Using a chronic hepatitis B Registry to support population-level liver cancer prevention in Sydney, Australia

Background: Approximately 1% of Australians have chronic hepatitis B (CHB), which disproportionately affects people born in hepatitis B-endemic countries. Currently, approximately half of the people affected remain undiagnosed and antiviral treatment uptake is suboptimal (~5%). This increases the likelihood of developing end-stage disease complications, particularly hepatocellular cancer (HCC), and largely accounts for the significant increases in HCC incidence and mortality in Australia over the last decades. As our previous economic modeling suggested that CHB screening and treatment is cost-effective, we tested the feasibility of a primary carebased model of CHB diagnosis and management to prevent HCC. Materials and methods: From 2009 to 2016, the B Positive program trialed a CHB screening and management program in an area of high disease prevalence in Sydney, Australia. Trained local primary care providers (general practitioners) screened and managed their CHB patients using a purpose-built CHB Registry and a risk stratification algorithm, which allocated patients to ongoing primary care-based management or specialist referral. Results: The program enrolled and followed up \u3e1,500 people (25% of the target population). Their median age was 48 years, with most participants being born in China (50%) or Vietnam (32%). The risk stratification algorithm allocated most Registry participants (n=847 or 79%) to primary care-based management, reducing unnecessary specialist referrals. The level of antiviral treatment uptake in Registry patients was 18%, which was the optimal level in this population group. Conclusion: This pilot program demonstrated that primary care-based hepatitis B diagnosis and management is acceptable to patients and their care providers and significantly increases compliance with treatment guidelines. This would suggest that scaling up access to hepatitis B treatment is achievable and can provide a means to operationalize a population-level approach to CHB management and liver cancer prevention

Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation

<p>Abstract</p> <p>Background</p> <p>Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the <it>B Positive </it>pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.</p> <p>Methods</p> <p>Estimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.</p> <p>Results</p> <p>Assuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.</p> <p>Conclusions</p> <p>While the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.</p

Surgical procedure for the cure of atrioventricular junctional (“AV node”) reentrant tachycardia: Anatomic and electrophysiologic effects of dissection of the anterior atrionodal connections in a canine model

AbstractObjectives. This study was undertaken to examine the electrophysiologic and anatomic efects of a surgical procedure that cures the anterior (common) type of atrioventricular (AV) junciional reentrant tachycardia.Background. The procedure was designed to interrupt the reentrant circuit at the point of earliest atrial activation during AV junctional reentrant tachycardia, the anterior atrionodal connections.Methods. Atrioventricular node function and the sequence of electrical excitation of Koch's triangle were examined in 18 dogs. Excitation of Koch's triangle was mapped using a 60-channel mapping system. Surgical dissection was performed in 10 dogs and a sham procedure in 8. After 28 to 35 days, AV node function and the atrial excitation pattern were reassessed. The AV junction was examined using light microscopy.Results. Some degree of AV node damage was visible in all dogs in the dissection group, but it was minor in 40% of cases. The anterior part of the AV node was disconnected from the anterior atrionodal connections in all cases. Anterograde AV node function was mildly impaired. The median AH interval was increased (62 vs. 76 ms [interquartile ranges 48 to 72 and 64 to 104, respectively], P = 0.05), and the AV Wenckebach cycle length was increased (210 vs. 245 ms [interquartile ranges 200 to 230 and 210 to 260, respectively], p = 0.02). The degree of impairment of conduction was directly proportional to the length of dissection (p < 0.05) but not to the degree of damage to the AV node. Ventriculoatrial (VA) conduction was destroyed in 50% of dogs undergoing dissection but in none of those with a sham operation (p < 0.04). The AV node remained responsive to autonomic blocking drugs, and atrial mapping during ventricular pacing revealed that the site of exit from the AV node had been altered.Conclusions. The atrionodal connections closest to the His bundle are the preferred route of conduction through the AV node during normal AV or VA conduction. Destruction of these connections modifies AV node conduction. The surgical procedure selectively interrupts these connections, and this interruption is likely to be the mechanism of cure

Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation

<p>Abstract</p> <p>Background</p> <p>Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the <it>B Positive </it>pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.</p> <p>Methods</p> <p>Estimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.</p> <p>Results</p> <p>Assuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.</p> <p>Conclusions</p> <p>While the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.</p

The Delphi process: a solution for reviewing novel grant applications

Tesis (Ingeniero Civil)--Universidad de Piura. Facultad de Ingeniería. Programa Académico de Ingeniería Civil, 2004.Texto: Dedicatoria. Prólogo. Resumen. Introducción. Cap. I: Descripción de la estructura y fundamentación de la tesis. Cap. II: Definición general de las propiedades de los elementos para la modelación de la estructura. Cap. III: Descripción del “FEMA 273¨ respecto a estructuras de concreto armado. Cap. IV: Descripción de métodos de rehabilitación estructural en concreto armado y albañilería. Cap. V: Descripción y modelación del edificio elegido. Cap. VI: Conclusiones y Recomendaciones. Conclusiones. Recomendaciones. Bibliografía Anexos. -- CD-ROM: Contenido idéntico al formato impreso.La presente investigación tiene como objetivo evaluar el comportamiento sismorresistente de una estructura de concreto armado aporticada y con muros de albañileria portante, su cimentación esta conformada por zapatas y cimentaciones corridas, en la azotea no existe ningun tipo de construction. Para este fin se empleó El FEMA 273, para identificar sus zonas debiles planteando alternativas de reforzamiento, si la estructura lo requiere, cumpliendo con lo exigido en la Norma Peruana Sismorresistente N'I'E-030

Hepatitis B prevention and control: Lessons from the East and the West

Despite being ten times more common than HIV infection, viral hepatitis has so far not commanded the same public health response worldwide, so a global viral hepatitis treatment program is still a long way from becoming a reality. However, much progress has occurred over the last few decades, with the screening of blood products, sound infection control practices and the introduction of disposable needles and syringes leading to significant reductions in nosocomial hepatitis B transmission in the developed world and increasingly in other countries. The introduction of hepatitis B vaccination in the 1980s and its integration into the Expanded Immunization Program have led to substantial reductions in chronic hepatitis B infection rates in children and to millions of lives saved. The availability of effective antiviral treatment has revolutionized treatment prospects, although access to treatment remains a significant challenge for most developed countries and remains out of reach for developing nations. Some of these breakthroughs have occurred in Asian countries, others in the West, but their unifying features are innovative research, timely clinical translation and a commitment to apply their findings to improve the health of populations, not just individuals. This paper reviews some of the challenges and opportunities for hepatitis B control at the end of the first decade of the third millennium and argues for closer East - West collaborations, to bring in fresh perspectives, avoid duplications of effort and in order to help answer many of the remaining challenges in making hepatitis B history