A review of the clinical utility of the Enhanced Liver Fibrosis test in multiple aetiologies of chronic liver disease

The rising incidence of chronic liver disease continues to be an increasing health burden. The morbidity and mortality associated with chronic liver disease typically occur in patients with advanced fibrosis. Hence, early identification of those at-risk is of vital importance to ensure appropriate ongoing management. Currently, tools for appropriate risk stratification remain limited. Increasing awareness of the limitations of liver biopsy has driven research into alternative non-invasive methods of fibrosis assessment including serological markers assessing functional changes. One such biomarker, the Enhanced Liver Fibrosis test, was initially validated in a cohort of 1021 patients with mixed aetiology chronic liver disease and shown to perform well. Since this pathfinder study, it has been independently validated in cohorts of hepatitis C, non-alcoholic fatty liver disease, alcoholic liver disease, primary biliary cirrhosis and primary sclerosing cholangitis. In addition to performing well as a diagnostic tool, the Enhanced Liver Fibrosis test has been shown to outperform liver biopsy in prognostic studies and is the only non-invasive marker to do so. However, questions remain regarding the use of this test, particularly regarding the possible effect age and alcohol may have on test scores. This review examines the current literature published in relation to the Enhanced Liver Fibrosis test and its clinical utility and highlights areas requiring further study

The Enhanced Liver Fibrosis test maintains its diagnostic and prognostic performance in alcohol-related liver disease: a cohort study

BACKGROUND: Alcohol is the main cause of chronic liver disease. The Enhanced Liver Fibrosis (ELF) test is a serological biomarker for fibrosis staging in chronic liver disease, however its utility in alcohol-related liver disease warrants further validation. We assessed the diagnostic and prognostic performance of ELF in alcohol-related liver disease. METHODS: Observational cohort study assessing paired ELF and histology from 786 tertiary care patients with chronic liver disease due to alcohol (n = 81) and non-alcohol aetiologies (n = 705). Prognostic data were available for 64 alcohol patients for a median of 6.4 years. Multiple ELF cut-offs were assessed to determine diagnostic utility in moderate fibrosis and cirrhosis. Survival data were assessed to determine the ability of ELF to predict liver related events and all-cause mortality. RESULTS: ELF identified cirrhosis and moderate fibrosis in alcohol-related liver disease independently of aminotransferase levels with areas under receiver operating characteristic curves of 0.895 (95% CI 0.823-0.968) and 0.923 (95% CI 0.866-0.981) respectively, which were non-inferior to non-alcohol aetiologies. The overall performance of ELF was assessed using the Obuchowski method: in alcohol = 0.934 (95% CI 0.908-0.960); non-alcohol = 0.907 (95% CI 0.895-0.919). Using ELF < 9.8 to exclude and ≧ 10.5 to diagnose cirrhosis, 87.7% of alcohol cases could have avoided biopsy, with sensitivity of 91% and specificity of 85%. A one-unit increase in ELF was associated with a 2.6 (95% CI 1.55-4.31, p < 0.001) fold greater odds of cirrhosis at baseline and 2.0-fold greater risk of a liver related event within 6 years (95% CI 1.39-2.99, p < 0.001). CONCLUSIONS: ELF accurately stages liver fibrosis independently of transaminase elevations as a marker of inflammation and has superior prognostic performance to biopsy in alcohol-related liver disease

Public sector reform agendas and outcomes for trade unions: the case of local government reform in Victoria, 1992-1999

From the early 1980s, Western governments, led mainly by those in the United Kingdom, have pursued public choice ideas in managing their public sectors, often targeting the monopoly position of public sectors in delivering public goods and services and also the influence and position of public sector trade unions. This policy approach also underpinned the reforms to local government in Victoria, Australia that occurred between 1992 and 1999. The Victorian State Government pursued an agenda of reform aimed at reducing costs in local government, reducing the size and scope of local government in delivering public goods and services and also seeking to reduce the perceived high level of influence of trade unions. On the basis of a literature review of the experiences of public sector reform in the United Kingdom during the 1980s, this study sought to test two propositions about public sector reform agendas and trade unions, using the Victorian local government reform as the primary research context. This was an important research gap since trade unions were a major target of the reform agenda and little research information existed as to how the reform agenda impacted on local government trade unions. Although the Victorian State Government did not possess direct legislative power over trade union behaviour, a reform agenda similar to that imposed by the governments in the United Kingdom, could inflict negative outcomes through the consequential changes resulting from competition in the delivery of local council services. The first proposition was that public sector reform agendas underpinned by public choice ideas sought to inculcate competitive practices in the provision of local government services and consequently reduce trade union influence and position in local government. The second proposition was that the level of success achieved by governments on these dual objectives was determined in part by the responses taken by trade unions to the reform agenda and on the extent to which local councils adopted a competitive culture. Five major research questions and a number of sub-questions were developed from the literature to test these two research propositions. In addition, models of effects on trade unions arising from public sector reform and on trade union responses were developed. The models were important for visually showing the areas of impact on trade unions and the level of impact caused by the reform and to identify the options available and responses undertaken by trade unions during this period. An analytical framework was also established and served as a template for organising and recording findings in this study. The analytical framework served to show the main causal links between the reform agenda and outcomes for trade unions. The study adopted features of both positivist and interpretive methodological approaches to address these research questions. A positivist approach was applied in the development of research protocols to ensure researcher independence. In addition, the information collected was matched to the models of union behaviour and to the relevant elements in the analytical framework. The study also adopted features of an interpretive approach in respect of using small samples and in gathering data through interviews with key informants from three case study organisations, one trade union and two local councils. The information collected on the research questions enabled conclusions to be reached on the two research propositions. The findings supported the first proposition and confirmed previous research studies in the United Kingdom that showed how governments are able to target trade unions in indirect ways through the consequences of the promotion of competition in the delivery of local government goods and services. The study identified the negative effects arising for Victorian local government trade unions in areas of access and influence on government policy decision making, membership levels, bargaining outcomes and relations within and between trade unions. The findings gathered in this study also supported the second research proposition. The level of success by the Victorian State Government in achieving local government reform objectives was in part limited by the responses taken by trade unions and also by the extent to which local councils adopted competitive practices. These findings have contributed important insights into local government reform and trade unions, which had not previously been addressed by researchers. The study has also contributed models of union behaviour and an analytical framework for addressing contemporary public policy issues and trade unions. The amalgamation of local councils planned by the Queensland State Government provides a similar research context in which to further test the usefulness of the models of union behaviour and the analytical framework. In addition, the return of the Australian Labor Party to Federal Government, and their aim of dismantling the previous Liberal-National Party’s WorkChoices industrial relations legislation, provides a context for testing these models and framework under conditions where more direct legislative changes affecting union rights to organise and bargain are pursued

Student evaluations and the impact on curriculum, teaching and assessment

This presentation discusses some of the major pressures on universities to frame curriculum around employability skills and professional requirements. Recent evaluation of Australian university courses by graduates suggests that many institutions remain perplexed as to how to do this. The presentation suggests that the student evaluations do not necessarily indicate poor curriculum development but possibly a lack of making skill development more overt through teaching and assessment. The main objective of this presentation is to outline and describe a project on how curriculum needs to and can respond to professional needs and what this may entail for the way in which traditional professional courses are taught and assessed. The presentation seeks to involve participants in identifying and discussing options for the teaching and assessment of skills and possible options for how these skills can be progressively developed throughout a course of study.<br /

Victorian local government reforms 1992-1999, revisited: implication for trade unions

Between 1992 and 1999 the Victorian State Government, Led by Jeff Kennett, set about implementing the most extensive public sector reform program ever witnessed in Australia, part of which involved significant changes in the organisation and operation of Local government. Although Local government had traditionally been \u27the blind spot\u27 in governmental arrangements, within three years of assuming office Local government had undergone major structural and operational change. This paper revisits this period by examining four elements of the reform agenda including the factors driving the reform, the Kennett government\u27s approach to Local government reform, the expected outcomes sought by this government, and the policies implemented in Local government to achieve the expected outcomes. The paper identifies a number of implications for trade unions arising from this reform agenda and concludes that further investigation is warranted in this area.<br /

Will it work? an initial examination of the processes and outcomes of converting course materials to CD-ROMs

The Faculty of Business and Law at Deakin University (Victoria, Australia) decided to dispense of all printed post-graduate learning materials and replace them with CD-ROMs from the commencement of the 2006 academic year. In addition, CD-ROMs were developed for a limitednumber of undergraduate units as part of a future delivery plan for this cohort of students. The following paper describes this project, the reasons underpinning it, and the processes the Faculty adopted to implement the project. The project is ongoing and part of a broader agenda for changethat will see an even greater application of electronic technology to teaching and learning within the Faculty. Although only initial findings and observations are possible at this stage, the project provides a basis for longitudinal reporting and, potentially, a guide for other institutions who maybe considering such a move. The paper reports on these observations and on those in the educational development arena and suggests that the Faculty will need to learn from these initial experiences and evaluate the project in greater depth to guarantee a smooth transition for all stakeholders.<br /