of time individuals are living as widowed persons and socioeconomic concomitants of long-term widowhood.

Simon Robbins . British Generalship during the Great War: The Military Career of Sir Henry Horne (1861–1929) . (Birmingham Studies in First World War History.) Burlington, Vt.: Ashgate Publishing Company. 2010. Pp. xvii, 321. $114.95.

Simon Robbins . British Generalship during the Great War: The Military Career of Sir Henry Horne (1861–1929) . (Birmingham Studies in First World War History.) Burlington, Vt.: Ashgate Publishing Company. 2010. Pp. xvii, 321. $114.95.

Predicting the trajectories of depressive symptoms among southern community-dwelling older adults: The role of religiosity

Background: This study examined the effects of religiosity on the trajectories of depressive symptoms in a sample of community-dwelling older adults over a four-year period in a Southern state in the US. Methods: Data from the University of Alabama at Birmingham (UAB) Study of Aging were analyzed using a hierarchical linear modeling (HLM) method. This study involved 1000 participants aged 65 and above (M age = 75 at baseline, SD = 5.97) and data were collected annually from 1999 to 2003. The Geriatric Depression Scale measured depressive symptoms; the Duke University Religion Index measured religious service attendance, prayer, and intrinsic religiosity; and control variables included sociodemographics, health, and social and economic factors. Results: The HLM analysis indicated a curvilinear trajectory of depressive symptoms over time. At baseline, participants who attended religious services more frequently tended to report fewer depressive symptoms. Participants with the highest levels of intrinsic religiosity at baseline experienced a steady decline in the number of depressive symptoms over the four-year period, while those with lower levels of intrinsic religiosity experienced a short-term decline followed by an increase in the number of depressive symptoms. Implications: In addition to facilitating access to health, social support and financial resources for older adults, service professionals might consider culturally appropriate, patient-centered interventions that boost the salutary effects of intrinsic religiosity on depressive symptoms.

Visual Acuity’s Association With Levels of Leisure-Time Physical Activity in Community-Dwelling Older Adults

Little is known about the effect of reduced vision on physical activity in older adults. This study evaluates the association of visual acuity level, self-reported vision, and ocular disease conditions with leisure-time physical activity and calculated caloric expenditure. A cross-sectional study of 911 subjects 65 yr and older from the University of Alabama at Birmingham Study of Aging (SOA) cohort was conducted evaluating the association of vision-related variables to weekly kilocalorie expenditure calculated from the 17-item Leisure Time Physical Activity Questionnaire. Ordinal logistic regression was used to evaluate possible associations while controlling for potential confounders. In multivariate analyses, each lower step in visual acuity below 20/50 was significantly associated with reduced odds of having a higher level of physical activity, OR 0.81, 95% CI 0.67, 0.97. Reduced visual acuity appears to be independently associated with lower levels of physical activity among community-dwelling adults.

Predictors of overnight hospital admission in older African American and Caucasian Medicare beneficiaries.

Potential disparities in health care utilization were examined using overnight hospitalization data from the University of Alabama at Birmingham Study of Aging, a longitudinal investigation of a stratified sample of Medicare beneficiaries. Racial differences in self-reported surgical and nonsurgical overnight hospital admissions were examined using Cox proportional hazards models. Andersen's Behavioral Model provided the conceptual framework to identify other potential predictors of admission. Nine hundred and forty-two participants, 50.1% African American, provided data at baseline and at least one follow-up assessment (mean age = 75.3 years, range: 65-106). African Americans were less likely to utilize surgical admissions compared with Caucasians in a bivariate model (hazard ratio = 0.63, 95% confidence interval = 0.41-0.98). This effect was not significant after controlling for demographics and self-reported physical health. Additional bivariate predictors of surgical admission were intact mental status, having private insurance, and higher education. African Americans were less likely to utilize nonsurgical admissions in both bivariate (hazard ratio = 0.74, 95% confidence interval = 0.59-0.93) and covariate-adjusted models (hazard ratio = 0.64, 95% confidence interval = 0.50-0.84). This effect was significantly stronger for men than for women, with African American men only 0.50 times as likely as Caucasian men to report a nonsurgical admission. Other bivariate predictors of nonsurgical admission were increased age, poor physical health, negative psychological characteristics, higher levels of social support, and low perceived discrimination. Underutilization of services has been linked to increased mortality in African Americans. Modifications in mutable domains associated with service utilization such as perceived discrimination, social support, and having private insurance may be beneficial.

Impact of Chronic Kidney Disease on Activities of Daily Living in Community-Dwelling Older Adults

Although chronic kidney disease (CKD) is associated with poor physical function, less is known about the longitudinal association between CKD and the decline of instrumental activities of daily living (IADL) and basic activities of daily living (BADL) among community-dwelling older adults. Participants were part of the prospective observational University of Alabama at Birmingham Study of Aging (n = 357). CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) using the Modification of Diet in Renal Disease equation. Primary outcomes were IADL and BADL decline defined as an increase in the number of activities for which participants reported difficulty after 2 years. Forward stepwise logistic regression was used to determine associations of baseline CKD and functional decline. Participants had a mean age of 77.4 (SD = 5.8) years, 41% were African American, and 52% women. IADL decline occurred in 35% of those with CKD and 17% of those without (unadjusted odds ratio, 2.62, 95% confidence intervals [95% CI], 1.59-4.30, p < .001). BADL decline occurred in 20% and 7% of those with and without CKD, respectively (unadjusted odds ratio, 3.37; 95% CI, 1.73-6.57; p < .001). Multivariable-adjusted odds ratio's (95% CI's) for CKD-associated IADL and BADL decline were 1.83 (1.06-3.17, p =.030) and 2.46 (1.19-5.12, p = .016), respectively. CKD Stage ≥3B (estimated glomerular filtration rate <45 mL/min/1.73 m(2)) was associated with higher multivariable-adjusted odds of both IADL (3.12, 95% CI, 1.38-7.06, p = .006) and BADL (3.78, 95% CI, 1.36-9.77, p = .006) decline. In community-dwelling older adults, CKD is associated with IADL and BADL decline.

Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort

BackgroundLiver function tests (LFTs) are ordered in large numbers in primary care, and the Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS) study was set up to assess their usefulness in patients with no pre-existing or self-evident liver disease. All patients were tested for chronic viral hepatitis thereby providing an opportunity to compare various strategies for detection of this serious treatable disease.MethodsThis study uses data from the BALLETS cohort to compare various testing strategies for viral hepatitis in patients who had received an abnormal LFT result. The aim was to inform a strategy for identification of patients with chronic viral hepatitis. We used a cost-minimisation analysis to define a base case and then calculated the incremental cost per case detected to inform a strategy that could guide testing for chronic viral hepatitis.ResultsOf the 1,236 study patients with an abnormal LFT, 13 had chronic viral hepatitis (nine hepatitis B and four hepatitis C). The strategy advocated by the current guidelines (repeating the LFT with a view to testing for specific disease if it remained abnormal) was less efficient (more expensive per case detected) than a simple policy of testing all patients for viral hepatitis without repeating LFTs. A more selective strategy of viral testing all patients for viral hepatitis if they were born in countries where viral hepatitis was prevalent provided high efficiency with little loss of sensitivity. A notably high alanine aminotransferase (ALT) level (greater than twice the upper limit of normal) on the initial ALT test had high predictive value, but was insensitive, missing half the cases of viral infection.ConclusionsBased on this analysis and on widely accepted clinical principles, a "fast and frugal" heuristic was produced to guide general practitioners with respect to diagnosing cases of viral hepatitis in asymptomatic patients with abnormal LFTs. It recommends testing all patients where a clear clinical indication of infection is present (e.g. evidence of intravenous drug use), followed by testing all patients who originated from countries where viral hepatitis is prevalent, and finally testing those who have a notably raised ALT level (more than twice the upper limit of normal). Patients not picked up by this efficient algorithm had a risk of chronic viral hepatitis that is lower than the general population.