Chronic hepatitis B-associated liver disease in the context of human immunodeficiency virus co-infection and underlying metabolic syndrome

Globally,a shift in the epidemiology of chronic liver disease has been observed.This has been mainly driven by a marked decline in the prevalence of chronic hepatitis B virus infection(CHB),with the greatest burden restricted to the Western Pacific and sub-Saharan African regions.Amidst this is a growing burden of metabolic syndrome(MetS)worldwide.A disproportionate co-burden of human immunodeficiency virus(HIV)infection is also reported in sub-Saharan Africa,which poses a further risk of liver-related morbidity and mortality in the region.We reviewed the existing evidence base to improve current understanding of the effect of underlying MetS on the development and progression of chronic liver disease during CHB and HIV co-infection.While the mechanistic association between CHB and MetS remains poorly resolved,the evidence suggests that MetS may have an additive effect on the liver damage caused by CHB.Among HIV infected individuals,MetS-associated liver disease is emerging as an important cause of non-AIDS related morbidity and mortality despite antiretroviral therapy(ART).It is plausible that underlying MetS may lead to adverse outcomes among those with concomitant CHB and HIV co-infection.However,this remains to be explored through rigorous longitudinal studies,especially in sub-Saharan Africa.Ultimately,there is a need for a comprehensive package of care that integrates ART programs with routine screening for MetS and promotion of lifestyle modification to ensure an improved quality of life among CHB and HIV coinfected individuals.

The impact of out-of-pocket expenditures on missed appointments at HIV r care and treatment centers in Northern Tanzania

Background:Missed clinic appointments negatively impact clinic patient flow and health outcomes of people living with HIV(PLHIV).PLHIV likelihood of missing clinic appointments is associated with direct and indirect expenditures made while accessing HIV care.The objective of this study was to examine the relationship between out-of-pocket(OOP)health expenditures and the likelihood of missing appointments.Method:Totally 618 PLHIV older than 18 years attending two HIV care and treatment centres(CTC)in Northern Tanzania were enrolled in the study.Clinic attendance and clinical characteristics were abstracted from medical records.Information on OOP health expenditures,demographics,and socio-economic factors were self-reported by the participants.We used a hurdle model.The first part of the hurdle model assessed the marginal effect of a one Tanzanian Shillings(TZS)increase in OOP health expenditure on the probability of having a missed appointment and the second part assessed the probability of having missed appointments for those who had missed an appointment over the study period.Results:Among these 618 participants,242(39%)had at least one missed clinic appointment in the past year.OOP expenditure was not significantly associated with the number of missed clinic appointments.The median amount of OOP paid was 5100 TZS per visit,about 7%of the median monthly income.Participants who were separated from their partners(adjusted odds ratio[AOR]=1.83,95%confidence interval[CZ]:1.11-8.03)and those aged above 50 years(AOR=2.85,95%CI:1.01-8.03)were significantly associated with missing an appointment.For those who had at least one missed appointment over the study period,the probability of missing a clinic appointment was significantly associated with seeking care in a public CTC(P=0.49,95%CI:0.88-0.09)and aged between>25-35 years(P=0.90,95%CI:0.11-1.69).Conclusion:Interventions focused on improving compliance to clinic appointments should target public CTCs,PLHIV aged between>25-35 years,above 50 years of age and those who are separated from their partners.

澳大利亚全科医师对基底细胞癌的治疗(德语)

Background: Basal cell carcinomas (BCCs) are a relatively common form of skin damage in Australians, involving approximately 1 in 200 general practice encounters per year. Aim: To determine current treatments and the associated healthcare resource costs of BCC therapy in Australia. Methods: A retrospective survey was undertaken relating to the treatment of patients presenting to their doctor with previously untreated BCCs. Data were collected from a sample of general practitioners who were asked to randomly select two BCC patients from their medical records and complete a questionnaire. Information about treatment types,number of doctor visits, treatment complications, and specialist referrals was extracted from the patient records. Results: One hundred and sixty-four patients were recruited into the study (59%male), who were treated for a total of 244 BCCs (average of 1.5 lesions per patient). Twenty two percent of patients were referred to a specialist, most being referred to a general surgeon (45%) or plastic surgeon (25%). Excision was the preferred therapy; second choices were cryosurgery or curettage and cautery. Few adverse events were recorded. The typical number of doctor visits varied from 3.2 to 7.4, with a range of total cost per patient of AUS＄146.60-496.20, depending on complexity and the need for referral. Conclusion: With a reported incidence in Australia of approximately 788 per 100,000 persons, BCCs are not inexpensive to treat for such a relatively common condition.

Economic costs of hospitalized diarrheal disease in Bangladesh:a societal perspective

Background:Diarrheal diseases are a major threat to human health and still represent a leading cause of morbidity and mortality worldwide.Although the burden of the diarrheal diseases is much lower in developed countries,it is a significant public health problem in low and middle-income countries like Bangladesh.Though diarrhea is preventable and managed with low-cost interventions,it is still the leading cause of morbidity according to the patient who sought care from public hospitals in Bangladesh indicating that significant resources are consumed in treating those patients.The aim of the study is to capture the inpatients and outpatient treatment cost of diarrheal disease and to measure the cost burden and coping mechanisms associated with diarrheal illness.Methods:This study was conducted in six randomly selected district hospitals from six divisions(larger administrative units)in Bangladesh.The study was performed from the societal perspective which means all types of costs were identified,measured and valued no matter who incurred them.Cost analysis was estimated using the guideline proposed by the World Health Organization for estimating the economic burden of diarrheal diseases.The study adopted quantitative techniques to collect the household and hospital level data including structured and semi-structured questionnaires,observation checklists,analysis of hospital database,telephone interviews and compilation of service statistics.Results:The average total societal cost of illness per episode was BDT 5274.02(US$67.18)whereas the average inpatient and outpatient costs were BDT 8675.09(US$110.51)and BDT 1853.96(US$23.62)respectively.The cost burden was significantly highest for poorest households,21.45%of household income,compared to 4.21%of the richest quintile.Conclusions:Diarrheal diseases continue to be an overwhelming problem in Bangladesh.The economic impact of any public health interventions(either preventive or promotive)that can reduce the prevalence of diarrheal diseases can be estimated from the data generated from this study.

Determinants of household catastrophic costs for drug sensitive tuberculosis patients in Kenya

Background::Despite free diagnosis and treatment for tuberculosis(TB),the costs during treatment impose a significant financial burden on patients and their households.The study sought to identify the determinants for cata-strophic costs among patients with drug-sensitive TB(DSTB)and their households in Kenya.Methods::The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample(n=1071).Treatment related costs and productivity losses were estimated.Total costs exceeding 20%of household income were defined as catastrophic and used as the outcome.Multivariable Poisson regression analysis was performed to measure the association between selected individual,household and disease characteristics and occurrence of catastrophic costs.A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored.Results::The proportion of catastrophic costs among DSTB patients was 27%(n=294).Patients with catastrophic costs had higher median productivity losses,39 h[interquartile range(IQR):20-104],and total median costs of USD 567(IQR:299-1144).The incidence of catastrophic costs had a dose response with household expenditure.The poorest quintile was 6.2 times[95%confidence intervals(CI):4.0-9.7]more likely to incur catastrophic costs compared to the richest.The prevalence of catastrophic costs decreased with increasing household expenditure quintiles(proportion of catastrophic costs:59.7%,32.9%,23.6%,15.9%,and 9.5%)from the lowest quintile(Q1)to the highest quintile(Q5).Other determinants included hospitalization:prevalence ratio(PR)=2.8(95%CI:1.8-4.5)and delayed treatment:PR=1.5(95%CI:1.3-1.7).Protective factors included receiving care at a public health facility:PR=0.8(95%CI:0.6-1.0),and a higher body mass index(BMI):PR=0.97(95%CI:0.96-0.98).Pre TB expenditure,hospitalization and BMI were significant predictors in all sensitivity analysis scenarios.Conclusions::There are significant inequities in the occurrence of catastrophic costs.Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs.